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Psychoanalysis and Trauma

Howard B. Levine M.D.
Published online: 08 Apr 2014.

To cite this article: Howard B. Levine M.D. (2014) Psychoanalysis and Trauma, Psychoanalytic Inquiry:
A Topical Journal for Mental Health Professionals, 34:3, 214-224, DOI: 10.1080/07351690.2014.889475

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 Psychoanalytic Inquiry, 34:214–224, 2014
Copyright © Melvin Bornstein, Joseph Lichtenberg, Donald Silver
ISSN: 0735-1690 print/1940-9133 online
DOI: 10.1080/07351690.2014.889475

Psychoanalysis and Trauma

Howard B. Levine, M.D.

This article articulates some of the problems that surround the use of the term trauma in
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psychoanalytic theory and suggests that the key element for a theory of pathogenesis and mental
functioning is not the either/or of external versus internal causation or trauma versus drive. Rather,
it is an understanding of whether, or to what extent, the raw data of existential experience is or is not
transformed into psychological experience. From this perspective, trauma is whatever outstrips and
disrupts the psyche’s capacity for representation or mentalization. Absent the potential for mental
representation, these events and phenomena are historical only from an external, third-person per-
spective. Until they are mentalized, they remain locked within an ahistorical, repetitive process as
potentials for action, somatization, and projection.

DIFFICULTIES WITH THE CONCEPT OF TRAUMA

The concept of trauma, so central to Freud’s (1895b) original formulations of hysteria, continues
to occupy a problematic place in psychoanalysis. In a classic article, Baranger, Baranger, and
Mom (1988) carefully explicated multiple and evolving meanings that this term had for Freud,
as he applied it to infantile psychic trauma and the origins of neurosis. Shifts in meaning and
usage of the word continued after Freud, and, in 1967, Anna Freud observed that, as a technical
term in psychoanalysis, trauma was in danger of being emptied of meaning through overuse and
overextension. In the same article, she referred to two different categories of psychopathology:
one caused by trauma and the other due to “pathogenic influences in general” (p. 236). However,
she neither illustrated the difference nor specified the boundary that she felt existed between
them. As a result, she left open the question of what this distinction referred to or if, in fact, we
agree that it even exists.
For Freud, the term trauma was associated with something overwhelming or disorganizing
that was taking place or had already occurred. He stated this most definitively in Beyond the
Pleasure Principle (Freud, 1920) and re-affirmed it in The Ego and the Id (Freud, 1923) and in
his later writings. What remained uncertain, however, was the question of whether, or to what
extent, trauma of some kind lay at the heart of every process that we view as pathogenic. Did
trauma produce a separate category of psychopathology that is different from neurosis, or is the
seeming distinction between the two categories only apparent? Did every neurotic conflict begin,

Howard B. Levine is a member of the faculty and a supervising analyst at the Massachusetts Institute for
Psychoanalysis (MIP), a member of the faculty at the Psychoanalytic Institute of New England East (PINE), and is
in private practice in Brookline, Massachusetts.
 PSYCHOANALYSIS AND TRAUMA 215

for example, with a micro-trauma and is any apparent distinction between the two categories
trauma/conflict simply a matter of the quantity of disorganization produced? (Recall that Freud,
himself, suggested that a kernel of actual neurosis might lie at the heart of every neurotic conflict).
Analytic theories do not always clearly address these questions. Consequently, there may
remain a sense in which, in the minds of many analysts, the effects of trauma are contrasted
with those of neurotic conflict and the two categories of occurrence are assumed to imply two
different realms of psychopathology. The confusion follows, in part, from the line of demarcation
that seems to exist between phenomena that are deemed to occur within versus those that occur
beyond the pleasure principle and in theories, explicit or implicit, conscious or unconscious, that
fail to recognize the continuity that I believe exists between what I have elsewhere described as
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the two tracks of psychoanalysis (Levine, 2010).

Additional confusion about the meaning of the term trauma has arisen from variations
in meaning, connotation, and usage that exist between the domains defined in various
psychoanalytic theories by the pairs internal and external; drive and reality; fantasy and real-
ity; psychic reality and external reality. And a still further difficulty may arise from common
parlance, at least for English speaking analysts. The Oxford English Dictionary (1971) applies
the same word to both the cause and its effects, defining trauma as: “A wound or external bod-
ily injury; also the condition caused by this” (p. 3387). This double referent tends toward an
overinclusive usage, a practice that analysts often follow, when they employ the identical word,
trauma—or its variants, such as traumatic to designate:
• The noxious cause of a complex process;
• The resulting acute, internal state of being injured, helpless, terrified, or overwhelmed;
• The immediate damage inflicted; and/or
• The longer range sequelae that these earlier stages may produce.
The potential difficulties for discourse that can follow from this conflation of meanings are evi-
dent. It is as if an enormous rock fell into a lake, producing a huge splash and ripples, which then
caused long-term ecological damage and the same name was used to describe the rock hitting
the water, the immediate perturbations that it produced, and the eventual ecological changes that
resulted.
Partly in response to this exigency, the psychoanalytic literature has developed various mod-
ifying terms that have attempted to specify and distinguish between different kinds of trauma.
Thus, we speak of adult or childhood trauma, shock trauma and strain trauma (Kris, 1956),
massive psychic trauma (Furst, 1967), cumulative trauma (Khan, 1963), micro-trauma, screen
trauma (Sandler, 1967) and so forth. But even if modifiers always carefully accompany the term
trauma—a solution proposed by Anna Freud (1967)—the problems of usage would still be far
from solved.
Despite the common elements of definition that may attempt to unite disparate phenomena,
such as an overwhelming of the stimulus barrier (Freud, 1920) or the production of a painful or
injurious state of helplessness (Freud, 1926), trauma, per se, is not a monolithic entity. Human
experience, even of the same or similar events—for example, war, genocide, torture, rape, child-
hood sexual abuse, early parental loss, neglect or misattunement, etc.—is individualistic, context
dependent and highly subjective. The forms in which trauma may appear, its impact and its out-
come, are expectably diverse and highly variable. The events, processes, and consequences that
 216 HOWARD B. LEVINE

are referred to as trauma or traumatic are as varied as the ages, developmental levels and mental
capacities of those who are affected and responses to potentially traumatic events are individu-
alized and highly subjective. It, therefore, is confusing—perhaps even impossible—to try to talk
generically about trauma or categorically about any given trauma or class of traumatic events,
as if or with the implication that one was speaking about unitary phenomena with specifiable,
generalizable characteristics.
From a clinical perspective, perhaps the most one can do in talking about categories of trauma
is to discuss the various challenges that a given set of potentially trauma-inducing circumstances
might pose for an individual and then look at each individual’s highly subjective mode of experi-
encing and responding to those challenges. This was the strategy that I employed in earlier studies
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of children of survivors of the Holocaust (Levine, 1982) and adults who were sexually abused as
children (Levine 1990a, 1997).
In considering the final outcome of an individual’s response to a potentially traumatic chal-
lenge, it is often important to assess the response of that individual’s significant social network
and milieu. The latter not only will include their immediate and extended family, but determi-
nants derived from their ethnic, cultural, national religious, and other significant large group
affiliations.1 The final outcome of a given event, whether and in what ways it is experienced as
traumatic, is often significantly influenced by what happens in the posttraumatic period. So much
so, that a colleague, speaking of adults who were sexually abused as children, commented, “We
cannot know whether, in what ways or to what extent a given incident is traumatic until the future
happens!” (Levine, 1997, p. 317). The concept of Nachtraglichkeit (apres-coup) is in order here
(Freud 1895a, 1895b, 1918), linking in a coherent way the possibility of deferred action, the post-
hoc nature of our interpretive predictions and the very workings of the psyche, as it continually
re-interprets memory engrams, some of which may either take on traumatic status or offer ther-
apeutic relief to injurious circumstances through recontextualization. (personal communication,
D. Scarfone 2005).
The use of the term trauma is further confounded by the history of our field and the political
positions and allegiances to which that history predisposes us. Freud’s earliest theory of patho-
genesis (1896a, 1896b) asserted that a childhood seduction, a real, external sexual trauma, lay
behind every adult neurosis. When he (Freud, 1897) realized that many of his patients’ reports of
childhood sexual trauma were actually fantasies,2 he revised his theory and replaced the seduction
hypothesis with a more complex formulation that located the cause of neurosis in psychic, rather
than material (historical) reality. His revised theory focused upon internal conflict generated by
unconscious fantasies and wishes (drive derivatives) and advanced psychoanalysis immeasurably.
Inadvertently, however, it also created a mind-set in which analysts tended to associate trauma
with external reality, as opposed to the internal reality of the drives, their derivatives (unconscious
wishes and fantasies) and the defences they evoked. Because it was the internal factors that were
seen as the crucial determinants of psychic conflict, they tended to be given more credence as

1 See Volkan (1997; 2004) for a description of how large social groups and large group identities may contribute

important components to a given individual’s capacity to respond to potentially traumatic stressors.

2 The extent to which Freud’s early patients actually reported memories of incest and childhood sexual abuse, as

opposed to having these events reconstructed and interpreted to them by Freud, remains an open question. See Levine
(1990b) for a detailed discussion.
 PSYCHOANALYSIS AND TRAUMA 217

causal factors in the production of neurosis. Trauma, now thought of predominantly in terms of
external factors, became increasingly neglected in analytic theories of pathogenesis.3
Social forces affecting psychoanalysis further accentuated this neglect. Particularly in the early
years of our field’s development, analysts tended to see themselves as members of an embattled
profession, struggling mightily against resistances to introduce and then preserve unwelcome
truths (e.g., the ubiquity of infantile sexuality) about the human condition. Given this mind set, it
was almost inevitable that trauma and the external, which were so central to the now discredited
seduction hypothesis, became associated with devalued or heretical formulations of pathogenesis
that then had to be resisted—even rejected—at all costs.
The movement away from the seduction theory and the relative deemphasis of trauma and
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external factors in pathogenesis also had important unintended consequences for psychoanalytic
attitudes toward the historical veracity of memories, dreams, and fantasies of childhood sexual
trauma, each of which tended to be viewed with suspicion. It was as if the newly discov-
ered role of unconscious Oedipal and pre-Oedipal wishes and fantasies in the production of
neurosis had to be protected against backsliding and denial. Thus, reports of—or dreams, fan-
tasies, and associations implying—actual childhood sexual trauma tended to be viewed as false
connections and screens derived from the presumably truer internal factors of drive, wish and
fantasy.
Slowly, over time, these excesses began to be corrected, as psychoanalysts took more careful
account of the degree to which expression of the internal factors (drives and ego capacities) was
governed by and developed within an object relational context. This meant that the actualization
of ego capacities and even the drives (Loewald, 1980) were dependent, in part, upon actual inter-
actions with significant external objects during crucial periods of development and thus subject
to potential influence by trauma. To be sure, psychological experience of these interactions is
complex and reflects, in addition to the actuality of external events, internal conflict, phantasies,
and projections, each of which can significantly influence how external reality is interpreted and
perceived.
For most contemporary psychoanalysts, the dichotomy of internal versus external is viewed
as less rigid and absolute than it historically has been. Today, analysts have increasingly come
to appreciate the extent to which the development of internal factors is heavily dependent upon
events in the external world. In terms of appreciating the role of trauma and the external, this
means that the internal factors are not simply determined by constitutional elements, but are
the products of the encounter of in-born potentials and a mixture of nontraumatic and traumatic
(both microtraumatic and macrotraumatic) interactions with actual objects in the external world.
This shift in perspective has led to, and been accompanied by, an increasing recognition (spelled
out by the Barangers, 1983; and Bion, 1970; Ferro 2002, 2005 among others) of the inherently
dyadic, interactive, and intersubjective (Levine and Friedman, 2000) nature of the psychoanalytic
situation.

3 Rangell (1967) is an exception to this neglect. He begins his comprehensive essay on the metapsychology of psy-

chic trauma by noting that, “The practising psychoanalyst or clinical psychiatrist deals essentially with the results of
traumas . . .” (p. 51).
 218 HOWARD B. LEVINE

TOWARD A UNIFIED VIEW OF EXPERIENCE IN THE CLINICAL SETTING

What I suggest that we should most be concerned with in our consulting rooms is the conscious
and unconscious experience of patient and analyst. Bion (2005) called everything else “hearsay
evidence” (p. 61), indicating that what a patient reported about what went on outside the con-
sulting room or in the past was not as fresh, relevant or immediate as what was happening at
each moment between the pair. The latter experience constitutes a unity, that which is, moment
to moment, for and between each participant in the analytic relationship. Attempts to understand
that unified experience may supersede considerations of the dichotomies inside versus outside or
constitutional versus environmental. Consequently, from the clinical point of view, the key ele-
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ment for a theory of pathogenesis and mental functioning is not the either/or of external versus
internal causation or trauma versus drive. Instead, it is an appreciation of the ways in which the
raw data of existential experience is or is not transformed into psychological experience, no mat-
ter where or from what substrate that data may originate, and then lived out within the immediate
here-and-now of the analytic situation.
No matter one’s past experience, the close emotional encounter between two human beings,
patient and analyst, is apt to be turbulent, disruptive, and disturbing. In every moment, each
individual in the analytic dyad must continually try to cope with an influx of raw, sensual data that
is potentially overwhelming and, if left unmodified, potentially traumatic (Bion, 1970). This data
is the product of phenomena that can originate in either the internal (psyche or soma) or external
world. What is crucial in determining both future psychopathology and therapeutic impact is how
effectively and in what way this raw data is mentalized and represented by the individual and by
the pair. That is, how effectively and to what degree it is transformed into the proto-elements of
thought, assembled into coherent narrative structures, contained by the mind and used to think
thoughts and to dream dreams (see Bion, 1970 and Ferro 2002, 2005).
The capacity to transform the inchoate raw data of experience into psychologically repre-
sentable (mentalizable) elements is a major goal of psychological development, the essence
of successful human mental activity and at the heart of the transformational aims of the
psychoanalytic process (see also Ferro 2002, 2005). From this perspective, what matters is not
where the stimulus (excitation, drive derivative, bodily sensation, fantasy, affect, tragic event,
etc.) originates—inside or outside—but whether, how and to what extent it is processed by the
mind and then how it is or is not used in a creative way in relation to the other.4
The mental processes of which I speak may be carried out alone or with the assistance of exter-
nal objects. Failure to sufficiently do so leads to varying degrees of micro- and macro-traumatic
states that are the precursors and cause of psychopathology. (We might call the more ordinary
of these states the trauma of everyday life). To the extent that one’s metabolic mental processes
are successful, anxiety is kept at the level of the signal. When they are unsuccessful, then the
anxiety signal builds in strength until it crosses a threshold and reaches at least microtraumatic
proportions.
A relative insufficiency of these representational processes can leave one susceptible to micro-
and macrotraumatic states that can be described in economic terms as the overwhelming of the

4 This, of course, also implies the freedom to “not communicate” to preserve one’s integrity and potential for future

creative manifestations (personal communication, D. Scarfone 2005).

 PSYCHOANALYSIS AND TRAUMA 219

individual’s stimulus barrier, ego defensive capabilities, or capacities for emotional homeostasis.
Alternatively, these states may be described in terms of the helplessness that can follow from
being overloaded with pre- and protomental elements that cannot be sufficiently transformed
into the precursors of thought, cannot be contained within the mind, and are fit only for denial,
evacuation, somatization, or characteropathic enactment (Ferro, 2002).
When these states are inadvertently produced or felt to recur for the patient within the setting
of an analytic relationship, when the analytic relationship becomes, in essence. the source of a
potentially traumatizing experience in the transference, then the analyst has the opportunity to act
analytically in the present to help the patient restore emotional equilibrium, understand, and put
into words the sequence of events that brought the relationship to a potentially disruptive head
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and, thereby, serve as a new object in the face of an all too familiar, potentially traumatic inter-
action. The process I am describing was alluded to by Freud (1912) in his papers on technique,
when he said that enemies could not be slain in absentia or in effigy and by Winnicott (1974),
who said that what had once been experienced by the infant in a state of helplessness had to be
reexperienced and worked through in the transference under the aegis of the omnipotence of the
patient’s self.

SUBJECTIVIZATION AND HISTORIZATION

That which earns the designation trauma is that which outstrips and disrupts the psyche’s capac-
ity for representation or mentalization. That which cannot be represented or mentalized—thought
about or contained within the mind—cannot enter into one’s subjectivity or the reflective view of
one’s personal history. Absent the potential for mental representation, these events and phenom-
ena are historical only from an external, third-person perspective. Until they are mentalized, they
remain locked within an ahistorical, repetitive process as potentials for action, somatization, and
projection.
Freud’s (1926) aphorism, “Where id was shall Ego be” (Freud, 1933, p. 80) succinctly
describes this point of view with regard to the drives and the unconscious. Freud saw the “id” as
something alien, within “me” but not yet “mine” (personal communication, D. Scarfone, 2005).
An analogous argument may be made in regard to trauma that arises from external occurrences.
Laub and Auerhahn (1993) described a gradient of mentalization in regard to memories of mas-
sive trauma that ranges from the unrepresented to the fully represented, with various forms in
between. To the extent that traumatic events and the experiences they produce remain unrep-
resented they, too, like the id, exist outside personal history. Achieving representation within
the mind allows experiences and memories of trauma to become subjectified—i.e., to enter the
subjective course of one’s personal history—where they may begin to undergo evolution and
transformation.
But how do we understand the processes that keep one’s experience from becoming rep-
resented, mentalized, subjectified, and part of our personal histories? Roussillon (2011) has
suggested that what we will later describe as trauma, either because it relates to events of a
preverbal period or has been accompanied by a level of anxiety and distress that overwhelms
and disorganizes the regulatory functioning of the ego, is accompanied by a particular form of
splitting that affects subjectivity itself. When faced with the possibility of primitive agonies or
catastrophic dread, the ego may attempt to protect itself by splitting.
 220 HOWARD B. LEVINE

However, unlike the splitting described by Freud (1940), in which “the ego is torn between
two set of mutually incompatible representations” (Rousillon, 2011, p. 13), here, it is subjectivity
itself that is split “into two parts, one of which is represented while the other is impossible to
represent” (Roussillon, 2011, p. 13).
Although registered, the split-off aspect is not psychically represented, does not develop, is
not and does not become associatively connected to other mental elements, and remains outside
the subjective sense of temporality and the self. Although the conditions for the original split are
defensive (self-protective) and, therefore, come under the aegis of the pleasure principle, once the
split is established, that which is split off from subjectivity is beyond the pleasure principle and
comes under the aegis of the compulsion to repeat. Therefore, it may be enacted, but it cannot be
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directly felt or known. It is “foreclosed”, “ejected from the psyche” (McDougall, 1989, p. 102),
cut off from subjectivization, and so not included in symbolic-mediated mental activities such as
temporal ordering, associative chains or symbolic condensations.
These split-off primitive experiences are atemporal and tend to remain current unless and until
they are subsequently reorganized and acquire a temporal ordering that is part of the process of
their becoming subjectivized (Roussillon, 2011).
It is only when the other-subject responds that they will acquire the status of a true (primary) symbolic
message; their value as message, their symbolic potential, depends on that other-subject. If they are
not acknowledged as such, their potential or virtual status as a symbolic message “degenerates” into
something that tends to become de-symbolized. (Roussillon, 2011, pp. 115–116)

That is, primitive experience must be transformed and “translated into [a form that has the poten-
tial for] verbal speech in order to insure continuity in the mind.” (Roussillon, 2011, p. 116). This
was the essence of what Freud described and is consistent with Bion’s (1962) theory of thinking.
When this transformation occurs, “words will begin to be associated with internal states and,
therefore, replace to some extent the narrativity of gestures and of actions of thing-presentations
and affects” (Bion, 1962, p. 116). The latter never fully disappear, but become subsumed in
qualities of speech, such as prosody, tone, rhythm, and intensity of speech, that will provide
emphasis, and embody (literally, as well as figuratively) action and affect beyond symbolical
meaning.

THE CASE OF MRS. E

In the description of Mrs. E, I believe we see an analyst struggling to make sense of how to
understand the positive impact of his treatment, which has no doubt been helpful to a very
traumatized and disturbed patient. As I read the report earlier in this issue, however, I am left
wondering how the author understood and applied his original theory, presumably a version
of classical Freudian theory, before his discovery of Self Psychology and the other contem-
porary trends— “motivational systems theory, . . . infant research, . . . attachment research,
theories of mentalization and affects, neural biology, relational theory, intersubjectivity the-
ory, specificity theory and non linear systems theory” (p. 191)—that he has used to good
effect. Of course, each of these may be helpful to an analyst in working with a severely
traumatized patient, but so would any of the other mainstream psychoanalytic theories—Ego
Psychology, Conflict Theory, Klein, Winnicott, Green, etc. We must remember that it is not
 PSYCHOANALYSIS AND TRAUMA 221

simply a matter of which theory we espouse, but how, or indeed whether, we try to make
use of it in any given instance. Obviously, practitioners have had success, as well as failure,
using many different theories with traumatized patients, sometimes because of and sometimes
despite their theories. Although theories may tell us what we might do with a patient, there are
sometimes great differences in how a theory is applied and, when it comes to practice, ana-
lysts often do what is intuitively necessary despite the precepts of their preferred or chosen
theory.
To assess the application of a given psychoanalytic theory to the treatment of a traumatic
situation, we must have data that can give readers access to what we might call the truth of the
analysis. That is, “not only to the experience that was [reported by and] observed in the patient,
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but to the more inclusive experience that was lived through in the dyad” (Scarfone, 2011, p. 756).
Elements of the latter, particularly those elements that have not yet been metabolized and suffi-
ciently articulated by the pair, will be unconsciously embedded in and embodied by the written
account of the case report. There, they will reside between the lines as it were, awaiting the
potential absorption, recognition, and transformational action of the reader that will lend them
form and will suggest and create their possible meanings. Just as we might say that the patient’s
unconscious and not yet represented elements of psyche are the hidden text of the analysis await-
ing transformation, representation, discovery, and/or creation, so, too, is there a hidden text of
the analytic encounter that is likely to be contained between the lines of a case description.
Unfortunately, the report of E will only allow me to draw the most tentative of conclusions. She
certainly qualifies as a very traumatized patient and her life story—and most likely her engage-
ment in the treatment—has been chaotic and self-destructive. Is the author still reeling from
exposure to that chaos and self-destructiveness? In trying to make sense of how he has helped
her, he keeps returning to the concrete facts of her past and present life, and expressing his dis-
belief that she seemed not to have much in the way of an early good enough object on which to
build a positive transference.

Why some patients with severe deficits . . . improve and others with a seemingly less traumatic past
don’t, is a puzzle that often confounds me. An answer, a piece of that puzzle that is often found is the
following: that there must have been some person, object, or selfobject experience from the past that
the patient had that gave the patient a sense of self that could be characterized as having a feeling of
coherence or wholeness. (p. 191)

He wonders about an older sister, a grandmother, even the father, but to my ear—and forgive me,
for this is a very subjective response to the material—he does not sound convinced that he has
found what he is looking for, but believes must be there.
I question what it means that he has prejudged what will be necessary and gone on in search
of it, rather than just reported what he has found in his work with the patient. What not-yet-
metabolized or articulated aspect of the transference-countertransference might this movement
refer to? Note how often his searches take him away from the immediacy of the here-and-now
of the analytic session, moving the locus of interest into the distant past. In the one session
the author does report, his interpretations keep directing the inquiry and the patient’s attention
to the disappointing objects of the past, rather than wondering if the recollection of these past
disappointments is not a covert reference to what E feels might be going on in the present analytic
relationship.
 222 HOWARD B. LEVINE

In my view, the assumption about the kind of past objects that must be found and the overem-
phasis on past history and the genetic point of view are potentially disruptive to exploring the
immediate experience of the analysis, because instead of opening up one’s mind to see what
might be there, they tend to proscribe what should be there. They are an illustration of what Bion
(1970) warned against when he asserted the value of listening without memory and desire. Are
they also an unconscious identification with a confused and traumatized part of the patient, who
is looking for solidity in the concrete and actual? Does the author’s search for a good enough
object mirror an important internal movement at the core of E’s psychic life? Rather than looking
for what a theory tells us should be there, I would have the author tell us what he found. Then
we can see what various theories have to say about that and decide if they are helpful or perhaps
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need to be altered to fit the facts of the analytic experience.

Although veridical history is, of course, determinative of character, it is only analytically
important in so far as it lives in some specific way in the patient’s mind, soul, and being.
Therefore, at any given analytic moment, the historical truth of how E was related to by par-
ents and siblings may be beside the point, when compared to the psychic reality truth of how
those relationships live on in her mind and are repeated and played out in the transference and
other important current relationships. I think we get a hint of that after E reports her first dream,
then resorts to self-destructive acting out and the author wonders if her acting out indicates that
he, perhaps, missed something. Although being able to have a dream that was not simply evac-
uative reflects a capacity for representation, the fact that the dream and its associations were all
about being out of control and come at a very early point of the analysis (the 32nd session), leads
me to wonder about the absence of any intervention aimed at her possible terror at what it felt
like to be starting analysis or relating to a new object, with all of their potentially disorganizing
effects on her mind.
Similarly, in the session of July 10, although the references to the women leaving the dis-
tressed child with the older man and the memories of the mother to whom she couldn’t get close
and the father who only used his position as headmaster to dominate and control his students,
rather than to help them are presumably historically accurate memories, to my mind, the more
pressing question may be whether they also, at the same time and from another perspective, refer
to something immediate going on within the analytic field. For example, what it may feel like
that day to E when she enters the session and later when she may try without success to feel
closer to the mother-analyst or escape from the analyst-father’s insistence on searching the past
to explain her distress, instead of exploring the present to try to see where she might locate its
origins. From this perspective, might not her complaints about having outgrown her husband also
refer to her sense that she was now ready to deal with a more exploratory and less concrete phase
in her treatment and to the shift in the listening and interpreting stance of her analyst that needed
to take place accordingly?
These are the kind of questions that can only be answered by closer exploration of the ana-
lytic interaction in the context of a fuller description of the moment-to-moment internal shifts
and subjectivity of the analyst. They reflect the complex relationship that I believe exists between
case reporting and the analytic process and the problem of which levels of reality the case report
is meant to convey. Is it the reality of the patient’s past or developmental history? The manifest
exchange that has taken place within the consulting room? The psychic reality of the patient’s
unconscious or the intersubjective psychic reality of the analytic pair to which the analyst’s ana-
lytic listening is supposed to give access? In addition, as I believe we can infer in this instance, the
 PSYCHOANALYSIS AND TRAUMA 223

report may also embody a potential dialogue between the author and his or her analytic theories,
mentors, supervisors, etc.
These are some of the fascinating questions that surround this case report and I am grateful
to Dr. Bodansky for the opportunity he has given us to raise and explore some of these issues that
are so vital to our further understanding of analytic work with traumatized patients.

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