Mentalization And Psychosomatics. Pierre Marty

2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43

We are individuals who are often subject to a certain amount of arousal from our instincts and our drives. Events and situations in which we find ourselves, more or less important, affect our affectivity, and provoke these excitements, which should be given a release or outlet. The main opportunities for exit and discharge are, on the one hand, in mental work to work through felt arousal, on the other hand, in motor skills and sensory, in different ways associated or not associated with mental work. In general, it can be assumed that when the excitement that occurs in us is not discharged or does not find a way out, it accumulates, sooner or later affecting the somatic apparatus in a pathological way. In particular, I will focus on the way out, presented differently for everyone, having considered the dynamics of our mental apparatus in my constant task of working out our arousals. To do this, I will consider, each time briefly, the following topics:

- The concept of mentalization, referring to our representations, to our mental images, as well as to their dynamism.

- Progressive organization of representations during individual development.

- The reason for the fundamental insufficiency of representations and the impossibility of using them, which creates obstacles to mental work.

- The main clinical forms of mentalization, that is, their semiological classification.

- Clarifications needed to better understand the individual economy about behavior and conflict.

- Links between various forms of mentalization and the main processes of somatization.

Mentalization

The concept of mentalization was developed in the 70-75 years [XX century]. Mentalization deals with the parameters of the mental apparatus, which until then were not the subject of special study. These parameters relate to the quantity and quality of mental representations of the individual.

Mental representations form the basis of the mental life of each of us. Usually, during the day, for example, they provide us with what we call phantasms. At night, they [psychic representations] provide the elements for dreams. Representations allow associations of ideas, thoughts, and inner thinking to be carried out. They are also constantly used in our direct or indirect relationships with others.

Thus, I hold in my hands, for example, my handkerchief. I remember that it was given to me by my cousin, who died today. Then I start thinking about the death of this cousin who was courted by his colleagues. I am very grateful to them for their help during his illness. I also think of my family, whom I just saw in the provinces, and I feel a certain guilt, especially because I did not visit this cousin's widow. I didn't have enough time for this. I will definitely do it next summer.

This example seems appropriate because it offers an actual perception that is prolonged through representation, and this representation is linked, through associations of ideas and inner reasoning, full of affectivity, with the past, as well as with the future, which concerns relations with other individuals.

Psychiatrists are well aware of the role of representations, their elementary [constituent] role in hallucinations that directly testify to them, and a more complex role in delusional states, when internal connections between different types of representations, different in time, produce a new organization of the psyche.

Physicians are also able to appreciate the role of representations, for example, when a patient tells them a history of his illness. This story may turn out to be dry, little representative, if only pathological facts and their prescription are taken into account; and, on the contrary, it can be rich when any pathological case (if necessary with the help of a consultant) is associated with affective events of the periods in question.

Mentalization is concerned, therefore, with the quantity and quality of representations in a given individual. This concept, which saw the light of day thanks to French specialists in psychosomatics, who are primarily psychoanalysts, was gradually formulated in the future as a result of their regular meetings (during initial interviews, and in psychotherapy) with numerous somatic patients of various kinds. The characteristics and various defects in the mental functioning of the subjects, in ordinary times, or during somatic illnesses, turned out to be actually different from those that were characteristic of neurotics studied by psychoanalysis.

Mentalization was not the goal of Freud's work, but only to the extent that he was interested in certain pathological organizations that abounded in his time: mental neuroses [psychoneuroses]. In classical mental neuroses, mental representations are quite rich in their ensemble. Their quantity and quality do not therefore attract much attention.

However, without Freud's discoveries and developments regarding mental functioning and without defining its place, and without allocating by him, starting in 1915, the first topic that defines the "preconscious" as the place where exactly representations appear, the concept of mentalization certainly did not appear would.

Progressive organization of representations

Representations consist of recalling primary perceptions, which are imprinted in memory and remain in mnezic traces. The capture of perceptions and their subsequent recall are most often accompanied by pleasant or unpleasant affective tones.

"Preconscious" indicates the place of representations and connections of these representations with each other.

Psychoanalysis deals with representations of things and representations of words.

Representations of things are reminiscent of experienced realities of a sensory-perceptual order. They evoke sensory and perceptual associations, as well as behavioral associations (for example, doing something in a specific order). They can be associated with affects, but in themselves do not correspond to the associations of ideas, and are not capable of mobilization from the mental apparatus.

Representations of words arise from the perception of the speech of others, from the most elementary to the most complex. At the beginning of the sensory order, representations of words are also representations of things. They gradually leave this status of representations of things during individual development.

They are born from communication with the mother, then they support and organize communication with other individuals, gradually allowing communication with themselves: we are talking about internal reflections.

Word representations constitute the basic basis for associations of ideas.

Typically, representations of words are associated with representations of things, and together they form the system of the preconscious.

For example, a certain “doll”, which is initially perceived as a visible and tangible thing for a baby, gradually takes on the affective meaning of “child”, and then, later, for a teenager and for an adult, the metaphorical meaning of “sexual woman”. This whole ensemble is imprinted in the preconsciousness.

You should know that, on the contrary, with possible disorganization of the preconscious, in pathology, the representations of words can be reduced to representations of things, losing most of the affective, symbolic and metaphorical components that they acquired during development.

The word "doll" will then be able to recall only a "child's play" in the given subject.

Night dreams, in general, convey well, at least, the quality of the individual's representations, at the moment. Sometimes these dreams consist only of representations of everyday things, without deviating from the reality of already realized facts or from those that have yet to be realized. They do not at all provide a basis for associations of ideas. Another time, even on the basis of simple images, they are able to open the way for a multitude of associations of ideas overloaded with affects or symbols, then succumbing, outside of their explicit content, to the discovery of their latent content, their real meaning.

I have already spoken several times about the quantity and quality of psychic representations of the preconscious system.

Their number is associated with the accumulation of layers of representations during different periods of individual development, from early childhood and later childhood, primarily. We have seen an example of the accumulation of meanings of the word "doll".

Their preconscious quality is at the same time:

- In the freedom of their memories.

- In the availability, freedom of their connection, when they are remembered, with other representations of the same period (different family circumstances from childhood, in which there was a play with a doll, for example) or from other periods (for example, three consecutive meanings of the word "doll"), the ensemble supplying the richest associations.

- In the constancy of the previous availability; this permanence, however, may be temporarily interrupted or seriously undermined by the avoidance or suppression of representations nevertheless acquired by disorganization of the preconscious system.

Insufficiency and impossibility of using representations

The natural insufficiency of representations finds its roots at the very beginning of the development of the subject.

It stems from:

A - Either from congenital or accidental failure of the child's sensorimotor functions, functions that represent the perceptual basis of representations. For example, due to the presence of vision, hearing or movement problems.

B - Either from the functional failure of the mother of the same order as the previous ones. It can be understood that a mother, more or less deaf, or blind, for example, is not able to provide sufficient communication with her infant or with her young child.

B - Either because of inadequacy or disharmony of the affective support of the child by his mother, and this is a much more frequent case. Here we find many problems that are posed by both somatically sick mothers and mothers suffering from depression, and highly agitated, authoritarian or indifferent, as well as problems that arise in large families in which the mother does not fully cope with her complex function.

In all these cases, at different levels of the progressive development of the infant, then the small child (sensory, motor, affective, verbal) and, finally, in the sector of the organization of representations, there is a shortage, deficit or insufficiency of the acquisition of representations of words associated with affective and symbolic meanings.

This deficiency or insufficiency cannot be corrected spontaneously afterwards. They [deficiencies and deficiencies] are also very difficult to correct, even during the likely specialized types of psychotherapy.

It should be noted that these defects are fundamentally different from those found in oligophrenics. There may be some mental superstructures, sometimes very developed, intellectual for example.

Inaccessibility of acquired representations.

It is about avoiding or suppressing mental representations, phenomena that are sometimes very difficult to distinguish from each other, or about mental disorganization.

Their origin is usually associated with three reasons:

A - We can talk about a particularly sharp or unpleasant affective coloration of some perceptions of early childhood and childhood, which could jeopardize the representations corresponding to these perceptions.

It is not only the representations involved that are subsequently subject to avoidance (one cannot think of this) or suppression, but avoidance and suppression spreads like an oil slick to a whole network of other representations that are affectively related to the previous ones.

In this case, the repression mechanisms (from the preconscious to the unconscious) do not seem to be affected, since the network of affected representations leaves no room for what we call outliers, derivatives of the unconscious in various aspects, because this entire network of these representations may reappear in its entirety under some circumstances … to disappear again later.

B - We can also talk about conflicts that collide representations containing a heavy load, from instincts or from drives, with more or less early mental formations, the order of ideas that have the effect of censorship. The emergence of directly or indirectly erotic and aggressive representations in the system of preconsciousness and in consciousness is first rejected, then they [representations] are suppressed and modified in their nature, under the conditions described by Katrina Para, which I will briefly summarize:

- In the beginning, the ensembles of representations and affects associated with them no longer appear.

- In the subsequent time, at different distances from the previous one, depending on the case, representations may reappear in their elementary descriptive form, but already devoid of those affective meanings that accompanied them at the beginning, that is, without the opportunity to participate in associations of ideas of mental life.

It should be borne in mind that the suppression of psychic representations, as a rule, is added to the suppression of behavior, containing identical charges, on the part of instincts or drives, of an erotic or aggressive nature.

B - Finally, we can talk about mental disorganizations, in which the following pattern is observed: it is known that an excess of arousal always tends to disorganize the functional apparatus that perceives it. This excess of excitement hits the mental apparatus, often at its most developed level, which it has reached, in what is considered the Oedipus organization of the genital stage.

In the best case, under such circumstances, regression is carried out (I will return to this concept when I touch on mentalization and somatization processes) to those systems of life that were previously noted in the evolution of the subject, to systems that are usually called fixation points, and which here give rise to the formation of mental symptomatology, neurotic (oral or anal order, pregenital stages of individual development, for example); at the same time, as a whole, the mental organization in its totality retains its functioning.

In the worst case, when the previous systems of the subject's life were not sufficiently marked, no mental symptomatology can be established, and the mental apparatus itself becomes disorganized (and then it is clear that neurotic mental organization can be a defense system against the likelihood of a more extensive disorganization). The first signs of this disorganization are always difficult to detect, since they are negative and relate to lack, scarcity, they consist of:

- Depression in the literal sense of the word [manifested] by a decrease in pressure, a decrease in vitality, [depression] called essential due to the absence of positive symptoms (absence of mental symptoms in particular).

- Disappearance of the functional meaning of the preconscious. Representations of words, previously capable of participating in the associations of ideas in the psychic life usual for the subject, are no longer encountered.

Thus, through these various processes of avoidance, repression and mental disorganization, the mental apparatus becomes unable to process excitations, which in turn continue to exist and accumulate (the unconscious receives, but no longer transmits). Despite the previous acquisitions of preconsciousness (and, despite the great hope that psychotherapy can give in these cases), we then again find ourselves in the same state of mental functional instability as in the cases of the main types of mental deficiency indicated at the beginning of this paragraph.

The main clinical forms of mentalization

In the clinic of somatic patients, depending on individuals, and for some of them, depending on their life moments, the noted differences are manifested both in terms of the number and in terms of the quality of representations.

A - Sometimes the representations seem to be absent.

Another time they turn out to be reduced in their quantity (numerous perceptions that undoubtedly existed at different times, but did not lead to the appearance of representations) and in their quality (returning to our example, the word "doll" never resembled anything other than a child's play) …

Subjects, thus limited in their ability to think, have no other means (and only when they have the opportunity for this), except for the action expressed in behavior, in order to express the various exogenous and endogenous excitations that life presents to them.

This is how the "behavioral neuroses" could be defined, and, with a lesser quantitative and qualitative degree of poverty of representations, "poorly mentalized neuroses".

We see in these groups subjects representing the lack of development of the preconscious, as well as subjects affected by disorganization of preconsciousness. The differential diagnosis between the two pathogenic formulas is sometimes difficult to establish at the first consultation.

B - I must say a few words now about good mentalization.

It is clearly manifested when individuals constantly have at their disposal a large number of mental representations, interconnected (subordinate to associations of ideas) and enriched during development with numerous affective and symbolic meanings.

This refers to the classic "mental neuroses" [psychoneuroses] identified by Freud, as well as to the "well-mentalized neuroses", whose symptoms, less organized and less supported than in mental neuroses, and also more fragile, turn out to be polymorphic, adding to mental symptoms (obsessive, either anal or phobic order, or oral type), more than in mental neuroses, character traits and behavioral traits.

B - Between the ensemble created, on the one hand, by "poorly mentalized neurotics" and what are "well-mentalized neurotics", on the other hand, there is a third group of individuals, which, due to its numerical value, deserves the greatest attention. This group consists of what we call "neurotics with undefined mentalization." By presenting "good mentalization", individuals seem to be capable of representation and thought. And then, having a "bad mentalization", their representations and thoughts demonstrate depressing scarcity. Their ability to change the quantity and quality of representations is sometimes astonishing.

We meet in this group of subjects who, for a more or less long time, are unable to use the acquired representations, due to the avoidance or suppression of these representations.

Uncertainty about mentalization arises both from the quantitative and qualitative variation of the subject's representations, which the consultant observes directly during the initial interview, and from his sense of similar variations, which could go to extremes, in the subject's previous life (periods of essential depression or indicated repressions [suppression] representations and behavior).

Translated from French by G. David, scientific edition - Cand. honey. Fusu L. I.