International Forum of Psychoanalysis.

2006; 15: 195 200

ORIGINAL ARTICLE

Distinction between mental pain and psychic suffering as separate entities in the patients experience

MANUELA FLEMING
Department of Behavioral Sciences, Abel Salazar Institute for the Biomedical Sciences, University of Porto, Portugal

Abstract Mental pain and psychic suffering are herein defined as two separate concepts in psychoanalysis. The concept of mental pain lies at the core of psychoanalysis; it was introduced by Freud and was further elaborated by a number of investigators, mostly by Bion. Mental pain refers to a pain that the patient reports as being impossible to describe in words, and lacking any associations, whereas psychic suffering can be both named and described by the patient. Mental pain is derived from non-tolerance on the part of the psychic apparatus when it is harmed by very painful emotions. In contrast to psychic suffering, mental pain resists elaboration and transformation by dream-work. How to address and transform the patients mental pain is a major challenge facing the analyst in his clinical work because mental pain may halt or slow the progression of the analytical process. To overcome this hindrance, the work of the analyst is focused on helping patients to modify their mental pain into psychic suffering, that is, to reactivate in the patient the chain of transformations that generates thought. The analyst is also challenged with the mental pain of the patients because he has himself to tolerate the mental patient induced by countertransference. Suggestions for the analyst on how to deal with the mental pain of the patient during psychoanalytic therapy are proposed.

Key words: Alpha function, Wilfred Bion, tolerance, transference, transformation

Introduction Freuds early training in experimental biology and neuroanatomy, prior to his pioneering discoveries on the human mind, probably contributed to his view that psychoanalysis would benefit from using the same discipline of thought that is employed by other sciences. Because a clear definition of concepts is among the foundations of scientific rationale, our aim here is to present the advantages for clinical psychoanalysis that derive from precise definitions of mental pain and psychic suffering. Mental pain and psychic suffering are often employed as synonymous concepts. Instead, the author proposes that they should be seen as separate concepts that refer to different kinds of emotional experience. Clearly, the nature of mental pain has been the subject of research since the very beginning of psychoanalysis, and this concept, although it is seldom referred to as such, has stayed at the core of the analytical theories of Freud, Klein, and Bion. In fact, Freud investigated the genesis and dynamics of

mental pain as part of his work on the relationships between frustration, modification, and thought, and also on how intolerance to frustration is related to escape and non-symbolization. Klein addressed mental pain when she defined the primordial anxieties of the human being, and also the mental structures to face them (paranoid-schizoid and depressive positions). The transformation dynamics of mental pain was described by Bion as part of his theory of thinking, as well as a component of his proposals on emotional links. To discuss mental pain, it is pertinent to present a more detailed description of some significant contributions to this concept. Previous contributions of the author to this subject in articles written in Portuguese will also be recalled (Fleming 2003 a c; Amaral-Dias & Fleming, 1994, 1998; Pinheiro et al., 2001, 2003). In a recent paper of mine published in this journal, I have also considered how the analyst may be harmed by mental pain during his clinical work (Fleming, 2005). A personal

Correspondence: M. Fleming, Department of Behavioral Sciences, ICBAS, Abel Salazar Institute for the Biomedical Sciences, University of Porto, 4099-003 Porto, Portugal. E-mail: [email protected]

(Received 3 May 2005; accepted 12 December 2005)

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M. Fleming the elements of psychoanalysis. Thus, for Bion, mental pain is an element of both mental functioning and personality. Bion related the genesis and dynamics of mental pain with the degree of tolerance/ intolerance of the mind to frustration. For him, the concepts of frustration and pain were similar, and he addressed them with his own theoretical tools, in order to understand how a seemingly unbearable pain is accepted, is elaborated, and acquires meaning in the mind. Bion challenged psychoanalysis with new questions on the nature and dynamics of mental pain. How does the mind that is assaulted by severe mental pain escape from insanity, false statements, or lies? What makes tolerance to mental pain greater or smaller in different individuals and in distinct situations? Bions answers to these questions were clear: tolerance to mental pain is a complex operation that depends on a number of factors at play in the human mind. For instance, it depends on innate dispositions of the mind itself, and on the quality and predominance of the links that relates the self with the object. Bion considered that the mind works as a sort of container allowing painful emotions to be taken in without damage until there is mental space available. Then, painful emotions that are capable of being contained in the mental apparatus will be retained in the mind (by the somatic pathway, through projective identification or other mechanisms), and digested by what Bion called the alpha function of the mind. This function is able to modify the so-called beta elements, which are toxic to the mind, into the alpha elements that are suitable of being thought by the mental apparatus (Bion, 1963). These concepts are present in the container contained model of Bion that was inspired by Melanie Kleins concept of projective identification. The successful transformation of intolerably mental pain into pain that is both tolerable and capable of being accepted by the conscience thus depends on the ability of the mental apparatus to transform painful emotions. According to Bion, this transformation can be done either in the spirit of love (L link), in the spirit of hate (H link), in the spirit of the desire to know (K link) or desire not to know ( K link), and, finally, in the spirit of arrogance, stupidity, or omnipotence. The predominance of hate and envy stimulates the attack of the alpha function. This phenomenon may destroy the rational contact with the self and impair the relationship of the self with live subjects, thus removing from the container its function of cleaning up the toxicity that is caused by being filled up with mental pain. In his model, Bion considered that the capacity of the mental apparatus to handle mental pain depended, most of all, on the early interaction

proposal to distinguish mental pain from psychic suffering will be presented, as well as advantages of considering this distinction in the clinical practice of the analyst. Original concepts of Freud on mental pain Since his early work on psychoanalysis, Freud (1954) [1895]) considered that the first pain that is felt by the newborn is that of the helplessness that the baby feels when he is separated from his mother, that is, the experience of the baby seeing himself in the radical absence of the other. For Freud, helplessness thus emerges as the primordial condition of the human species. To name the non-helpless is to speak of the negative, the primordial negative on which the human mind will be structured. Freud was the first to discover that the primitive psychic apparatus of humans does not have the capacity to think or elaborate pain. After this capacity has been acquired by the mind, Freud (1961, [1911]) proposed that a second mental condition is required to handle mental pain: that of being able to tolerate frustration. He also found that the incapacity to tolerate frustration causes the failure of the symbolic function, and also that of the thinking process. Later on, Freud (1997) [1926]) proposed a distinction between pain and anxiety: pain is thus the actual reaction to loss of object, while anxiety is the reaction to the danger which loss entails and, by a further displacement, a reaction to the danger of the loss of the object itself (p. 417), and mourning occurs under the influence of reality-testing; for the latter function demands categorically from the bereaved person that he should separate himself from the object, since it no longer exists (p. 419). Thus, for Freud, mourning is separated from mental pain in general, since it is a particular kind of loss of an object, that of an object that no longer exists. This clarification of the nature of mental pain led to new challenges. For instance, what are the factors that modulate the reaction of the mind to loss of the object? Does mental pain depend both on the personality features of the patient and on his interaction with the lost object? Bion and the dynamics of mental pain With regards to the dynamics of mental pain, Bions contributions deserve to be singled out. In his book Elements of Psychoanalysis (1963), Bion considered mental pain as a key element in the workings of psychoanalysis. In accordance with Freud, he viewed pain as a constitutive condition of the human psyche: pain can not be absent from the personality (p. 174), and also I will consider pain as one of

Distinction between mental pain and psychic suffering 197 between the child and the maternal object. In addition, it also depended on the quality of the relationships of the self with other objects, that is, on the emotional links that are established by the self with the goal of tolerating the gap that separates the self from the other. Other previous contributions on the specificity of mental pain Several other psychoanalysts have favored the conceptual separation of mental pain from other emotions or feelings. Most of these researchers have accepted the classical Freudian concept of mental pain as a phenomenon that results from a breach in the protective barrier of the ego, and they have also underscored the role of intolerance to (or noncontainment of) painful experiences. Some of these previous contributions on mental pain are briefly revisited. A pioneering interpretation by Weiss (1934) on the genesis of mental pain proposed that mental pain occurs when an injury is located within the ego: the open wound thus produced in the ego just comes to expression as mental pain (p. 12). Weiss was one of the first to call for an urgent need to investigate the different origin of pain (Seelenschmerz ) and suffering (Seelenleid ), and he further suggested, in accordance with Federn (1926), that the former is associated with object cathexes and the latter with narcissistic cathexes. Szasz (1955) saw mental pain as an emotion coming from how the ego relates to the body, in contrast with anxiety, which he considered to be derived from the orientation of the ego toward the object; he viewed. pain as being located at the frontier between ego and body, more specifically as a result of rupture of the ego body integration. More recently, Ramzy and Wallerstein (1958), accepting Freuds definition of mental pain as a breach in the protective barrier of the ego, have proposed that there is an intimate association between primary pain and fear experiences, and the nature and degree of ensuing anxiety phenomena. Both the somatic and mental origins of mental pain were considered by Spiegel (1966), who pointed out that mental pain should be viewed as a specific entity, that is, as different from other painful phenomena, namely anxiety. He added that mental pain is derived from a narcissistic lesion: a damage of the self ascribed to the absence of a constant external object, creating an internal pain stimulus * the constant object presentation (p. 90), whereas anxiety resulted from loss of a transient external need or satisfying object (Spiegel, 1966). Others have stated that mental pain implies diffuse emotional states of an uncomfortable, displeasurable, and distressful nature (Valenstein, 1973, p. 367), or is a sharp, throbbing, somewhat unknowable feeling of despair, longing and psychic helplessness (Akhtar, 2000, p. 231). Valenstein also saw a frontier nature in the concept of mental pain that would be functionally and developmentally located between the biological and psychological domains of the mind. Psychoanalysts of the French school have studied in particular how mental pain relates to pleasure/ displeasure (Unlust ). For instance, Pontalis (1981) proposed a clear distinction between mental pain and displeasure: the former is beyond the pleasure/ displeasure principle, whereas the latter is associated with an experience of disatisfyingness. This author also stressed the nature of painful feelings: where there is pain, it is the absent, lost object that is present (p. 90). Anzieu (1985) found differences between displeasure and mental pain: whereas displeasure does not alter the functions of the self, mental pain causes self dysfunction and attenuation of the frontier between ego mind and ego body, as well as between id, ego, and superego. Pleasure offers the human mind a release from tension and a recovery of balance, whereas pain has an opposite effect; Anzieu wrote that mental pain forces the network of contact barriers, lowers the unleveling between psychic subsystems and has a tendency to spread in all directions, and thus the self does not exist anymore as self (p. 204). These authors have not, however, established clear differences between mental pain and psychic suffering. Distinction between mental pain and psychic suffering The distinction between mental pain and psychic suffering is useful in psychoanalysis and finds its theoretical roots mainly in the work of Bion, namely in the following statement of his: the patients come for treatment, of whom I wish to formulate theories, experience pain but not suffering . . . the intensity of the patients pain contributes to his fear of suffering pain . . . pain is inflicted or accepted but is not suffered, except in the view of the analyst or other observer (Bion, 1970, p. 19). Bion thus considered that mental pain emerges when the patient lacks the capacity to suffer, and suffering is associated with the capacity of the patient for containment and for the mental elaboration of painful emotions. The main goal of this paper is to put forward the psychoanalytic principle that mental pain is clearly distinct from psychic suffering, and that this distinction is of heuristic value in clinical practice. The author thus proposes that mental pain and psychic

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M. Fleming (Lecours & Bouchard, 1997, p. 856). They considered that the levels of emotional tolerance or containment and abstraction are disruptive impulsion, modulated impulsion externalization, appropriation of affective experience, and abstract-reflexive meaning association (p. 857), and also that mentalization absorbs internal as well as external stresses, traumatic excesses and internal pressures by mentally processing their effects on the soma/body and by elaborating these further (p. 857). Marty, de MUzan, and David (1963), and also Luquet (2002), proposed that the channels of expression of the mental elaboration, going from less to more complex levels, are somatic and motor activity, imagery, and verbal expression. Bions conceptual framework is the foundation the proposal given here that mental pain is derived from traumatic experiences (beta elements) that are not suitable for mental elaboration. This lack of elaboration of traumatic experiences has not allowed their construction into the contents and structures of higher level of mental complexity, such as symbolization, appropriation of affective experience, and abstract association; that is, Bions alpha function was not activated, and toxic beta elements remained as such, being expressed as mental pain. In contrast, psychic suffering is the result of a negative experience that has been tolerated by the mind and symbolized by the alpha function of the mental apparatus. Thus, to understand the origin of psychic suffering and mental pain, it is useful to consider that there is a personal threshold for emotional pain in each patient and that this threshold will make a traumatic experience lead to either psychic suffering or mental pain. To consider this idea of a threshold is also to accept a bimodal response of tolerance/intolerance (within the limit/ beyond the limit) to pain by the mind. Clinical illustration Clinical examples are now presented in order to illustrate the expression of psychic suffering and mental pain by patients during psychoanalytic therapy. Maria is a 32-year-old woman; she is single and a psychologist. She describes a suicide attempt when she was a teenager and her parents were getting divorced. She has always lived with her mother. When Maria first came to my office asking for psychoanalytic therapy, she complained of persistent feelings of emptiness and despair. In a therapy session, Maria tells me: today I woke up crying . . . I remembered when I was a baby that there was nobody near my crib . . .

suffering should be used to name distinct emotional experiences of the patient. Psychic suffering is related by the patient to his own self (I suffer), whereas the patient who is under mental pain does not refer it to the self or to the other (i.e. nobody and no event is charged by the patient as being the cause of his mental pain). This implies that psychic suffering is suitable for description in words by the patient, in contrast with mental pain, which is deprived of sense and cannot be explained in any way by the patient to another. In psychic suffering, the patient feels some relief when he talks about his psychic suffering to someone else, namely the analyst, whereas mental pain is not suitable for communication and is beyond pleasure or displeasure. These features indicate that psychic suffering can be elaborated by the patients mental apparatus, for instance through the work of mourning, whereas mental pain resists elaboration by the patients mind. It is plausible to consider that mental pain is an emotional phenomenon located at the frontier between soma and psyche, and is also made up of undefined sensations that the patient is not able to name or describe through words or representations. The above definition of mental pain is in accordance with Freuds views (1997 [1926], p. 417): the only fact that we are certain of is that pain occurs in the first instance and as a regular thing whenever a stimulus which impinges on the periphery breaks through the devices of the protective shield against stimuli and proceeds to act like a continuous instinctual stimulus. Illuminating concepts on the functioning of the human mind were introduced by Bion. Indeed, he proposed the concept of alpha function to name the process of mentalization that digests raw beta elements (which may emerge in the patient as mental pain) into elaborated thoughts (Bion, 1962, 1992). According to Bions followers, for instance Lecours and Bouchard (1997), mental pain would be described as a non-tolerated and non-contained experience that, though mentalised, fails to be elaborated by the psychic apparatus and to progress into symbolization (p. 856). These two authors considered mentalization to be an intrapsychic activity that leads to a transformation and elaboration of experiences into increasingly organized mental phenomena and structures that progress from representation (first step) into symbolization and abstraction; psychic tolerance and containment are central to this progress: elaboration will be seen to progress with an increasing capacity for tolerance, containment and then abstraction

Distinction between mental pain and psychic suffering 199 My mother was living alone because my father was in a Portuguese African colony as a soldier fighting against the liberation army of that colony . . . I remember seeing my mother standing in a dark room and not moving at all . . . I think that my mother was feeling very lonely and afraid that my father would not come back. Then I let myself cry and numerous images of that time came back to me . . . Afterwards, although I was suffering, I stop crying and I felt some relief. This is a clear example of psychic suffering that finds words to express the suffering, and the words chosen by the patient refer to emotions, images, and remembrances. In contrast, I am now presenting a transcription of another session with the same patient. Maria is now silent and I get the intuition that she is revisiting the places of a non-tolerated mental pain and trying to confer emotional meaning to what she calls something (with no name or image associated with this something) that is, according to her words, a something that is always there. Here is the transcription of that incident: Maria: Sometimes I feel that I am under a paralysis, there is a chaos inside me . . . A cold chaos. I do not know what I am feeling then, or why I am having that feeling, I do not relate it with any images or remembrances. It is a white sensation, an icy one . . . I always had this sensation, but there is always a cloud, a mask covering something . . . I feel something . . . A permanent pain that I do not know how to define. I would like you to explain it to me, that thing . . . Analyst: What is the name of that thing? Maria: I do not know its name . . . I just know that it is bad for me . . . A bad thing that is unbearable for me. Analyst [Following my own countertransferential feelings, I then risk suggesting of a name]: Maybe the name of the thing is helplessness. Maria: Yes, helplessness! Like the sensation of seeing me floating in a void. Now I recall that, when my mother played with me and threw me in the air, I felt a great terror because it was as if I was a planet lost in the wide universe, with nobody holding me, with no limits or shapes that would impair me becoming lost in an enormous distance. This transcription illuminates the nature of mental pain that is dominated by silences and an inability to use words or images. It also show that the analysts suggestions may help the patient to transform mental pain into psychic suffering, that is, help the patient to find the words to express what was before a nameless pain and is now a suffering that can be communicated with images and representations. A model of mental pain Freud considered that the functioning of the mental apparatus must bear similarities to that of other biological systems, even though the workings of the mind are operations of great complexity. Thus, he envisaged the response of the mind to external stimuli as obeying thresholds of tolerance. For instance, when the threshold of frustration is overreached, this will result in paralysis of the mental apparatus. According to Bion (1962), paralysis of the mental process derives from damage in the transformational ability of the mind that is expressed by a loss of its capacity to digest beta, unthinkable elements into alpha, constructed ones. This paralysis of alpha function is the result of insufficient tolerance to mental pain. In fact, my clinical experience has shown me that the patients mental pain can only find a container in psychoanalytic holding, that is, in the space/time of a long-term relationship with a reliable and available other, because the analyst will not retaliate or allow himself to be damaged by the destructiveness of the patients mental pain. In these situations, the analytical space is one of contention, mental pain emerging as the not told that aims to be told: the patients long silences express a search without words for a listener with whom to enact or rebuild the genesis of the patients mental pain. Using transference, patients use the analyst to offer themselves anew the opportunity to relive, in a different setting, the trauma that caused their mental pain. Therapy is a work of mutual construction that involves a labor of word-searching and, according to Bion, a betainto-alpha change. Mental pain may be so undifferentiated that is considered by the patient to be located in such a faraway site that the patient denies feeling mental pain, and he may even not allow that the word pain has been said by the analyst, because what can be shared is not the pain, but the defense against it (Anzieu, 1985, p. 204). The analyst often has an intuition of a mental pain that is not referred to at all by the patient. Bion saw psychoanalysis mostly as the development of a container contained relationship that used both transferential and countertransferential mechanisms: the analyst offers his container and alpha function to do the mental digesting of the non-thought contents of the patients mind that are associated with mental pain. Using his alpha

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Fleming M. The mental pain of the psychoanalyst: A personal view. International Forum of Psychoanalysis. 2005;14:69 75. Freud, S. (1954 [1895]). Project for a scientic psychology in the origins of psycho-analysis. London: Imago. Freud, S. (1961 [1911]). Formulations on two principles of mental functioning. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud, SE 12. London: Hogarth Press. Freud, S. (1997 [1926]). Inhibitions, symptoms and anxiety. In Selected writings. New York: W. W. Norton. Lecours S, Bouchard M-A. Dimensions of mentalisation: Outlining levels of psychic transformation. International Journal of Psychoanalysis. 1997;78:855 75. Luquet P. Les niveaux de pense e [The levels of thought]. Paris: PUF; 2002. Marty P, de MUzan M, David C. L?investigation psychosomatique [Psychosomatic Research]. Paris: PUF; 1963. Pinheiro R T, Sousa P L, Horta B L, Silva R A, Souza R M, Fleming M. Cocaine addicts and their families: An empirical study of the process of identication. International Journal of Psychoanalysis. 2001;82:347 60. Pinheiro R T, Amaral K C, Sousa P L R, Horta B L, Silva R A, Fleming M. The relationship of cocaine dependence and parental psychopathology: A case/control study. Canadian Journal of Psychoanalysis. 2003;11:170 84. Pontalis J-B. Frontiers in psychoanalysis: Between the dream and psychic reality. New York: International University Press; 1981. Ramzy I, Wallerstein R. Pain, fear and anxiety: A study in their interrelationships. Psychoanalytic Study of Children. 1958; 13:147 89. Schneider M. La tombe e du jour [Fall of the day]. Paris: Seuil; 1989. Spiegel L A. Affects in relation to self and object. Psychoanalytic Study of Children. 1966;21:69 92. Szasz T. The ego, the body, and pain. Journal of the American Psychoanalytic Association. 1955;3:117 200. Valenstein A F. On attachment to painful feelings and the negative therapeutic reaction. Psychoanalytic Study of Children. 1973;28:365 92. Weiss E. Bodily pain and mental pain. International Journal of Psychoanalysis. 1934;15:1 13.
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function, the analyst will offer back the contents of mental pain to the patient, now in a form that will be tolerable and detoxified of the excess of suffering, thus recreating cognitive, emotional, and affective conditions for the autonomous emotional growth of the patient in search for his inner self. Several issues in clinical psychoanalysis will gain from the use of the concepts presented here of mental pain and psychic suffering. Upon identifying mental pain as a key emotional feature of the patient, the analyst must push the analytical process into a transformation of patients mental pain into new organizing myths, rather than searching for the exact meaning of mental pain. Because the analyst offers himself as a container of the mental pain emotions, he must enhance his threshold of tolerance to mental pain, as was discussed in detail in a recent paper by the current author (Fleming, 2005). The work of the analyst must open up to semiotic dynamics, namely to dream what the patient is not able to dream because of the patients mental pain * the alphadream-work of Bion * to listen to the musical features of the therapeutic setting, and to be able tolerate doubt and uncertainty in a relationship of emotional contention that is dominated by mental pain.

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Author Manuela Fleming, Ph.D., is a Titular Psychoanalyst at the Portuguese Psycho-Analytical Society, and Associate Professor of Psychology at ICBAS, University of Porto, Portugal. She received her rst degree of Psychology at University of Paris. She is senior member, training and control analyst, and has published several chapters and articles in international journals. She has authored seven books, namely Nameless pain: A reection on suffering , recently reviewed in the International Journal of Psychoanalysis (August, 2006).