About Your Next Patient: A Response to Anne Erreich

The Two-Track Model of Psychoanalysis

In previous writings (e.g., Levine, 2010, 2012, 2022; Levine, Reed, & Scarfone, 2013), drawing on the work of Freud, Bion, Winnicott, Green, and authors from the Paris psychosomatic school, I formulated a two-track model of psychoanalysis whose aim was to extend the application of psychoanalytic clinical theory, understanding, and practice beyond neurosis to patients and psychic organizations that had previously been thought to lie beyond the limits of psychoanalytic efficacy. In so doing, I questioned the time-honored assumptions that all impulses, actions, somatic discharges, and perhaps even some psychological states possess and reflect a fully saturated, repressed unconscious meaning and that all symptomatology is conflict based.

My reason for doing so was simply that of expediency. I found that either the ego psychologically based assumptions that I had been taught or my ability to master and use them effectively were not sufficient in helping me deal with many of the patients and/or clinical situations I was encountering in my practice. Searching outside the established canon of the American and Boston-based psychoanalysis that I had been exposed to in my training, I found increasing therapeutic success as I developed and integrated other traditions and models into a broadened view. I did not, however, challenge, much less throw away, all of conflict theory and the other extraordinary discoveries made by Freud with regard to dreams, phantasies, neurotic symptoms and organizations, and the dynamic (repressed) unconscious. Instead, I proposed adding a transformational component to Freud’s well-established archeological model, one that I believe Freud’s later writings implied and that he was moving toward, especially after 1920 (Beyond the Pleasure Principle [Freud, 1920]), and I attempted to forge a language for this model by speaking of the unrepressed unconscious and unrepresented states.

With regard to neurosis, the tenets of the archeological model still applied. With neurotic patients and for the neurotic part of the mind—a part that I assume exists in even the most disturbed and psychotic patients—these tenets remain vital and, when faced with a neurotic patient, often prove sufficiently effective with regard to analytic understanding and treatment. But neurotic patients did not constitute the majority of patients who were appearing in my consulting room. In the treatment of borderline and primitive narcissistic patients, traumatized patients, patients with impulse disorders, eating disorders, perversions, psychosomatic symptoms, and so on, the classical tenets and assumptions seemed to sometimes fall short.

In response to the problems that these patients presented, I tried to extend the reach of what was then the dominant, traditional view of psychoanalysis by generating an expanded theory of psychic functioning that took into account the impact and consequences of psychic energies and forces that were not yet bound by, contained in, or linked to already formed ideational meanings. It is in this sense that I referred to them as unrepresented (Levine, 2012). That is, I followed Freud (see the following discussion) in postulating the existence of what I called force without meaning and Bion (e.g., alpha function and container/contained) in theorizing about processes, many of which are intersubjectively derived, by means of which meaning was created.

This elaboration was based in part on a very different reading of Freud and a different set of assumptions about the implication of Freud’s (1923) structural theory than what I had been taught. Although Hartmann and the ego psychologists focused on adaptation and defensive activity—see Erreich’s example of how Arlow and Brenner viewed all physical symptoms and somatic discharge—Green (2005) emphasized that Freud’s (1923) theoretical shift marked a change from a theory centered on psychic contents (ideational representations) to a theory about process and the movements needed to tame the unstructured, not yet represented aspects of the drive—that is, emotion, impulse, and somatic discharge—within the psychic apparatus.

To the eyes of some—and I think Erreich is included among them—my proposed model suggesting that some patients may suffer from not yet qualified and therefore not yet psychologically motivated forces represented a deficit model. Perhaps. But I wonder if conflict should be seen as the shibboleth of psychoanalytic theorization. My inclusion of a possible category of the unformed or not yet formed ineffable was not meant to be taken as an either/or challenge or a replacement of conflict theory.

Theorizing about the movement of not yet contained force, impulse, and energy toward containment in thought and the potentially verbalizable is a natural extension of Freud’s final drive theory and his article on construction (Freud, 1937; Levine, 2022). What it means for our understanding of somatic symptoms, for example, is that although for some patients, somatic discharge might be structured as a primitive organ hysteria that reflected an unconscious symbolic meaning that could be inferred or discovered, for others, somatic discharge is better viewed as an economic overflow phenomenon that has no a priori meaning. Rather than being a consequence and product of repression of the anxiety inducing and unacceptable, the latter is a reflection of what Marty (1980) called operational thinking. ¹

Although operational thinking may be seen from an outsider’s view as a form of self-protection or rigid defensive organization, from the perspective of one’s self, it is closer to a biological tropism than a psychological defensive operation. Marty’s formulation asserts that not every somatic discharge reflects an unconscious, preexisting semiotic or symbolic meaning. In the absence of such meaning, there is a concomitant failure of one’s ability to reduce tension through the elaboration of primary process displacements and linkage via the creation of associative chains of symbolically or semiotically related feelings and ideas. These operative somatic events are not yet symbols, icons, or indices but await assignment and creation of meaning (i.e., linkage to ideational forms and attendant emotions) so that they can become so retrospectively, après coup. As indicated in Winnicott’s theory of development and implied by Bion’s models of projective identification as communication, alpha function, and container/contained, it often takes two minds working in unconscious concert to extract and/or create sense and meaning from raw existential experience. ²

In his 1975 International Journal of Psychoanalysis article, André Green insisted that analytic work with borderline patients required a model whose assumptions differed from those assumed in the treatment of neurosis. ³ However, he never suggested that even the most borderline or psychotic of patients did not also have some neurotic-normal capacity for representational psychic functioning. Nor did he suggest that what I have called “beyond neurosis” psychic functioning was absent from the rest of us. So, too, Bion (1959), who spoke of each of us containing a neurotic/normal and what he called a “psychotic” ⁴ part of our personalities. The implication of each of these authors is that all of us may be seen as having different levels or qualities of psychic organization and that how a given patient presents is a matter of which organization dominates under what circumstances at any given moment of time. Consequently, Erreich’s demonstration of the competence and representational capacity of the infant’s psyche is not at all an argument against there also being unrepresented forces present. ⁵ As we shall see, I think it is pretty clear that unrepresented force without meaning is how Freud thought of the id and probably the drives in their originary state.

According to Green (2005), the major development in Freud’s 1923 revision of theory was the change from the topographic model,

at the centre of which one finds a form of thinking (desire, hope, wish), to another model [the structural model or, as it is called in Europe and Latin America, Freud’s second topography] based on the act (impulse as internal action, automatism, acting). . . . the analyst now not only has to deal with unconscious desire but with the drive itself, whose force (constant pressure) is undoubtedly its principal characteristic, capable of subverting both desire and thinking. (p. 47)

For Green, following Freud, certain drive related movements of what we might call the primordial mind ⁶ (Green, 1998) may not be organized around ideational representations and so may not deserve to be designated as “wish” or “desire.” They should be seen instead as nonspecific sensorial tensions or stimulus overloads in search of reduction via discharge or linkage to an ideational form within which to contain and direct them. He therefore cautions that it can be misleading to “speak of desire . . . [when] it is legitimate to ask . . . if this category is really present, . . . raw and barely nuanced forms [of action], expressions of imperious instinctual demands, throw a doubt over the relevance of this qualification” (Green, 1998, p. 102). Recall here Freud’s (1933) characterization of the id:

the dark, inaccessible part of our personality . . . something that we must approach . . . with analogies: we call it chaos, a cauldron full of seething excitations. . . . It is filled with energy reaching it from the instincts, but it has no organization, produces no collective will, but only a striving to bring about the satisfaction of the instinctual needs subject to the observance of the pleasure principle. . . . Instinctual cathexes seeking discharge—that, in our view, is all there is in the id [italics added]. (pp. 73–74)

Freud further asserted that the quality of the cathexes of the id differ so completely from those of the ego that we cannot speak of or expect to find in the Id “what in the ego we should call an idea” (p. 75). To my mind, this leaves little doubt that he is talking about forces that in their initial state are not yet ideationally linked or represented.

The Clinical Importance of Metapsychology ⁷

What is psychoanalytic theory and why do we bother with it? For clinicians, the answer to this question lies in the problem of what to do with the next patient who comes to see us in our consulting room. How will we make psychoanalytic sense and use of what they say and do and of what we imagine and feel in response? How do we engage our patients in an analytically useful discourse and relationship? How do we communicate with and/or respond to them in ways that we feel might be of interest and use to them in the service of emotional development and psychic growth?

Bion reminds us that psychoanalytic theories are just that: theories. Their truth value, compared with the truths of related sciences and fields and measured outside of their application in the clinical situation, is secondary to their pragmatic value within the process of the cure. In his introduction to Learning From Experience, Bion (1962) wrote, “In psycho-analytic methodology the criterion cannot be whether a particular usage is right or wrong, meaningful or verifiable, but whether it does or does not promote development” (p. iii). He was in effect suggesting a deeply pragmatic vertex for the evaluation and assessment of any psychoanalytic theory. Indeed, it was clinical exigency that led me to attempt to expand psychoanalytic theory in the way that I did. My clinical impression and that of others who have attempted to apply similar models has been that that expansion has proved useful. I have not been concerned with how this expansion fits with the facts, findings, or theories of related disciplines. The problem I have sought to address has been and continues to be how to understand and respond to my next patient.

Erreich questions the two-track model I have proposed on the basis of its neglecting the findings of scholarly work in cognitive psychology and infant developmental research and not being “compatible with clinical or academic research regarding infant representational capacity” (p. 19). I have never sought congruence with the findings of these or other extraclinical, extra-analytic fields. My only concern has been the clinical usefulness of the model I was proposing. In fact, I have even tried to forestall such criticism. In the introduction to our 2013 book, Unrepresented States and the Construction of Meaning, written along with Gail Reed and Dominique Scarfone, I proposed that we limit the term representation in psychoanalytic discourse to a Freud-based psychoanalytic meaning, in the hope of defining and restricting its usage to being a specifically psychoanalytic term of art:

However it is conceptualized psychoanalytically, representation is the culmination of a process through which impulse and content, and in favorable circumstances disguised versions of that part of the content that is unconscious, must all be linked. It is a term with historical roots in Freud’s metapsychology, and its psychoanalytic usage refers back to that tradition and theoretical domain. It should not be confused with the way it or similar terms are used in other disciplines—e.g., child development or neuroscience—nor should references to its absence be misunderstood to necessarily imply the total absence of some kind of registration or inscription in “the being,” i.e., the psyche or the soma, of the individual. (Levine et al., 2013 p. 4)

Although this attempt—some might say a clumsy attempt—at definition was necessary, it was also a move that was not without its risks. Perhaps the term representation has already been so oversaturated with connotations and meanings derived from ordinary usage and other fields that it can never achieve the specificity and status I hoped to give it. Perhaps my model would have received easier acceptance if instead of “the unrepresented” I had spoken about “other levels of representation” that must remain unknowable to us.

Much of what psychoanalysts must deal with and talk about (i.e., psychic reality) is only indirectly discernible, never fully knowable, and can be approached only via intuition and conjecture. As Bion (1970) noted, “The realizations with which a psycho-analyst deals cannot be seen or touched; anxiety has no shape or colour, smell or sound” (p. 7). To add to the complications, there is even a sense that although the words used in our psychoanalytic theories, discussions, and interpretations may seem as if they belong to the language of everyday discourse, “the kind of talking and the kind of thinking that we do in analysis is not ordinary talking, it’s not even about an ordinary subject” (Bion, Supervision A49, quoted in Levine, Brito, & Junqueira, in press).

“As analysts, we have to invent the tools we use, as we are using them. It sounds easy, because it sounds as if we just use the ordinary language. Well, so we do, but it doesn’t mean quite the same ordinary things. That’s the trouble. (Bion, Supervision D2, quoted in Levine et al., in press)

That trouble inheres in both the subject we wish to study and describe—the psyche and psychic reality—and the words with which we must use to try to communicate about it.

Unfortunately, there is a great deal in life and in analysis that is ineffable and unknowable and that evades our comprehension. In his essay on the psychoanalytic frame, Green (1997/2023b) wrote,

The act of verbalization translates all the psychic movements that carry within them something that is not in the nature of speech but that infiltrates it and carves out a path for itself through it. Affect finds a space for expression there. Speech, which is movement, is inhabited by force; thus it cannot be reducing to meaning. (p. 135)

It is for this reason that Green (1997/2023b), probably here influenced by Bion (1962, 1970), argued in favor of metapsychology:

Psychoanalysis . . . has to break with ordinary modes of understanding. . . It is not enough to start from common sense, to make a critique of it and to identify a rational principle in it in terms of unconscious desire. . . . We cannot content ourselves . . . with following common sense, but must make a detour. We cannot be satisfied with a meaning that originates in the emitter and reaches the recipient intact, as traditional theories of communication claim. . . . Another logic is necessary. But how is it to be defined? Are we faced here with an aporia ⁸ at the epistemological level? The domain that is the object of psychoanalysis cannot be approached by the usual instrument of knowledge, namely, by the ego . . . as Freud indicates in his New introductory Lectures on Psychoanalysis: “What little we know of the [the id] is of a negative character and can only be described as a contrast to the ego” (Freud 1933:73). It is a matter of thinking the unthinkable. (p. 134)

And, I would add, a matter of trying to say what was previously unsayable. Unsayable not only because the saying might prove anxiety producing or arouse the censure of one’s superego. This latter possibility, of course, is the formulation of repression and neurotic resistance that is adequately described within Freud’s first topography and remains a possibility. But what if there is not yet anything ideational “there” that is hidden to be discovered? What if there is only a pressure, turbulence or sensorial overload or furor? Only an accretion of stimuli or emotional force awaiting containment in some ideational and therefore potentially speakable form? ⁹

Hence the absolute clinical necessity of metapsychology. As Green (2023a) wrote, in psychoanalysis, “we have placed our bets on myth as a fiction of what is unthinkable by reason alone” (p. 16).

A model that includes the unrepresented and its transformation not only requires analysts to reflect upon the effects of an often enigmatic evolving analytic process. It also requires them to dwell for long periods of time in the realm of ignorance and negative capability, ¹⁰ bearing the anxiety and narcissistic injury of uncertainty as they wait for psychic developments to occur and make themselves known. With regard to the latter, in the first of his Tavistock Seminars, Bion (2005) wrote,

“when we are at a loss we invent something to fill the gap of our ignorance—this vast area of ignorance, of non-knowledge, in which we have to move. The more frightening the gap, the more terrifying it is to realize how utterly ignorant we are of even the most elementary and simplest requirements for survival, the more we are pressed from outside and inside to fill the gap.

. . . in a situation where you feel completely lost, you are thankful to clutch hold of any system, anything whatever that is available on which to build a kind of structure. So from this point of view, it seems to me that we could argue that the whole of psychoanalysis fills a long-felt want by being a vast Dionysiac system; since we don’t know what is there, we invent these theories and build this glorious structure that has not foundation in fact – or the only fact in which it has any foundation is our complete ignorance, our lack of capacity.

However, we hope that it isn’t completely unrelated to fact that psychoanalytic theories would remind you of real life at some point in the same way as a good novel or a good play would remind you how human beings behave. (p. 2)

Reminding us of “how human beings behave” goes beyond demonstrable assertions of “facts” to include and evoke metaphors and the polysemy of language. For example, “she relates to me like she was Cinderella and I was the wicked stepmother”; “his mind is like a hummingbird that can’t settle in any one place.” If a finding in a related field such as neuroscience or the observation of infant development challenges or contradicts a psychoanalytic metapsychological assumption, then the crucial clinical question would be whether changing the analytic theory to fit the finding in the related field adds something to the therapeutic pragmatism of its application and efficacy in the analytic situation. From a pragmatic clinical perspective, a change is warranted only if it leads to something that has new therapeutic value. This has been the justification for my extended discourse on unrepresented states and the vicissitudes of representation.

Freud’s (1937) article “Constructions in Analysis” announced his extraordinary recognition that the patient’s sense of conviction about a presumptive statement can serve the same dynamic role in the process of the cure as the patient’s recall of a memory of a previously repressed, actual childhood traumatic event (see Levine, 2011, 2022). He was in effect implying that sometimes the truth value in psychic reality lies in plausibility rather than veridical fact. Notice that Freud implied “sometimes” and so included both possibilities. What I wish to emphasize is that in relation to the unrepresented, what is seen in retrospect as having emerged may not always be congruent with some preexisting, unacceptable, and therefore hidden actual fact.

Interpretation is often a process that is like a Winnicottian squiggle game played with verbalizations rather than lines. The end-product statement that the analyst pronounces, the interpretation, may be or may allow the patient to spontaneously create a “truth” in the form of a new meaning that captures and says more than the patient could have felt or known on their own or a new metaphor that offers new connections to some things that were previously known but not yet put in contact or connection with each other. It is as if one built a traffic circle that now connects a previously small or unbuilt county road to a number of other highways. Suddenly, there is a potential richness of semiosis and symbolization, associational connection, circulation and exchange, where it had not existed before.

A colleague described a moment in a treatment in which he spontaneously said to an insomniac patient, whose character defenses required him to be self-holding and on guard against the possibility of impingement and intrusion, whose childhood seemed to have required him to be the parent to his mother and to himself, a posture that he could not yet relinquish to her or to others in his adult life: It is as if you wished that I would be at home with you at night to stand watch over you so that you could relax and feel safe enough to allow yourself to let down your guard, stop working so hard at feeling safe and fall asleep. The patient let out a sigh and the atmosphere in the session softened.

Although I suppose it could be possible, one would be hard pressed to say that prior to the moment of interpretation, the patient had an actual wish to be put to bed by the analyst. But this analytic bedtime story hit so many of the right notes for this moment in this patient’s analysis, gave words in an imagined scenario to something that the patient recognized as the kind of longing that if he actually had felt and had it, it would have captured what he felt. It was the kind of experience that “felt so right” to both patient and analyst that we might say that if that wish didn’t exist, it would have had to be invented!

In offering a construction such as this, we must often remain agnostic about whether the interpretation corresponded to an unconscious wish or captured an elusive, not yet represented something that could be spoken of in these terms. What is clear, however, is that it forever more would be linked to the memories of this moment in the analysis, the patient’s relationship to the analyst, and the history of the analytic experience. It is out of this present-day material that the myth Green spoke about is created. It is this myth that can form the patch that can cover the void left by what was once needed in development and might have been but was not offered; a new ideational representation imbued with emotion and available to memory—“I remember the feeling in analysis when my analyst said to me . . .”—that contains and plausibly articulates meaning of an emotional state by giving form, object, aim and meaning to a not yet qualified constellation of forces. This is the kind of clinical relevance that I believe my proposed addition of the transformational model holds, speaks of, and attempts to describe; the metaphor of movement from unrepresented force to ideational representation. As for its nonclinical uses, its relationship to neuroscience, infant observation, and cognitive psychology, I leave that to others.