PHOTOGRAPHS:
A micropsychoanalytic technique applied in psychotherapy*
By Gioia Marzi
Translated by Concetta Violante Rutigliano
(part 1)
October, 20, 2005
(*) (an extract from the paper presented to the National Congress of the Italian Society of Medical Psychotherapy. Biella, 21-23 May 2004)
INTRODUCTION
This work aims at exposing the practice of photo study in psychotherapy and within an institutional ambit, in accordance with the micropsychoanalytic model. Details on this technical device and its insertion in the practice of micropsychoanalysis in itself are widely explained in the works mentioned in the micropsychoanalytic bibliography and particularly in the works by S. Fanti published in the years ’71-’72, and in “Image and photograph“ by N. Peluffo.
The large review on the interest of clinical psychology, psychoanalysis and psychotherapies in photographs is reported in a thorough article by Dr. Stefano Martelli 
, who gives paragraph 9 to micropsychoanalysis.
The author clearly shows how, among the working techniques, the use of images, especially the personal photographs of the patient and of his/her family, is indicated in the development of the numerous schools of psychotherapy.
I want to stress that from the psychoanalytic point of view as well, with Kohut ( 1970 ), photographs have been used in order to facilitate the process of evaluation and diagnosis and explain salient aspects of the patient’s childhood.
In these years Silvio Fanti publishes his first works, in which he explains his way of using photographs by exposing his clinical cases: an accurate technique of the enlargement and description of the visual datum, which, used during a session, forms a part of the associative dynamics, as a specific inductor.
We can deduce from the amount of these works that photography has been considered to be an interesting and useful means in almost every psychotherapeutic approach.
On the other hand I think that many psychotherapists experience the fact that their patients refer to photographs or show them spontaneously: I still remember my youthful astonishment during my first years’ work, when a woman, who needed some help during a serious illness of her mother-in-law’s, brought, the first time we met, a gigantic photo that represented her husband and mother-in-law on her wedding day. She showed it without speaking: in her opinion the bond between them was already eloquent and so was the fierce rivalry that was structured that day. The woman did not understand why she was suffering so much until she worked on her family’s female images and found Oedipus’ main points.
The following case shows the possible resources of transference and how much can filter through photographs even if it is not a psychotherapeutic case following the common criteria of being undertaken by therapists, continuity and session structuring.
JOY
The first news about Carla M. came by chance through personal relations with a law firm to which the father of the girl, who was then 22, had applied. Scotomizing the fact that his daughter was widely of age, he wanted to take legal proceedings against her live-in lover since he thought the young man exerted undue influence over her and seriously limited her individual liberty. During the first phase of consultation, which was completely informal, we limited ourselves to decoding the request and there was not a follow-up to the matter, until two years later when, accompanied by her father, the girl presented herself at the Mental Health Department on the advice of the First Aid which had had to intervene because hysteric symptoms had occurred again. To be short, I will give only the essential news about the girl: she had broken off the preceding love affair and had come back into the bosom of her strict family. She was dominated by a mother figure that suffered from a claustrophobic pathology, tyrannized over by the presence of a handicapped sister, saddened by her eldest sister’s death, at a neonatal age and, last, looked after by her father, whose behaviour was almost acted out by Oedipic dynamics ( the attempt at eliminating his daughter’s partner-rival had been only a little mediated by the request turned into legal terms, which was, after all, a possession claim).
Carla found a husband who was accepted by her family, a good boy, who was a neighbour and who, nevertheless, appeared ( and has afterwards proved to be ) insubstantial and manipulable.
After a first classic period of conflicts with her mother-in-law, the girl showed the first symptoms of conversion, which, as customary, dragged the whole family, involved and collusive, to several medical visits.
The meetings were only 3; moreover a psychodiagnostic battery was done: it confirmed the clinical opinion and the reception diagnosis.
The meetings revealed that the patient had grown up in the shadow of the handicapped sister, perhaps because of her mother’s inability to manage such a frustrating situation, and that she had related her school failures to the presence of this deficient pathology in the family, identifying right with her sister. She reported dispareunia and during the age of puberty had tried to become a nun.
Later she had begun her career as a singer, naming herself Joy and having the approval of her father who acted as her manager. She showed one of her advertising images where she exposed herself sensual, blinking, thin and with a vacant stare. This had been the moment when she had met the partner her father was hostile to.
On the third meeting the patient was calm and serene and had taken no more benzodiazepines prescribed in case of need. Nevertheless, she presented a considerable tumefaction of the left parotid cavity. She reported that a tumour of the parotid had been diagnosed to her and that each doctor consulted had urged her to undergo surgery.
The attitude of indifference confirmed the preceding remarks, but the case had already slipped into the sinkholes of a somatic acting out and no decoding could be tried. I had just begun to know her when the competence of the case seemed to move on to the surgical ambit: I thought it savage to make an all-out attempt of the precocious interpretation and a contact with the surgery ward was then not used. We decided to give up a forced clinical intervention, which is a delicate problem in the psychiatric and psychotherapeutic ambit too.
I met the patient about two years later, in the hospital I was working at, and so I could collect more information on the case: Carla was well, she did not have parotid operation, on the contrary she took her young husband to various medical examinations. She was cheerful and physically sturdier, had also begun singing again, but had had a total makeover: she was no longer blinking and the advertising image she had quickly taken out of her handbag and proudly offered me, portrayed her in proper clothes as it suits an honest girl. But the most enlightening detail was the work done on her name: the young woman bore a new stage-name, which was identical to her therapist’s except for one single letter of her surname, which took nothing from the assonance.
It is clear that the presence of the photographic images is, in this case, rather a proof than a recovery of mnestic fragments utilized during sessions as an associative inductor, as in the classic situation of the use of this technique.
An uncommon proof of the expression of the process of identification, which had allowed the patient’s ego to interiorize some of the elements of the relationship established with the therapist. If we consider that everything had occurred during three meetings mediated by institutions, this process can be considered particularly amazing and the support of healthy elements had helped to establish relationships less difficult and more sticking to reality.
As Peluffo writes in “Image and Photography” ( pages 61 & foll. ) “a name passes on physiognomic information, as drawing, sculpture, photography or other forms of representation do, since libido is invested on the object, whether it is a person, a thing, a word or a situation, which gives life to the object itself “…”A name, as an image, is the interiorized substitute of the relationship with the object”. In this sense the adoption of the therapist’s name as a substitute for the positive transference investment, acted as a support for the young woman’s ego and accompanied her when this casual and lucky observation was possible.
Now as regards our training, it must be clarified once again that the use of photographs is a technical device introduced into the ambit of sessions and is sometimes extremely useful during the associative work.
The photographic material should be given after simple but precise rules: after photograph cataloguing you go on with a first descriptive phase and a second associative one.
The first phase usually takes place at a table and includes:
- the indication of the subjects, place , time and author of a photograph
- a description with the naked eye and with the help of progressive magnifying glasses
- a description of the sections of the image and a careful description of the faces and individual and reciprocal postural aspects represented in the photograph
During the second phase the patient lies on a sofa bed, as during a classic session, and works according to the basic rule of the free associations of ideas.
This technique, which can be defined active, makes the analyst temporarily and partially leave his position of abstinence.
The material evoked should not be roughly traced back to the perceptive datum of the photograph and its details, but will contain the elements involved in the affective tone of that moment of the analytic work and then of transference.
All this must be taken into consideration when such a technique is used: the analytic setting allows the transference analysis, but in psychotherapy there will be more difficulties, especially if in an institutional ambit, as I am about to explain.
For the same reasons the importance of the psychotherapist’s training does not allow the extension of institutional treatment to a whole Service. This is the reason why the number of the cases put on the list of institutional works is limited to the casual presence of a psychotherapist trained for micropsychotherapy.
As regards the concept of “Micropsychotherapy” I shall confine myself to Peluffo’s definition:
“Micropsychotherapy:
1) a period of preliminary treatment that consists of two hours’ meetings
2) the treatment in itself which can be organized as follows:
a) three meetings a week; each meeting is to last two consecutive hours;
b) two meetings a week; each meeting is to last three consecutive hours;
c) two meetings a week; each meeting is to last two consecutive hours;
d) one meeting a week; it is to last three consecutive hours.
The interventions c) and d) are called back-up micropsychotherapy.”.
( For closer examination you can consult Peluffo’s article published in this very review ).
THE USE OF PHOTOGRAPHS WITHIN AN INSTITUTIONAL AMBIT
In the 1980s, in a job done at the University of Besancon, Courtit-Codoni exposed the treatment of hospitalized psychotic patients in accordance with what today we call “integrated model”: which is psychotherapeutic and provides for the use of active techniques and a pharmacologic therapy. On that occasion the photograph study technique following the model of micropsychoanalysis was applied.
From 1989 to 1994 I applied this very model at the Mental Health Department of Frosinone.
I can’t help revealing the difficulties it was necessary to overcome in order to fit such a methodology to the public Health Service, clamped in the vice of a large number of requests, of the seriousness and chronicity of the pathology and of time, always very limited. Yet we managed to assure of the continuity of the meetings ( 1-2 a week ) and guarantee an adequate length ( 30-90 minutes ); the preliminary data of the work were published in the proceedings of the Congress of the Psychiatry Italian Society, in Lazio in 1992.
I am referring to that experience because we tried, among other things, to define some criteria of case reception and aid protocol.
We therefore included:
- subjects who, during the first meetings, had spontaneously referred to some photographic material, apart from the diagnostic orientation;
- subjects who had already been treated by psychotherapists and presented a renewal of their symptomatology;
- resisting subjects;
- borderline cases or emerging psychoses;
- cases where the evoked material was scarce and the influence of the image could represent a perceptive connection with the reality.
The problem of diagnosis may be a limitation of this work from the point of view of the criteria generally shared.
In his speech at the SIPPM National Meeting ( Biella, 21-23 May 2004, proceedings in course of publication ), Prof. Francesco Galli also tackled the diagnostic problem in terms of consistency in the analysis of the therapeutic factors in the main psychotherapeutic policies, without minimizing the narrowness of the obligation to a shared ( see MHD IV ) and necessary but not thorough diagnosis. On this point Peluffo writes that one can try intervening provided that “the soul ( the psyche ) is not dead”; that is to say that the consistent nucleus of the potentiality of attempts has not exhausted its energetic content. When only the vital biological processes remain consistent and nothing more supports the motivation for epistemephilia, there are no possibilities of a psychological intervention of any type. In other words “one can risk a psychotherapeutic intervention towards somebody who makes attempts, although in an uncoordinated and jumbled way, but not towards somebody who is blocked in a pathologic condition where the principle of inertia cannot be changed in any way. The therapist can act as a catalyst of the patient’s attempts and guide them only if such attempts exist”.
I think that the lesson of the renunciation of omnipotence is also the measure of the condition of art.
Now let’s go on with the case selection scheme for the psychotherapeutic work at the DSM.
The photographs were used after a period long enough to allow the therapist and the patient to get to know each other well, as an emotional shock caused by the images had not to be undervalued and in order to prevent the abandonment of the therapy, acting out or psychotic breaking which might require even hospitalization.
However, by carefully sticking to the protocol and by ensuring the regularity of the treatment, such risks were minimal. On the other hand it was not unimportant to reach, through the preverbal connection with the image and through the following verbal working out by means of associations, the reconstruction of the existential material, the mobilization of affection and its reactivation in the ambit of the therapeutic relationship.
The report summarizes the data related to this experience.
The 7 patients who followed this treatment have reached a good stabilization from the point of view of the symptoms brought at the time of reception, and a better compliance with the institution.
In particular the 2 patients suffering from psychosis did not undergo hospitalization during the following 5 years and, although they were hit by more fits, they made use of outpatient treatment as they had become good critics of their conditions.
The data of that experience allowed then to maintain that psychotherapy can allow an acceptable settling, in institution too, and be an easy means of intervention, with the specific technical support of the study of photographic material in accordance with micropsychoanalysis, even though this technique is applied on a small scale.
I should like to briefly expose two cases of schizophrenic psychosis, treated at the MHD in those almost pioneering years and in which it was possible to utilize photographs.
The first case was R., arrived at the MentalHealth Centre when he was 33 and put under observation on the advice of the Drug Addict and Alcoholic Service
The moment of his psychotic breaking had been sensational: loss of job, waste of payment, abandonment of family, several self-destructive acting ( road accidents ). This man was living with delusions of influencing, in which the narcissistic stimuli were translated into statements of omnipotence: “I can control the whole world with my thought and communicate with other planets…..”
A long period ( 8-9 months ) was necessary: the patient was treated with long-acting and weekly control meetings: while his productive symptomatology was disappearing, the patient tended to a withdrawal into himself and to isolation, the contents of the talks were poor and affection was practically inexistent. The only datum that confirmed the importance of the therapeutic relationship was an absolute accuracy and care during the meetings and the regular taking of the medicines.
His photographs stimulated the production of some life material which replaced the silence left by the withdrawal of psychotic ideation, lysed by medicines. Before this the contents had been as follows: “I am a researcher…I always work. I have found out that, through the CNS, I do not fall ill any more: you, too, know that one may never die. I am researching DNA… the brain is already in contact with other brains at birth”: these were interesting contents, but inaccessible to associative work and, above all, absolutely separated from affection.
On the contrary in front of the photographs the tenor of the sessions was different, more faithful to the actual datum of percept: “…I do not approach my sister because there is my father ( and here the Oedipal connotations displaced on the only sister are clearly expressed ); …I do not see my father and mother well … there is something wrong … there is the bedroom behind the shutter … ( he refuses the photograph which, after various digressions about the weather, he spontaneously takes up again ) … I do not know what to say … we are made to be a little disgusted …”.
He tried to put a distance between himself and the photograph even with the royal we, as the phantasm of the primary scene, activated by his parents’ image, reproposed him childhood anxieties in front of the parental sexuality.
After looking at a photograph where he was portrayed as a two-year-old child, the patient took note of his antique pain and its aggressive urge and withdrew from it frightened. The happy memory of his carefree childhood was shattered in front of the reality of the image. On that occasion he had a relapse, characterized by a resumption of psychotic defence, but did not interrupt the meetings and weathered the crisis, also saying he wished to work again with photographs.
Besides an unusual associative fluency, the content of the sessions came to a criticism of the experience of his illness, to affectionate thoughts towards his children, about whom he had never talked before, to autonomous accommodation hunting and to the resumption of a job.
All these elements were the evidence of a considerable improvement of this man’s conditions, steady at 5 years’ lengthwise control.
© Gioia Marzi
