On Agoraphobia

Abstract from: Rivista di Psicoanalisi, Volume XXXVIII - 4 - Ottobre-Dicembre 1982
Edizioni Borla

Original italian version: Sull'Agorafobia

The patient perceived her mother as asexual, lacking communicative potential and full of anger and envy. The ambivalence and death wishes she felt toward her mother - as in Deutsch's agoraphobic patients - compelled her to control the people that appeared to her as maternal substitutes.
I do not know what extremely primitive presentation passed between me and the patient, aside from the contents, the images and the words said and alluded to; but it was as if terribly violent and destructuring affects were released from the presentation and a chain of connected presentations gave way and disintegrated. It was as if the persecutory and indispensable object was externalized, a partner to dialogue with. Indeed, our relationship was improved, and in the transference I became an object more narcissistic than anaclitic.

I recall another case of agoraphobia in which the fatal disease of the patient's mother - whose whole body gradually became paralyzed until only her eyes indicated imperiously what was to be done - was experienced by both of us as the terror of motor and emotional paralysis, felt as a threat and as a projection of one into the other. In that case, too, we were able to share a primitive and paralyzing emotion, a need for control and a rebellion against control, which involved us mutually. The mother was impenetrable for the patient, a tangle of unpredictable passions, in which he was unable to find a place for his own tensions, so that from an early age he had learned to use other available objects. The death wishes toward the mother had always been conscious and verbalized; the father was absent. After his mother's death, the patient was able to separate from his wife and to live alone. In the transference he slowly succeeded in communicating emotions and thoughts to me and thus became more actively mobile of his own accord and began to travel.
In other cases of agoraphobia I have had there was an inability to communicate at deep levels, which did not impede a good or even excellent possibility of communication at more evolved levels.

These were, one could say, relatively successful analysis, aside from that tough nut to crack, the patient's inability to consider himself truly autonomous and differentiated.

Agoraphobia can be associated with the most diverse structures, the most varied psycho-pathological frameworks, but there is always an archaic nucleus that remains embedded, difficult to reach. This nucleus gives rise to an entire corollary of symptoms; thus elevating agoraphobia to the status of a syndrome. The analyst who was most responsible for achieving this classification was Weiss (1966), who studied the problem for fifty years and agreed with Federn that the cause of agoraphobia was to be sought in some deteriorating of the bodily ego's sensory experience of a vast, open space. It seems that later writers treated agoraphobia in more generic terms as phobic anxiety, separation anxiety, or symbiotic neurosis (Rhead 1969), or in terms of fusionality and ambivalence. All this may be a part of the symptoms associated with agoraphobia but, as Weiss himself said, it is secondary to the primitive bodily ego disturbance and may appear in other pathological conditions which do not involve agoraphobia.

Fusionally, for example, has been the subject of recent studies (Pallier, Tagliacozzo et al. 1990) which situate this phenomenon in an extremely precocious phase of development, before the schizoparanoid position. These authors consider a good fusional experience to be necessary for the primitive mother-child relationship, while a "bad" experience of this kind will be at the base of "a violent and possessive projective identification which tends to annul separateness, individuation and separation" (Tagliacozzo). According to Pallier with some patients it is necessary to allow an adhesive transference to develop, thus allowing for a situation of fusion with the analyst and the constitution of a phantasy of "extension of the self".

I believe that in clinical practice it is possible to use different models, which may be complementary, if a particular model seems better suited to solve certain problems, while other models may be more useful to tackle other problems. This corresponds to M. Hesse's theory of models (1966), according to which different theories can be treated as models which may be integrated while avoiding negative analogies, using positive analogies and, most importantly, making use of neutral analogies (to be verified) to extend the theories themselves. What is more, as M. Black has written (1962), scientific theories are subject to continual shifts in meaning, and this meaning is always metaphoric. In Black's view the encounter between the explanans - that which is known and non-problematic - and explanandum - what is unknown and problematic - results in a reshaping of the meaning of both.

It was a case of agoraphobia that, in 1980, offered me the occasion to test a model I had elaborated together with C. Gragnani, like myself member of a research group which also included A.M. Muratori, E. Cargnelutti, and A. Cerletti. Beginning with a basic structuralistic-operational model, agreed upon by all the participants in the group, and drawing on Freudian metapsychology, C. Gragnani and I integrated economic, systemic and information models and advanced the hypothesis that the analytic relationship is grounded in a time-space continuum, in which there are no precise qualities, and therefore no differences. The analytic situation interrupts that continuum, creating a new dimension.
This dimension is a structure-function which evolves out of the two components of the analytic relationship or, more precisely, out of the point-moment of their encounter. This results in a system (of which the analyst and patient are subsystems) which is self-regulating by means of links that allow for differentiation from the external environment, that is, from everything that lies outside the system.
This environment, however, serves as a reservoir for the system from which it draws its supply. If we distinguish the concept of communication - understood as sharing according to the most probable state in conditions of weak organization tending toward Immobility (fusion, symbiosis) from that of information, in which the increase in links leads to increased organization and selective, discriminating activity (Muratori 1981), we must consider these two levels (communication and information) as co-present in the analytic situation and responsible for continual processes of restructuring and destructuring.
According to my model, the transfer of information is tied to boundary processes, which I liken to those that occur in a semi-permeable membrane in which the two sides of the polarized surface represent the poles between which, creating a difference of potential, the passage of matter-energy takes place in the form of information.
The inversion of the polarization may result in a continuous process of structuring and destructuring. Just as we can suppose that this occurs in the primitive formative processes of psychic structure - similarly to Freud's statement about instincts - in a like manner we can suppose that it takes place in the bi-directional exchange between analyst and patient, where information runs over into interpretation. Freud, in fact, regarded instincts as a constant impact force with the consequent need for countercharges to offset free charges, thus raising the threshold of discharge.

This, in my view, is the primitive boundary (between the charge systems and the countercharge systems), where the crossing of the threshold determines the depolarization and the passage of information. The boundary is what makes every process of interaction between parties possible, both within the psychic structure and in the relationship between this structure and what lies outside it.
The boundary is the frontier between different systems that approach one another, and it has the task of delimiting but also of creating and building the systems themselves, for which it ensures processes of exchange.
The boundary processes can be conceived of as organizing factors, in the sense that they contribute to the structuring of systems, as in the case of the primitive psychic organization not only of the ego but also of the id, leading to the constitution of the secondary repression. This may be due to codes, which are formed with the first groove in which, according to Freud, mnemic traces are recorded. These traces are understood as the place in which, with the establishment of identical perceptions, primal experiences are recorded. The successive recordings of these experiences in the preconscious will lead to the organization of recollection and memory (Freud 1895).

The boundary, then, contains codes, that is "mechanisms that enable the transformation between systems linked to a communication hypothesis; though these systems do not guarantee the passage of information, but rather structural coherence" (Eco 1980).
These codes, organizers of affective-ideational representations, can mediate not only communication, but also non-communication. While the secondary system draws energy from the primary system, it discharges into the latter waste products (secondary repression).
The energy resources of the unconscious are increased by the charges of these waste products, which, although bound, can potentially be made present thanks to the tendency of the repressed to become conscious again and thus to tend toward communication, though at times without success. In this way there is an underground flow of non-communicated elements underlying all communication. The sender's message is decoded by the receiver, and this induces a change in both, in a continuous action of feed-back, in which meanings are continually reshaped into variables which are dependent on context. But to retain its integrity the structure must resist, and new countercharges will be mobilized to oppose destructuring, in that every code seeks to block extraneous elements, which it regards as threatening "catastrophe". This opposition is not necessarily radical. The structure may be able to accept new links relative to the other code, as long as they are compatible; this will allow it to effect a transformation while maintaining its own structural coherence.

In the analytic relationship what is not communicated provides a basis for and determines each act of communication-information, while at the same time preserving its distinction from the latter.
This makes it possible for the relationship to structure itself in accordance with the modalities most appropriate to the subsystems of the analytic relationship. In this way the boundary becomes a virtual space which can operate at the various levels involved and include varying contents, thus posing as the locus of interpretation. This occurs only when the structures of the analyst and patient can accept new links compatible with their own code. In the analytic relationship the boundary may operate as a wall, a sort of protective resistance that stimulates the system to close in on itself and contributes toward the isolation of the split parts though it does not protect against intrusion.
At times, the boundary is like a moat which holds a magma of fusionality (in which communication is exasperated) that cannot be verticalized, and which blocks out information. At other times the border is a meeting point where new meanings and meaningful differences are created, a mobile and articulated hinge that joins non-communication and communication.
This is because we can hypothesize the constitution of a third subsystem at the boundary, in addition to that of the analyst and that of the patient. This is to be considered a fixed system, in contrast to the other two, and it is an indispensable reference point with the aim of delimiting, collecting and preserving experiences, and transforming them into information. This system continues to accumulate information up to an optimal level which, once reached, becomes an exponent of the entire relational system, revolutionizing it, introducing asymmetry, bearing sense and meaning through information, and allowing the acceptance of mutual differences and individuation-separation. The boundary, then, becomes an intersystemic system, which while originating from the encounter of the two systems at the same time shapes them.

Returning to agoraphobia, it seems that, leaving aside the various models adopted, there is a widespread opinion among psychoanalysts that this pathology has to do with the constitution of the bodily and mental limits of the ego, that is with levels very near to the biological.

This opinion is also expressed by Battistini and Petronio (1991), who stress the anxieties of the loss of the ego and of the object, the difficulty in establishing a boundary between inside and outside, the scoptophylic aspect, the presence of the feeling of shame (entirely characteristic of the syndrome) together with the role of monarch and slave assumed by the patient, as well as the phobic and/or persecutory attitude toward the external world on the part of one or both of the parents.

These clinical observations are in agreement with my own experience, on the basis of which I would speak not so much of agoraphobia as of phobia of one's own body, experienced as a space whose limits cannot be fixed with respect to external space.
The motor inhibitions, the measurements of space that can be crossed, the paths permitted and those precluded; all this can be read in terms of the inhibition or of the opening of drive itineraries, while the acceptance of one's own container (home, automobile, a place to stay), the intolerance toward this container, and claustrophobia can be understood as attempts to delimit and control one's own bodily space in an effort to establish the optimal dimension to contain the drives and to determine the optimal itineraries of these drives within these limits.
This inner space should also be able to contain compatible external drives, but this would presuppose the existence of an acquired, stable organization, which the agoraphobiac does not feel he possesses. The non-self seems to be represented as an open, unlimited square marked by manifold criss-crosses with intertwining multiple and non-saturable valences.
The dependency of the agoraphobiac is not his subjection to the other as such, since the other is massively denied and incorporated, rendered indistinguishable from the self, a mere enlargement of the representation of one's own vital space. The partner's drives are fought energetically, if they do not coincide with one's own; quite often the partner's personality is annulled and he is emptied to the point of becoming useless. As the other's space coincides with that of the agoraphobic, the dependency is extended to others. It is as if one's own boundary were moved, so as not to come in contact with the boundary of the other and to establish processes of exchange (Giordanelli 1981), but so as to take possession of a territory which enriches it and protects it from possible invasions.

The disturbances of a hypochondriacal nature, which occasionally appear, seem to be manifestations of alterations of the bodily scheme, short-circuited by the intertwining of drives and often loaded with significant symbolic value: a little spot, a boil, an imperfection on the body never noticed before, or even the idea of a possible illness; all these can serve as a pretext for a crisis of anxiety, in which they are interpreted as signs of a deadly threat. Then the symptom loses meaning and everything passes without leaving a trace.
These symptoms generally resemble delusions, partly because they appear so suddenly as a sort of delusional intuition, and this often leads the analyst to suspect that patients are psychotic even if they should not be considered as such. Unlike hypochondriacal symptoms, there are no signs that the organs are experienced as persecutory internal objects, nor do we find the poverty of symbolization typical of the hypochondriac. Indeed, the agoraphobic patient is prepared to accepts symbols and to work through and even overcome the disturbances that result from interpretation.

There are various symptoms that accompany an attack of panic, when the patient finds himself alone; this is when tachycardia, extrasystole, perspiration, vertigo, and the various neurovegetative disturbances express a death anxiety which subsides only in the presence of another person who is able to reassure the patient. It is as if the other allowed him to extend his own vital space, a sort of shifting of the boundary that channels through normal circuits the drives that otherwise would be randomly heaped together and intertwined, threatening explosion and destructuring. At this point the fear of a heart attack or brain haemorrhage disappears, even though the reassuring love object is often inadequate and, as the patients- themselves say, totally incapable of providing help.

It is characteristic of all the agoraphobic patients I have had that they have not accepted their own bodies, One patient spoke of an uneasiness she felt since birth that expressed itself in her dreams as the mark of forceps; another said that he felt that his body was segmented and that he had no perception of his body as a unit; Both the latter patient and another took possession of the idealized body of others through visual and physical contact in an effort to give form to their own bodies, which they always felt as shapeless and inadequate. I have notice that all my agoraphobic patients are unable to experience their bodies as "well built"), and yet they have the desire to exhibit them as a megalomanic manifestation of the self. A feeling of shame is often connected with this desire as well with the tendency to occupy the space belonging to others. Megalomanic aspects are often present, as an expression of a hypothetical limit tending toward the infinity of one's own somatopsychic space, as are aspects of perversion, resulting from an intertwining of drives with aberrant courses in compressed, and thereby distorted, circuits.
It seems to me that results in analysis are inversely proportional to the distance created between the patient and the analyst; the more the relationship tends toward fusion, the more possible it is to obtain a reassuring, defined identity of the pair, in which drive circuits can be kept under control and gradually differentiated.
If, as Freud suggests in Analysis Terminable and Interminable (1937), the success of the analysis depends on the influence of trauma, on the constitutional force of drives and on the alteration of the ego, the trauma can be resolved, but the ego must be able to curb the drives.
Thanks to analytic therapy the ego revises its repressions: some are demolished, others confirmed but restructured with more solid material; thus analysis would allow the correction of the original process of regression, a correction which puts an end "to the dominance of the quantitative factor".

It would be a question, then, of allowing the drives, which are constitutionally strong in these patients, to integrate themselves with those of the analyst, thus making it possible for the patient to have a corrective experience compared with what he experienced with his parents. It would also be necessary to make it possible to repair the damage inflicted on the ego, a damage experienced as biological: the ego, then, requires interventions perceived as concretely restructuring. Only a strong ego is able to manage strong drives, and the analyst, who offers his own ego as an auxiliary, must not let himself be engulfed.
The boundary between the patient's ego and the analyst's ego is indeed difficult, a boundary which tends to coincide at moments of fusion but which is prepared to shift and differentiate itself when the conflicts require that the internal have a power of management and regulation with respect to the external.
In the illustrations I cited at the beginning, the patients were able to communicate those sensations of powerless anger and emotional and motor paralysis which were a reissue of the primitive experiences in the relationship with parental imagoes. In the first case the patient could accept a partial identification with the father, who, while remaining vital, had been previously rejected because of his violence; in the second case it was possible to reject the identification with the mother, whose death was later perceived as a liberation. In both cases the ego was able to test itself by using the analyst's ego as an extension of the patients' force field.
The limits of this field were drawn by the analytical couple, without pointless restrictions, megalomaniacal expansions, or the illegitimate occupation of the space of others.
This delimitation was created from within, as the relationship between the drives and the needs of external reality. These needs were identified as forces with which it was possible to negotiate, accepting those compatible with one's own needs and rejecting those that were incompatible.
This activity was initially carried out between the analyst and the patient on the one hand and the external world on the other, and could gradually take place between the patient and the analyst perceived as non-self, that is, as - entity with its own drives. It was necessary, however, to pass through the preliminary phase of fusion and then submit to a test to determine the analyst's capacity to withstand the impetus of the patient's drives and to survive.

In the two cases I have cited, then, there was a passage - in the first case abrupt and in the second gradual and slow - from a condition of fusionality, with a prevalence of communication over information, to a condition of individuation, with a reshaping of meaning of both the childhood and the analytic experience.
With both patients I reached a point of emotional saturation, evidently related to personal experiences intertwined with the relationship, which led to a crossing of the threshold and a change in the relational system. Personal experiences, relative to one's own identity and history, represent variables in the analyst-patient system, and these variables are functions of the system, which regulates itself as it reacts to external stimuli - that is, environmental stimuli, or those perceived as such - according to the internal stimuli, which determine a spectrum of possible transformations. The system rejects external stimuli that are not compatible with itself, choosing the compatible ones and giving them meaning.
The analyst and patient can perceive movements within the system, such as those of union and separation between parts of subsystems, only as external observers, since an experience, even at the moment in which it is lived, is already interpreted and transformed by conscious thought (Vergine 1981). When the analyst is called on to live such profound and primitive experiences, such as those relative to fusionality, he can say very little about his own experience, which is inextricably bound to that of the other or to what the other represents to him. It is only at the moment of separation that he can attempt to recover his own identity and his own boundaries, fully aware, however, that transformations have taken place in him as well.
The two functions of internal and external observer cannot be reduced one to the other, but may be considered complementary for the purposes of knowledge. The observer that stands outside the system - whether he be analyst or patient - advances theories utilizing models and assesses change on the basis of codified parameters; the meanings that derive from this process are the result of selected pieces of information which discard other information considered to be merely noise, and therefore factors of disturbance and disorder in the system.
On the other hand, for the internal observer - who is the system itself - these factors can be, especially if marked by repetition and redundancy (almost the echo of repetition compulsion), responsible for change, a creative act of the system. This occurs when the disturbing element succeeds (as in Prigogine's gigantic fluctuation (1972)) in imposing itself on the system. In this
case binds, that up to that point had been tight, may loosen and others may form, thus generating a new structure involving events that until that moment could not occur.
In the cases cited it seems that the events that were experienced and remembered in the analytic experience can be considered catalyzers of the change that manifested itself when a series of events took place which had previously been considered impossible.
The constellation of symptoms - a chain of signifiers deriving from the body which used the symbols of a particular language - seemed to alter in response to a change in code, although the old code was forgotten only slowly, like a language which is gradually abandoned in order to adopt another, but which continues to function through particular semantic and syntactic constructions.

This is what occurs not only in cases of agoraphobia but in every successful analysis, and it seems to me that the "impossible profession" of the analyst is to make it possible to understand and speak different languages, which are the expression of a nearly infinite potential for language creation which we draw out of ourselves by communicating with the other.

SUMMARY

The Author derives agoraphobia from an extremely primitive damage of the bodily ego, linked with difficulties in establishing a boundary between the self and the non-self and in delimiting internal space in relation to the originary force of drives. Following a structuralistic and systemic model, the Author suggests that the agoraphobic tends to move his own boundary at the expense of the external world, which is felt as infinite and uncontrollable, engulfing his partners and taking possession of their space. In therapy the Author suggests that the analyst initially offer himself to the patient as an auxiliary ego and permit fusion; subsequently, the analytic pair may be differentiated from the external environment, and finally the patient can be differentiated from the analyst and the patient may acquire autonomy.

BIBLIOGRAFIA

Battistini A., Petronio G.M. (1991). Seminano sull'agorafobia, Seminari Multipli. Bologna, 1991

Black M., (1962), Modelli Archetipi Metafore, Pratiche Editrice, Parma, 1983

Ceruti M., (1986). Il vincolo e la possibilità, Feltrinelli, Milano

Ceruti M., (1989). La danza che crea, Feltrinelli, Milano

Eco U., (1980). Metafora. In Enciclopedia, Einaudi, Torino

Freud S., (1895). Progetto di una psicologia, O.S.F., 2.

Fnud S., (1915), Pulsioni e loro destini, O.S.F., 8.

Freud S. (1937), Analisi terminabile e interminabile, O.S.F., 11

Giordanelli L., Gragnani, C., (1981). Dal non comunicato aIla comunicazione: alcune ipotesi sul cambiamento. In C. Brutti et al. La relazione analitica, Borla, Roma

Giordanelli L., (1986), Scissioni e significato nella "relazione analitica". In C. Traversa (a cura
di), Soggetto relazione trasformazione, Borla, Roma

Giordanelli L., (1988), Sulla tecnica: l'interpretazione come funzione strutturante di spazi relazionali, Riv. Psicoanal., 36, 5-23

Hesse M.B., (1966), Modelli e analogie nella scienza, Feltrinelli, Milano, 1988.

Muratori A.M., (1981), Dal non comunicato alla comunicazione alcune ipotesi sul cambiamento. In C. Brutti et al. La relazione analitica, Borla, Roma

PalIier L., (1990), Fusionalità, agorafobia, claustrofobia e processi schizo-paranoidei. In C. Neri et al., Fusionalità, Borla, Roma

Prigogine I., Nicolis G., Babloyantz A., (1972). Termodinamica dell'evoluzione. In La nuova alleanza, Longanesi, Milano, 1979

Rhead C., (1969), The Role of Pregenital Fixation in Agoraphobia, Int. J. Psycho/Anal, 17, 848-861

Tagliacozzo R., (1990), Angosce fusionali: mondo concreto e mondo pensabile. In C. Neri et al., Fusionalità, Borla, Roma

Vergine A., (1981), Relazione analitica, codice, processo di significazione. In C. Brutti et al., La relazione analitica, Borla, Roma

Weiss E., (1966), La formulazione psicodinamica dell'agorafobia, Psiche, 3, 3-17

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