Psychoanalytic Psychology 2009, Vol. 26, No.

3, 259 273

2009 American Psychological Association 0736-9735/09/$12.00 DOI: 10.1037/a0016448

NONINTERPRETATIVE MEASURES IN THE ANALYSIS OF TRAUMA

Arnold Wm. Rachman, PhD, Margaret A. Yard, PhD, and Robert E. Kennedy, PhD
The Institute of the Postgraduate Psychoanalytic Society

Psychoanalysis has a long and distinguished history in the use of noninterpretative measures, rst introduced by Freud in the case of the Rat Man and, then, formalized in the case of the Wolf Man. Freud passed the mantle to Ferenczi when he declared the future development in psychoanalysis would center around Ferenczis introduction of the role of activity in psychoanalytic technique. Over the course of his clinical career Ferenczi described a theory of trauma, the Confusion of Tongues paradigm and experimented with Relaxation Therapy which included a wide array of non-interpretative measures in order to successfully treat trauma. Three clinical cases are presented by the authors to illustrate the use of on-interpretative measures in the contemporary analysis of trauma. Trauma creates a developmental freeze which interferes with the individuals capacity to mentalize, i.e. create representations which can be stored in language and thus, symbolize concepts for meaning formation. Arrested development of cognition and verbal interaction is stored in the body as a somatic memory. Non-interpretative measures are an effort to reach the split-off precognitive and somatic aspects of the trauma. Keywords: non-interpretation measures, analysis of trauma, Ferenczi, role of activity

Freuds Introduction of Noninterpretative Measures

There is a signicant history in psychoanalysis for the use of noninterpretative measures to aid the expression of suppressed affect, as well as to aid the working through process. Although Freud is considered to be the prototype of the analyst as interpreter, it is seldom recognized that the founder of psychoanalysis pioneered the employment of noninterpretative measures. Freuds original introduction of noninterpretative measure began with feeding the Rat Man (Coltrera & Ross, 1967). After much discussion feeding
Arnold Wm. Rachman, PhD, Margaret A. Yard, PhD, and Robert E. Kennedy, PhD, The Institute of the Postgraduate Society. Correspondence concerning this article should be addressed to Arnold Wm. Rachman, PhD, 8777 Collins Avenue, #210, Surfside, FL 33154. E-mail: nancy.rachman@nick.com

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the Rat Man was attributed to Freuds humanism (Boyer & Giovaccini, 1967). In his pioneering case of the Wolf Man, however, Freud formally introduced four noninterpretative measures: (1) a cure was promised; (2) the patient was treated without a fee; (3) money was raised for the treatment; and (4) a termination date was set (Freud, 1918/1955). It was Freuds clinical acumen that moved him to deviate from his own standard procedure (Roazen, 1975). The analysis of The Wolf Man could not be conducted, Freud believed, by only the use of his standard technique. His idea was to match the analysands developmental and real-life needs with meaningful therapeutic procedures. Although it cannot be said that the noninterpretative measures provided a cure for the Wolf Man, it did elasticize the concept of psychoanalytic treatment. Freuds inuence continued after his death, when a series of analysts would journey to Germany during the summer months, to continue to treat The Wolf Man without a fee (Roazen, 1975).

Ferenczis Elasticity Principle

Freud believed the treatment of difcult cases where childhood trauma was evident was the future of psychoanalysis (Freud, 1919 [1918]/1958). While Freud turned his attention to the further development of theory, he entrusted the evolution of analytic method to Ferenczi (Rachman, 1997, 2003a). Ferenczi devoted his career to the study of trauma and the elasticizing of the boundaries of the analytic method (Rachman, 1997, 2003a, 2007). In a series of groundbreaking papers, Ferenczi described the expansion of the analytic method to include a wide array of noninterpretative measures (Ferenczi, 1980a1980l, 1988). These were measures that allowed the analysts to create a variety of clinical interactions other than the tradition of interpretation, such as active roles for the analyst and the analysand; cocreated clinical interventions; clinical empathy; countertransference analysis; analyst self-disclosure; and mutual analysis (Rachman, 1997, 1998, 2003a, 2004, 2007). The most extensive description of an analysis where noninterpretative measures were used was Ferenczis case of Elizabeth Severn, (R.N. in The Clinical Diary [Ferenczi, 1988]). Ferenczi conducted his analysis with Severn to deal with severe and persistent childhood trauma (Balint, 1968; Ferenczi, 1988; Rachman, 1997, 1998, 2003a, 2007). Both Eisslers idea of parameters (Eissler, 1953) and Stones concept of widening the scope (Stone, 1954) brought the idea of noninterpretative measure into the domain of traditional psychoanalysis. In the ensuing years since the Eissler and Stone publications, noninterpretative measures have been explored, reformulated, extended, and integrated into the object relations: interpersonal/humanistic, self-psychology, and relational perspectives (Rachman, 2003a). The British Object Relations perspective, most notably Balint (1968) and Winnicott (1965), integrated an active role for the analyst when working to the zone of regression with severe neurotic, borderline, or psychotic disorders. Balint was a witness to Ferenczis extensive use of noninterpretative measures in the analysis of Elizabeth Severn (Balint, 1968). In fact, one could say that Ferenczis case report about Severn was the rst attempt to formally use noninterpretative measures to aid in the analysis of trauma (Rachman, 2009). Margaret Little reported on her analysis with Winnicott and his use of noninterpretative measures (Little, 1981). Self-psychologists, most notably, Bacal (1990) and Estelle and Morton Shane (Shane & Shane, 1996), have attempted to expand the traditional Kohutian model to include noninterpretative measures. Both Bacal and Morton Shane were students of Balint. Bacal also has integrated object relations ideas into his self-psychology perspective (Bacal & Newman, 1990).

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Three Cases of the Use of Noninterpretative Measures in the Analysis of Trauma

Three clinical examples will illustrate the contemporary use of a relational perspective informed by Ferenczi and Balints ideas (Rachman, 2003a, 2003b, 2007), where noninterpretative measures were employed in the analysis of trauma (Rachman, 2003a, 2004, 2007, 2009). These examples are Margaret Yards Case of Denise, Robert Kennedys Case of Patrick, and Arnold Rachmans Case of Winston. These cases illustrate elasticizing the boundaries of analytic work to reexperience and work through childhood traumas unreachable by conventional verbal interaction and interpretation. Noninterpretative measures are seen as a meaningful, and at times necessary, adjuncts to the analysis of trauma (Rachman, 2004, 2009; Rachman, Kennedy, & Yard, 2005; Rachman, Kennedy, & Yard, 2009). Noninterpretative measures should not be viewed as nonanalytic. In the relational perspective, especially the view that integrates Ferenczi and Balints ideas (Rachman, 1997, 2003b, 2009), the use of activity that goes beyond traditional clinical boundaries is a necessary step toward freeing up associations so that the analysis can reach rock bottom (Ferenczi, 1980l) and work through the basic fault of the origin of personality trauma (Balint, 1968). It is the contention of the authors that noninterpretative measures may be a necessary and sufcient condition for analyzing trauma. As we have discussed, Ferenczi profoundly understood this idea based on his commitment to Freuds analytic theory and his own clinical acumen. What is more he had the personal courage to cocreate clinical encounters. It is clear to any clinician who regularly participates in clinical work with difcult cases, where trauma is at the heart of the difculty, that exibility, responsiveness, and creative clinical encounters naturally evolve in a mutually democratic therapeutic process.

The Case of Denise: (Margaret Yard)

Denise, a 38-year-old grammar school teacher, with a long history of parental rejection, sought therapy because of a history of lost jobs. Denise had a history of conict with supervisors in her teaching positions. She had difculty accepting direction and was confrontational with supervisors and teachers. She shared a lack of impulse control and grandiosity. She wound up being escorted out of schools. She came to treatment in hope of keeping her new teaching assignment in a small church-run school. Denise obtained this new job by plagiarizing a referral from a college friend, rewriting her resume, and editing out her previous job failures. Despite her elaborate attempts at being hired, Denise continued to jeopardize herself, by showing up late. Ironically, she took her students occasional lateness as a personal affront, with no awareness that she had herself modeled the boundary-breaking behaviors. She developed creative lesson plans, but soon procrastinated, lost interest, and had difculty executing her detailed and expert class plans. Some perceptive students sensed her problem with boundaries, experienced her erratic and unpredictable behavior, her excitability, and began to take advantage of her by purposefully challenging her. Psychodynamically, they mimicked the humiliation Denise felt at home when her mother had taunted her. Denise thrived on and created the tension of a chaotic and destructive environment. Doing this, she reenacted the malevolent and unsafe atmosphere of her early home. Severely traumatized by her strict, authoritarian mother who was inconsistent, inad-

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equate, and punitive, Denise suffered violent conict in her home. Her Italian mother adored Denises two older brothers obsessionally, shopping for them, doing their accounting, and cleaning for them, even as adults. Yet, Denise states, her mother treated her like an undeserving stepdaughter, a Cinderella without hope to nd her prince. Her symbolic prince was her father who was loving toward her, but whom her mother banned from her household when Denise was 4 years old. Developmentally, Denise never obtained a sense of safety and security from her mother. She both hated and feared her mothers power in driving her father away, whom she never saw again. Denise had been unsuccessful in a previous therapy. She complained that the therapists were always making interpretative statements that made no sense to her and were unhelpful. In our analysis she immediately challenged the notion of the analytic frame. On her rst session Denise could not choose a seat and sit in it. Instead she circled the room wringing her hands and talking over my voice. I wondered if she could even sit through a session. That rst session, I suggested that she try sitting with the chair at different distances from me until she felt right about it. My suggestion that she move the chair to her comfort level of distance reassured her. It allowed her choices, and with this option, lowered her internal agitation enough for her to sit and save face by not giving in to me, the female authority. Rather than the designated chair, she chose the window sill as her seat. This choice was an emotionally meaningful compromise for her. Her internal preoccupation with a perceived insult by me because her boundaries were frail prompted her, on occasion to storm out of my ofce. Later in therapy, in a malevolent transference toward me, she described a game she played called Russian roulette. In this game, she attempted to challenge and unsettle me by disclosing violent and disgusting material about herself and her family. She was observing whether I was actively listening and focused on her material and then, immediately deny it, laughing that she had fooled me. When this happened, I struggled with my own countertransferential anger at her attempts to fool and control me. Yet, beneath her overt behavior, I sensed the turbulent mental states verging on panic that she was having trouble regulating. This prepared me to empathize with Denises rage and fear. This kind of primitive emotional game lead me to believe that Denises low frustration tolerance and motor agitation would be best helped by noninterpretative measures. One such noninterpretative intervention occurred the next time Denise walked out of our session. When she stormed out, I waited, but left the door ajar. I continued to sit through the empty session acting as if I expected her to reappear and resume our work. She often stood outside of the room and waited silently. I did not speak, only left the door obviously open and sat across from her chair in silence. Soon her waiting outside diminished in time and she rejoined out session, picking up where she had left off. I did not interpret, nor did I focus on her leaving. She experienced this as empathetic silence, that I was there, I was waiting, but that I would not intrude on her desire or behavior as her mother had done. What I experienced, especially in the beginning, was a series of reenactments derivative from her early attachment ruptures with her mother. Denise lived out an intense love hate drama with all signicant objects in her life. She exhibited poor affect regulation and attentional control, which destabilized all her attempts at relationship and undermined her ability to experience self-coherence. Denises history suggested that she had had a developmental arrest at the preverbal level, as a response to attachment trauma. She experienced genuine malevolent treatment from her mothers active rejection in denying her a place in the family. Her mothers libidinal xation on her sons drove Denise to run away from home when she was 16 years old. Yet, it is incommensurate for the child to understand that the parent, whom they are wholly dependent upon, is malevolent toward

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him/her (Ferenczi, 1988j). Denise did not recognize the nonloving, jealous, competitive, and actively destructive intent of her mother. This resulted in Denise remaining dissociated and fragmented. She suffered from attachment trauma as she had severe decits in keeping a connection with another (Beebe, Lachman, & Jaffee, 1997; Bowlby, 1969). As a result of attachment trauma, Denise had difculty holding another in her mind. She lacked the means for emotional sustenance and self-soothing, which could be used later for the development of a positive self-concept and supportive relationships. Because she lacked object constancy, she lacked the anchoring function, which helped her in the perseverance of her relations with others (Winnicott, 1965). Denises mentalizing decits, that is, her inability to think about her own mental state, and to organize herself, combined with the lack of background trust that would create object constancy left her at risk for developing a therapeutic working alliance. The use of interpretation was counterindicated because Denise had limited ability to contain an idea or to cognitively reect on her behavior. Because she had difculty containing her feelings and putting them into words, Denise needed a more concrete and literal model for treatment, one in which behavior and actions contained the therapeutic message, our instructions in the here and now. We enjoined in a cocreated partnership (Fiscalini, 2006), which broke the strictures of aloneness and hostile isolation and allowed Denise to begin to participate in an analytic relationship. Denise began attending, paying attention, and interacting in our sessions. Our next goal was to work on her obsessive preoccupation with her mother, which precluded her ability to reect on herself. Together, we talked about how to alleviate her obsessively debilitating negative thoughts, which retraumatized and consumed her life. Denise wanted to bury her persecuting thoughts about her mother and never see them again. The word bury ignited a creative ood in her, and taking it literally, Denise imagined a full-blown funeral for her mother. I did not analyze this as a morbid preoccupation with death, or as a sign of regression. Instead, her new ability in symbolizing her conicts and entering into a mutually created noninterpretative frame allowed her to accept support and empathy from me. The idea of a funeral would help her cathect her trauma in concrete terms that she could understand. Being handy in arts and crafts, Denise decided to build a miniature cofn and drape it in black. In this cofn she put her mothers letters, mementos, and pictures. She decided to bury her mothers effects and imagined a funeral. She went through the following steps: creating a chapel atmosphere with owers and arrangements, including condolences written out by friends and relatives on little cards, placing lit candles all around to create a solemn mood, addressing prayer cards to her mother, playing Schuberts Traumerel, pacing solemnly to this slow-measured music, wearing a black dress, gloves, and hat with black lace veil. She chanted other death dirges and lit the pungent incense used in the Catholic Church in a background of the Mea ulpa of the Catholic mass. She envisioned a long procession for the burying of mothers body and effects in a casket in the ground. After hearing her detailed description, much like a screen play, I offered here a response that was intended for her to reect or mentalize on her proposed noninterpretative measure. Denise wanted to bury her handmade cofn with her mothers effects in the ground. That act would certainly provide a catharsis for her murderous feelings toward her mother, and so there would be immediate short-term relief. However, I reasoned that if she buried her mothers artifacts in the ground, they would not be able to be retrieved. They would not be available to her should she overcome her developmental arrest. Denise at that time understood things only in concrete terms and could not imagine that as she progressed in therapy she might want to unearth pictures and artifacts of mother to undergo a symbolic mourning process so that she might nally nd some resolve of this

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early traumatic experience. If she went ahead and buried the objects, I reasoned, she would have restricted her opportunity to work out her conicts. I made the suggestion to store her mothers things in a storage rental box, so that she could revisit her past and retrieve it when she wanted. This degree of personal efcacy appealed to her. It also had the value of giving Denise the clear message that I intuitively felt that with intense work and commitment she had the potential for making change in her life. I became aware that I had a countertransference reaction to Denises burying her mothers material in the ground. My countertransference analysis revealed my reaction was related to not being able to reach my own mother, unavailable to me with Alzheimers disease. My projection on Denises desire to get rid of the noxious mother who disappeared on her, was, in part, a countertransference reaction to preserve my connection with my own mother and not bury her, so she would not disappear in my life. Denises mother was alive and had an intact sensorium, she did not have Alzheimers disease. On a compassionate note, I realized that Denise had an opportunity to grieve the bad treatment she had experienced from her mother. On an intellectual and experiential note, I concur with the clinical utility of the concept of mentalizing and the working through of traumatic and developmental psychopathology (Fonagy, Gergely, Jurist, & Farget, 2001). The noninterpretative measure of the funeral and burying the mothers contents proved effective. After performing her funeral at the storage box company, Denise began to focus more on understanding her conicts and enactments. She experienced relief from past persistent traumatic material. As time went on Denise spoke again of her mothers funeral and the space it made in her life so that she could put the trauma behind her. Her negative obsessive thinking about her mother diminished, as did her frequent nightmares. During the rst year of analysis, Denise began taking continuing education courses to enhance her teaching credentials. The following year she began teaching again in a concentrated and organized manner. During the third year of analysis, Denise began a deep process of reection and was curious enough to want to reopen the casket of mementos from her mother, to examine them, and to retrieve the photo of her mother to place in her home. This then, was the beginning of the working through process. In retrospect, Denise reected on her analysis over her other therapy experiences. The funeral measure helped her cathect her strong unresolved feelings so she could go on. She stated that the differences was that I allowed her to feel her stress had a legitimate source and that she herself was an authentic, but troubled person. I believe this insight would have never come to actualization without the very concrete and active noninterpretative measures taken.

The Case of Patrick (Robert E. Kennedy)

Patrick was a 50-year-old Catholic priest, born of Irish American parents. He came to analysis to fulll the requirement for training as a pastoral counselor. Although he was aware of his basic personal issues, he was not aware of the depth and scope of a specic early trauma. Patrick had been a child who was emotionally neglected. As an adult, this trauma was manifested as an insensitivity and lack of empathy to the suffering of particular groups, such as the British, the Scots-Irish, and the Jews. All of these groups were identied by his parents as different and antagonistic to the Irish Roman Catholic belief system. The indifference to his needs by his family paralleled the training he received as a priest, which lacked an empathetic response to the trauma of other groups. There was a historical and familial background to Patricks emotional deprivation. The

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long history of the brutalization of the Irish people had created his familys solidarity and painful victimhood. That environment isolated Patrick and gave him little encouragement or opportunity to develop empathy for others. As the priest grew to manhood he lacked condence in his own ideas. Instead, he developed a naive and excessive loyalty to his own clan, church, and family, which he took to be a virtue. This blinded him to the sufferings of others. If Patricks family was matriarchal and hierarchical, the Catholic Church was even more so. His religious education stressed sermons over discussion. Catechism had to be memorized, the priest was not to be questioned, and cooperation with non-Catholics was not encouraged. Patricks education taught him to be loyal and faithful. It taught him to be wary of liberal inuences outside the protective embrace of the Church. One day, a group of friends invited Patrick to join them on a week-long pilgrimage to the Auschwitz-Birkenau Concentration Camp ruins to bear witness to the suffering of the Jewish people. Patrick never intended to go to Auschwitz. He had read about the Holocaust and he was not particularly emotionally moved by what he had read. He was not motivated to investigate it further. He went on the trip to please the group with which he had a strong afliation. Once he began the concentration camp journey, step-by-step, Patricks struggle with empathy was revealed. The many silent dead brought him to a sensitivity to others he had never imagined possible. Patrick was personally exposed to material and graphic evidence of the suffering of the Jews for the rst time in his life. He was emotionally moved by their suffering. The exploration of the trauma of indifference to the suffering of others, although explored in psychotherapy sessions, never produced any emotional insight. This case is an example of early trauma projected on latter objects, for example, from the family to the Catholic Church. The original trauma of maternal deprivation was then reenacted on the journey to the sites of Jewish suffering. The bearing witness of the suffering of the Jews occurred through a series of intensive emotional experiences, such as the viewing of the concentration camp; the platform where Jews were separated; the barracks for the children and women; the ash pit where remains of people were dumped; the museum where hair and clothes were kept; the gas chamber and crematorium. Bearing witness was intensied by group discussions about the experience, the lms of the actual running of the camps, the reading of the names of the people who died in the camps, the living presence of the Jewish witnesses and relatives of survivors. These activities of viewing the aspects of the concentration camp and group discussions about the experience constitute an intensive emotional experience outside the consultation room, which became an adjunct noninterpretative measure to his analysis. The immersion in this active and emotionally intensive experience lessened Patricks defense system so that an empathic response was possible. Patricks experience at Auschwitz-Birkenau was reviewed in his analysis. The analysis of the emotional experience at the concentration camp encouraged change in four ways: his self-understanding, his relationship with his analyst, and his relationship with others, for example, friends, students. First, there was a change in his self-understanding. Patrick saw that his celibate priesthood was a way of evoking affection and esteem from people without having to take personal responsibility for them. No matter how hard Patrick worked for them to believe that he loved them there was an antiseptic quality to his love that kept him separate and safe from their suffering. Patrick was taught that this freedom from domestic entanglement was a necessary quality in a priest, but he realized it was also a way of being untouched and nally irresponsible. He initially found himself walking through Auschwitz-Birkenau as a spectator viewing a car wreck

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involving others. He learned to grieve for his shallowness and lack of humanity, but this was only a halfway house. The nal gift of Auschwitz-Birkenau was the ability to grieve not for himself but for the suffering of others who neither loved nor esteemed him. Second, his experience at Auschwitz-Birkenau changed his relationship with his analyst. He had prided himself on his good working relationship with his analyst, but there was always present a subtle note of competition and a need for reciprocity. The element of competition with the analyst could take various forms: a verbal sparring match so as not to be defeated or taken over by an opponent, or a fear of being emotionally dependent on him, or a need to win his approval. The element of reciprocity with the analyst showed itself in Patricks need to have the analyst change. If the analyst wanted him to grieve for the lost Jews, Patrick wanted the analyst to grieve also for the lost Irish. Patrick wanted his analyst to actively acknowledge that the Irish had been brutalized by the British. He resented the analysts claim that his sufferings were unique or special. At AuschwitzBirkenau all thoughts or competition or reciprocity were swept away. When his analyst told him he wept at Yad Vashem, Patrick wept with him. Third, in his group analysis with other analysands Patrick experienced his own defensiveness and resistance to change. For example, Patrick saw or rather experienced that in a group of equals he became a silent observer. Stripped of clerical privilege Patrick was forced to converse with men and women not as students but as equals who could more than hold their own with him and were not afraid to correct him. He felt envious of the women who ourished in open conversation and felt fear of the men whose anger ashed for reasons buried in their own past and as yet unanalyzed. Patrick listened more carefully to fellow priests at their dinner conversation, realizing that his fellow priests and he himself were storytellers. Telling a story kept them from any personal self-revelation. Tales of ancient history were often repeated as safer topics then revealing their loneliness, depression or doubt about the value of their common religious enterprise. Good storytellers also wielded the power to determine what topics would be admitted to the conversation and which ones would be dismissed. Patrick saw that some of the clerical conversation that he experienced was competitive to ensure that no one would stand out above the signicant others, such as fellow priests or members of the hierarchy. Men without wives or children often found their identity in the small recognition and promotion that the clerical state afforded. Such men ran the risk of being frozen in an adolescent posture of high school boys with their endless teasing and putting each other down. Although the changes discussed seemed genuine, I was concerned that he was learning to deect anger by pleasing the Jews, pleasing the analyst, pleasing God. Clearly Patrick needed deeper understanding and insight if he were to become anything more than a good boy who pleased everyone out of unconscious fear. We needed to revisit his childhood trauma. He insisted that his mother was a good person, strong and self-giving. He said his siblings felt no such deprivation and they said his feelings toward his mother were preposterous. He wanted to take the blame for his feeling deprived on himself. He believed he was the weakest of his brothers and said if he were just stronger, he would only achieve more, and if he did all this then maybe he too would be loved. At this point my countertransference to Patrick was intense in two ways. First, I wanted to rescue him the way a parent will rush into the ocean to save a drowning child. Second, I was not sure it was in Patricks interest to continue analysis. In his present state, Patrick was a successful teacher and a beloved priest, although with a touch of melancholy and loneliness. The next stage would bring Patrick to confront his darker sense of self and his priesthood.

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Patrick stopped making light of his trauma and accepted the dissociative power of deprivation. Auschwitz was a mirror that brought him to accept his own deprivation and become less dissociated from his own pain. For the rst time, Patrick experienced that he had never grieved for himself. And coming out of his own dissociated condition, he was able to grieve for the victims at Auschwitz. At a deeper and more painful level, Patrick grasped that his maternal deprivation led to a defensive response on his part in which he sacriced his own identity. The integrity of his own self was diminished and replaced by the aggressive demands of his mother. He dissociated himself from his own aggression and embraced his mother to save his life. The most painful realization was yet to come. Patrick had always prided himself that his priesthood had nothing to do with his mother. She had not suggested that he choose this way of religious service. In the end, however, Patrick knew his mother did not have to suggest it. His power of independent choice had long since withered under his anxiety-ridden introjection of his mothers way of life; for example, devoutly Catholic, self-sacricing, and deferential to authority. Having accomplished this much it was a small step for Patrick to see and accept the narcissistic disorder in his priestly personality: his need for admiration, his sense of entitlement, his lack of deep empathy for the feelings of others.

The Case of Winston: (Arnold Wm. Rachman)

The difculties in the case of Winston were connected to the intense personal and interpersonal psychopathology developed from childhood traumas such as being dominated and controlled by his mother, sexual seduction, emotional distance from the father, and social isolation. These traumas encouraged a series of disturbing feelings and thoughts, for example, intense anger, fantasies of murder and dismemberment, paranoid ideation, and social isolation. The analysis began in a traditional way. The rst 4 years of our interaction was characterized by the analysis of dreams, early recollections, fantasies, and transference/ countertransference reactions. In fact, Winston brought in hundreds of dreams for analysis. The analysis of these dreams were greatly aided by his superior intelligence, ability for eidetic imagery, and extensive capacity for analyzing puns, puzzles, anagrams, and symbols. The content of the dreams and the analysis of the associations to them revealed a childhood of severe traumas and the development of a false self. A fundamental maternal trauma occurred during the rst 4 years of his childhood: for example, his mother had sexual contact with him; his mother was intensely manipulative, domineering, and intrusive. After a period of 4 years of analysis, Winston spontaneously expressed a desire to add an active dimension to the analysis. He felt he had gained signicant insight into his basic emotional issues, which were unknown to him before analysis. But, he felt that he needed help taking the next step in the working through process. Specically, he said, Ive analyzed hundreds of dreams from my early childhood experiences and the fantasies I have had through the years. I understood myself better, but I need help to change. A signicant aspect of Winstons psychodynamics was the intensive feelings of powerlessness that developed during early childhood because of maternal seduction, manipulation, dominance, and intrusion. What is more, he was convinced that his mothers strong will and desire to force herself into every cell of my mind and body produced a pathological sense of passivity and defeat. A prototypical experience of passivity and defeat was recalled during the rst stages of analysis. His capacity for eidetic imagery allowed a vivid recall of this event:

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I am sitting in a corner of my playpen, my back to my mother. My mother is looking at me with a gaze only she has. Yes, its like shes trying to control me with her look. She wants me to do what she wants. I am playing with large blocks, making a structure. As soon as I made the block structure she came over and knocked it down. I built the structure two more times. After she knocked down the structure for a third time I crawled into a far corner and rolled up into a ball.

These events became known as the building block trauma. All his adult life he was haunted by this childhood event, which he viewed as a prototype for his mothers domination, control, manipulation, and emotional seduction of him. Our analysis of this prototype event as well as data revealed in dreams and interpersonal experiences reinforced the intense feeling that he was defeated in his pursuit of self-denition and felt his negative material experiences had destroyed his creativity, sapped his capacity to act, and made him powerless. He was desperate for help to release his creative impulses. He longed to become emotionally free to creatively express himself. It should be made clear, at this point, that the individual analysis was successful in uncovering the basic traumas, working out their psychodynamics and beginning the working through process. It was the analysands expressed need for activity and the analysts willingness to empathically attune to this need that helped to develop a period of activity characterized by noninterpretative measures. A Ferenczian view of resistance is seen as an opportunity for empathic understanding and, if necessary, elasticizing the analytic situation (Ferenczi, 1980i). Rather than automatically assuming that a request for activity is a resistance to exploring the unconscious, expressing a desire to act out, or a negative transferential reaction, the analyst explored the need for activity and its meaning for the analysand. Winston was very clear he was very satised with the analysis of dreams, fantasies, and early recollections. In asking for greater activity he was expressing his need to work through his sense of powerlessness forged by maternal control manipulation, seduction, and narcissism. I experienced him as expressing a developmental need for a positive empathic parental gure who could afrm his need for expressing a sense of power. Noninterpretative active measures were employed to meet these needs (Rachman, 1998). I did not suffer a narcissistic wound when Winston wanted activity, nor did I feel it was a criticism of me and my work. It was seen as a way to expand and to jointly improve the clinical boundaries of our therapeutic work to satisfy unfullled developmental needs thwarted by trauma. In fact, one could view the analysts inability to satisfy the need for activity, whether through theoretical prejudice or clinical rigidity, as a sign of a countertransference reaction. The more we analyzed this childhood trauma, the more convinced he became that he needed an active measure in the here-and-now of our analytic relationship to create a reparative therapeutic experience (Rachman, 1998). First, in a series of preparatory sessions, we reviewed his childhood trauma of being thwarted in his playpen by his mothers intrusive behavior. Winston wanted an active measure that would help him release his anger toward his mother and liberate his suppressed creative impulses. We cocreated a reparative therapeutic experience (Rachman, 1998), with the building block trauma as the basic fault experience (Balint, 1968). The following noninterpretative measure was created to address the issue during a time extended individual session:
The lights of the room were darkened. The blinds were drawn. The phone in the ofce was turned off. (Outside stimuli were reduced to a minimum to encourage a focus inward and

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heighten the here-and-how experience). Using large pillows from the ofce sofa a symbolic playpen was created. Winston sat in a corner of the playpen with his back to the analyst. He was given small pillows to use as building blocks. He readily became engrossed in building a structure. He appeared very happy. When the structure was nished the analyst went over and pushed it down.

Winston made some irritated sounds when the structure was toppled. After a moment or two, he resumed building the structure. A moment or two later, the analyst entered the symbolic playpen again knocking down the structure. Then Winston began murmuring to himself. He pulled at his hair and began rocking back and forth. Finally, he assumed a fetal position. Then the encounter was stopped. Directly after this event, we analyzed the experience. Winston became aware of his mothers need to have the emotionally/interpersonal focus be exclusively on her. She was jealous that her son was more interested in building a structure than paying attention to his loving mother. His mothers angry possessiveness led her to destroy his building block structure, an activity that took him away from her. We also discussed the intense feelings of anxiety, dread, and fear of annihilation that the building block measure had aroused in him. As a result of the reenactment, he was frightened he would regress and become so emotionally vulnerable that he would withdraw into social isolation. His fear was transitory, and he did not withdraw. After Winston expressed the anxiety, dread and fear of annihilation stimulated by the noninterpretative measure, the analyst wondered whether his participation as the intrusive mother both added to his anxiety and interfered with his feelings of me as a therapeutic agent. He responded in an interesting way, which seemed to verify the emotional relevance of the noninterpretative measure. He said that once we began the experience he became so emotionally absorbed in it, he felt as if, his mother knocked over the building blocks, not the analyst. When the experience was ended, the analyst allowed for a period when Winston could emotionally return to his natural functioning. When he indicated he was ready, we began the analysis of the experience. Winston indicated that he was able to separate the role playing of the intrusive mother from the ongoing therapeutic functioning of the analyst. Winston reported a dream that literally brought a ray of light into his existence:
I am an architect working on a model of a building that has been commissioned. I am working in my ofce on the top oor of a townhouse which contains a skylight. The light is shinning through the room. I am very happy.

Winston interpreted the dream as meaning the building block encounter had freed up his anger and frustration toward his mother and allowed him creative self-expression. I offered the interpretation that the light had never gone out on his creativity; rather, the light had been dimmed. Winston became eager to immediately translate his newfound feeling of creative potential into action. He saw the architect dream as a desire to fulll a lifetime dream of being an architect. As a rst step toward fullling the dream he enrolled in a draftsman course. Unfortunately, he suffered frustration and severe disappointment. He did not have the skill of coordination necessary to produce the drawings necessary for the course. Once again, he went through a period of depression and withdrawal, rekindling the feeling that he had lost the capacity for creative expression. At this point, Winston interpreted the building block encounter and the architects dream as a momentary ickering of the creative light before it went out for good. He thanked me for the good effort. We spent the next months reanalyzing the original trauma to understand and repair the

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damage it had done. We explored his inability to produce architectural drawing, which may be because of cognitive/eye/hand coordination, rather than a lack of creativity. He consulted a neuropsychologist and conrmed that he had cognitive issues. In addition, I continued to afrm his capacities to be creative in language, fantasy and thought. What is more, I afrmed his creative capacity in cocreating the building block encounter. In a matter of months, after the use of the noninterpretative experience and the subsequent analysis of its effects on his functioning, Winston resurrected an abandoned interest in photography. He became devoted to taking photographs. These photographs expressed his own idiosyncratic preoccupations (Rachman, 2003a). During a 3-year period after the noninterpretative experiences, he received a degree in photography, was part of a photography exhibition, and had his work reviewed in an art journal.

Analysis of Trauma and Reparative Therapeutic Experiences

Our aim has been to explore efcacious ways to use noninterpretative measures to expand the boundaries of the analytic method for treating trauma. When trauma occurs at an early age, it arrests the development of cognitive and verbal interaction and is stored in the body as somatic memory. Noninterpretative measures are an effort to reach the split-off, precognitive and somatic aspects of the trauma. Originally, the tradition of psychoanalysis had been verbal interaction and interpretation of the clinical data. But, since Freuds pioneering work on activity (Freud, 1919 [1918]/1958), and Freuds endorsement of Ferenczis clinical experiments on active analysis (Ferenczi, 1980a, 1980b, 1980c, 1980d, 1980e, 1988), the boundaries of the analytic method have been elasticized (Rachman, 1997, 2003a, 2003b). The present discussion is a further attempt to elasticize the boundaries of analyzing trauma by including data that has been stored in a split-off way not amenable to direct verbal interpretation. Trauma creates a developmental freeze that interferes with the minds capacity to mentalize; that is, create representations that can be stored in language and thus, symbolize concepts for meaning formation. We now have neuroscientic evidence indicating that the trauma is stored in the brain (Allen & Fonagy, 2006). Therefore, these ndings present evidence that trauma can be retrieved (Van der Kolk, 1994). We have tried to demonstrate in the three clinical examples presented a way to integrate noninterpretative measures within the analytic process in order to analyze deep-seated childhood traumas. In the Case of Patrick, Robert Kennedy presented an example of signicant emotional change that occurred outside the consultation session, where the changes were built upon the analytic work of individual analysis. The analysand was emotionally challenged to experience his childhood trauma by going through a rsthand viewing of, and group discussion about, the attempt to annihilate a particular group of people. This immediate experience, which occurred over a period of a week, became an intensive noninterpretative measure that emotionally softened his defenses and opened him up to an empathic response. In fact, he reported being emotionally transformed by the experience. His understanding of himself and others was signicantly changed. The analysand developed insight, empathy, and a capacity for intimacy. In the Case of Denise, Margaret Yard believed that the most salient method to help an individual with severe childhood maternal trauma who lacked the capacity for selfsoothing, object constancy, metabolizing verbal interpretation, and self-reection was to consider a more concrete and literal mode for clinical interaction. Together, analyst and analysand created a way to bury the negative traumatic thoughts and feelings about her

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mother, which were haunting the analysand. The analysand suggested a symbolic funeral, including a cofn, to put to rest the manifestations of her childhood maternal trauma. Of particular importance was Yards receptivity to entering into a joint venture with the analysand so they both created the reparative therapeutic measure. The analysand not only contributed to the technique but also contributed relevant interventions to her trauma. Such interaction extends Ferenczis idea of mutuality (Ferenczi, 1988) into the notion of afrming the psychic wisdom of analysands. Trauma survivors develop an emotional sensitivity to their needs based upon the frustration, abuses, and defects caused by their negative childhood experiences. They develop a psychic wisdom about what has been missing in their development and how these deciencies can be fullled. There are two issues in the analytic encounter relevant to the expression of psychic wisdom. They are: Can the analyst provide an empathic climate that fosters the analysands full disclosure about their needs? Can the analyst respond positively to the analysands stated needs? Psychoanalysis as we have outlined in our introduction has struggled with this issue of accepting the analysands stated needs as real, rather than as resistance or acting out. In Arnold Rachmans Case of Winston, the analysands stated need for greater activity was seen as a response to an unfullled developmental need. Overwhelming maternal intrusion and dominance produced a profound sense of helplessness, a suppression of creativity and an inability to act. A cocreated noninterpretative measure, the building block encounter stimulated a reexperiencing of the material trauma as well as providing a reparative therapeutic experience which aided working through toward the development of a satisfying creative outlet. As a nal note to our discussion, we would like to address the issue of countertransference when employing noninterpretative measures. Deviating from a traditional clinical stance can stimulate countertransference reactions since the analyst is placing him/herself in a more emotional and interpersonal vulnerable stance. In Robert Kennedys Case of Patrick, it was necessary for him to analyze his feelings of inadequacy as an analyst and to accept that the individual treatment could not help Patrick work through his trauma. A real life experience outside the consultation room could become an important vehicle for emotional confrontation and personality change. Margaret Yards Case of Denise, evoked a countertransference reaction of anxiety, dread, and fear during the development of the funeral and burying of the maternal objects. She confronted the emotional origins of this anxiety in her dread about the death of her ailing mother. Burying Denises mother would be akin to prematurely burying her own mother. Arnold Rachmans Case of Winston evoked the issue of control, manipulation, and dominance so prominent an issue in Winstons psychodynamics. Clinical interaction with Winston necessitated an analysis of Rachmans needs for control, manipulation, and dominance as he presented the clinical dimensions of the noninterpretative measure of the building block encounter. When Winston made it clear it was essential that they both needed to cocreate the clinical experience, Rachman became aware of the enactment of maternal control that was evoked in him. All three analytic cases we believe demonstrated the necessity to become exible in theory and technique in dealing with clinical trauma. Noninterpretative measures present this opportunity for exibility and innovation.

References
Allen, J., & Fonagy, P. (Eds.). (2006). Handbook of mentalization-based treatment. New York: John Wiley.

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Bacal, H. A. (1990). The elements of a corrective self-object experience. Psychoanalytic Inquiry, 10, 347372. Bacal, H. A., & Newman, K. M. (1990). Theories of object relations: Bridges to self-psychology. New York: Columbia University Press. Balint, M. (1968). The basic fault: Therapeutic aspects of regression. London: Tavistock and Jaffee. Beebe, B., Lachman, F., & Jaffee, J. (1990). Mother-infant interaction structures and presymbolic self object representation. Psychodynamic Dialogues, 7, 113182. Bowlby, J. (1969). Attachment. New York: Basic Books. Boyer, L. B., & Giovaccini, P. L. (1967). Psychoanalytic treatment of characterological and schizophrenic disorders. New York: Science House. Coltrera, J. T., & Ross, N. C. (1967). Freuds psychoanalytic techniques- from the beginnings to 1923. In B. B. Wolman (Ed.), Psychoanalytic techniques. New York: Basic Books. Eissler, K. R. (1953). The effect of the ego on psychoanalytic technique. Journal of the American Psycho-Analytic Association, 1, 104 143. Ferenczi, S. (1980a). On the technique of psychoanalysis. In J. Rickman (Ed.), Further contributions to the theory and technique of psycho-analysis (pp. 177189). New York: Bruner/Mazel. (Original work published 1919) Ferenczi, S. (1980b). Technical difculties in the analysis of a case of hysteria: Including observations on larval forms of onanism and onanistic equivalents (J. L. Suttie, Trans.). In J. Rickman (Ed.), Further contributions to the theory and technique of psychoanalysis (pp. 189 197). New York: Bruner/Mazel. (Original work published 1919) Ferenczi, S. (1980c). On inuencing of the patient in psycho-analysis (J. I. Suttie, Trans.). In J. Rickman (Ed.), Further contributions to the theory and technique of psychoanalysis (pp. 198 217). New York: Bruner/Mazel. (Original work published 1919) Ferenczi, S. (1980d). The further development of the active therapy in psychoanalysis (J. I. Suttie, Trans.). In J. Rickman (Ed.), Further contributions to the theory and technique of psychoanalysis (pp. 198 217). New York: Bruner/Mazel. (Original work published 1920) Ferenczi, S. (1980e). Psycho-analytical observations on tic (J. I. Suttie, Trans.). In J. Rickman (Ed.), Further contributions to the theory and technique of psychoanalysis (pp. 142174). New York: Bruner/Mazel. (Original work published 1921) Ferenczi, S. (1980f). On forced phantasies: Activity in the association technique (J. I. Suttie, Trans.). In J. Rickman (Ed.), Further contributions to the theory and technique of psychoanalysis (pp. 68 77). New York: Bruner/Mazel. (Original work published 1924) Ferenczi, S. (1980g). Counter-indications to the active psychoanalytic technique (J. I. Suttie, Trans.). In J. Rickman (Ed.), Further contributions to the theory and technique of psychoanalysis (pp. 217230). New York: Bruner/Mazel. (Original work published 1925) Ferenczi, S. (1980h). Psycho-analysis of sexual habits (J. I. Suttie, Trans.). In J. Rickman (Ed.), Further contributions to the theory and technique of psychoanalysis (pp. 259 297). New York: Bruner/Mazel (Original work published 1925). Ferenczi, S. (1980i). The elasticity of psycho-analytic technique (E. Mosbacher, Trans.). In M. Balint (Ed.), Final contributions to the problems and methods of psychoanalysis (pp. 87101). New York: Bruner/Mazel. (Original work published 1928) Ferenczi, S. (1980j). The principle of relaxation and neocatharsis (E. Mosbacher, Trans.). In M. Balint (Ed.), Final contributions to the problems and methods of psychoanalysis (pp. 108 125). New York: Bruner/Mazel. (Original work published 1930) Ferenczi, S. (1980k). Child analysis in the analysis of adults (E. Mosbacher, Trans.). In M. Balint (Ed.), Final contributions to the problems and methods of psychoanalysis (pp. 126 142). New York: Bruner/Mazel. (Original work published 1931) Ferenczi, S. (1980l). Confusion of tongues between adults and the child: The language of tenderness and of passion (E. Mosbacher, Trans.). In M. Balint (Ed.), Final contributions to the problems and methods of psychoanalysis (pp. 156 167). New York: Bruner/Mazel. (Original work published 1933)

NONINTERPRETATIVE MEASURES IN THE ANALYSIS OF TRAUMA

273

Ferenczi, S. (1988). Clinical diary. In J. Dupont (Ed.), The Clinical Diary of Sandor Ferenczi (M. Balint & N. Carday Jackson, Trans.). Cambridge, MA: Harvard University Press. Fiscalini, J. (2006). Principles of co-participant inquiry: An introductory outline with implication for therapeutic action. International Forum of Psychoanalysis, 15, 214 219. Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2001). Affect regulation, mentalization and development of the self. New York: Other Press. Freud, S. (1955). From the history of an infantile neurosis. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 17, pp. 122). London: Hogarth Press. (Original work published 1918) Freud, S. (1958). Lines of advance in psycho-analytic therapy. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 17, pp. 157168). London: Hogarth. (Original work published 1919 [1918]) Little, M. (1981). Transference neurosis and transference psychosis: Toward a basic unity. New York: Aronson Press. Rachman, A. W. (1997). Sandor Ferenczi: The psychotherapist of tenderness and passion. North brook, NJ: Jason Aronson. Rachman, A. W. (1998). Ferenczis relaxation principle and the issue of therapeutic responsiveness. American Journal of Psychoanalysis, 58, 63 81. Rachman, A. W. (2003a). Psychotherapy of difcult cases: Flexibility and responsiveness in contemporary practice. Madison, CT: Psychosocial Press. Rachman, A. W. (2003b). The relational dimension in psychoanalysis. Integrative Therapie, 29, 314, 356 367. Rachman, A. W. (2004). Beyond neutrality: The creative function of analyst self-disclosure in the psychoanalytic situation. In J. Reppen, M. A. Schulman, & J. Tucker (Eds.), Beyond Freud: Postmodern psychoanalysis evaluation. London: The Open Gate Press. Rachman, A. W. (2007). Sandor Ferenczis contributions to the evolution of psychoanalysis. Psychoanalytic Psychology, 24, 74 96. Rachman, A. W. (2009). Sandor Ferenczis analysis with Elizabeth Severn: Origins of the psycho analytic treatment of trauma. Manuscript in preparation. Rachman, A. W., Kennedy, R., & Yard, M. (2005). The role of childhood sexual seduction in the development of an erotic transference: Perversion in the psychoanalytic situation. International Forum of Psychoanalysis, 14, 183187. Rachman, A. W., Kennedy, R., & Yard, M. (2009). The role of childhood seduction in the development of an erotic transference. Psychoanalytic Social Work, 16, 1. Roazen, P. (1975). Freud and his followers. New York: Knopf. Shane, M., & Shane, E. (1996). Self-psychology in search of the optimal: A consideration of optimal responsiveness, optimal provision, optimal gratication and optimal restraint in clinical situations. Progress in Self-Psychology, 12, 3754. Stone, L. (1954). The widening scope of indications for psycho-analysis. Journal of the American Psychoanalytic Association, 2, 567594. Van de Kolk, B. A. (1994). The body keeps the score: Memory and the evolving psychobiology of post-traumatic stress. Harvard Review of Psychiatry, 1, 253265. Winnicott, D. W. (1965). Playing and reality. London: Routledge.