key: cord-1047730-b3vgzllg
authors: Kirchkheli, Maia
title: Holding and Visceral Attention: Bodily Concentration of an Analyst under COVID‐19 Lockdown
date: 2021-07-05
journal: Br J Psychother
DOI: 10.1111/bjp.12642
sha: f7922ebf9e3cf86539d1af8fe549b45071c80394
doc_id: 1047730
cord_uid: b3vgzllg

This essay emerged from my clinical experience of working psychoanalytically by remote means due to the pandemic of COVID‐19. During analytic listening, in the absence of bodily togetherness and in the presence of heightened anxiety about survival, I turned my attention inwardly towards the interior of my own body and made a spontaneous gesture of doodling. These two moves, mental and bodily, both unintentional and unconventional to my analytic training, restored my psychic aliveness and facilitated the process of analytic holding. I will reflect on this particular experience using Milner's concepts: framed gap and the analyst's concentration of the body, which I further conceptualize as ‘visceral attention’. I consider it as a corporal counterpart of ‘free‐floating attention’. It is my contention that the concept of visceral attention has a wider implication for analytic technique in the ordinary psychoanalytic setting when uncertainty prevails in psychoanalytic treatment and with patients whose predicament is marked by body–mind split. The essay explores an analogy between visceral attention and doodling to hold the analytic process at a non‐verbal level. The blank paper and blank inside of the body stand for the ‘framed gap’, the negative space for a new symbol to emerge.

feels unfamiliar. I stare at the empty couch with an empty chair behind itan absent couple. I see the loss. I am anxious, frightened and overall too agitated for feeling the loss, but I see it out there lying on the couch. It is almost as if there is no time for mourning. It is psychic surviving that I am doing. It is going-on-being that matters (Winnicott, 1956) .

Telecommunication is an inevitable sensorial deprivation and feels like being torn away from an analyst mother's body. You have not entirely lost her, there is a voice. You know she is alive but you do not know when the two of you will be reunited. There is a traumatic rupture of the illusion of union. The physicality of the illusory space has been lost and sound becomes the only envelope to hold the dyad. But there are many other sounds: technical, human, animal that interfere with the line. Yet silence is also feared: is the other still there? This coupled fear of intrusion and absence feels too noisy and too silent almost at once. Parsons (1999) wrote about the need for the negation of ordinary reality, for psychic reality to be allowed in the analytic session. We are in a situation when disengagement from external reality equates with denial. If we stay in touch with it, external reality takes over. I can tell you how it feels: it is too real to be real. It is surreal. I stopped dreaming at night. Psychoanalytically speaking I could not represent this experience because of the loss of the intermediate space between inner and outer from which creativity and imagination derive and where meanings are created (Winnicott, 1971) . There is no overlap of the two but disconcerting fusion. What happens when this is a state of mind of the analyst?

I was sitting at my desk on an audio call with my patient. Before I knew it, I reached for a pen and began to doodle. My hand drew lines while my mind followed my patient's anxious discourse. Doodling has become a part of my listening, something that I usually do when being with myself. Now whenever my hand is searching for a pen, I just surrender to it. I pay hardly any attention to what I am doodling. What matters is that somehow this automatic activity helps me to focus more fully on my experience with patients. I have realized, however paradoxical it may seem, that doodling in the process of listening enhances my psychic receptivity and availability. VIRTUAL ANALYTIC ENCOUNTERS Mira 2 dreamt that she was being chased and beheaded: 'now, it's only our heads that could meet', she tells me; a disembodied encounter. Her unconscious is also saying that the traumatic separation of our bodies leads to a loss of her link with her own body. A psyche-soma rupture within herself. She has a developmental need to be in my bodily presence in order to be in-dwelling in her own soma (Winnicott, 1949) . It is indeed the body that became the principal character in dreams, in my view, as a response to the premature loss of the maternal body. The loss of the physicality of the analytic space has exposed the fragility of mental space.

Amadea has recurrent dreams of being cut open and left with her insides exposed. She was trying to stitch her own tummy.

How to stitch the rupture? How to repair the loss of the holding frame? I wonder. The weekends have become unbearable and a source of anguish. P: I don't know how to plug this void.

She is right. It is not the broken frame that we need to repair. For her the room represented my body that she would enter and feel safe. She does not yet have a psychic awareness of boundaries that hold her. She wants to get back into my body. It was the emergency C section. She was not ready to come out, to be born. She did not initiate the separation. Amadea is in agony as she feels she is falling forever in this void. My voice is the only proof of my existence and therefore of her existence.

The long silence on the phone lacks substance. I don't have non-verbal cues to gather the affective communication. At times I draw on my intuitive knowledge of the patient. P: It is so different to be silent now. I feel abandoned, left on my own.

Amadea draws my attention to a new element of the experience that needs to be accepted and acknowledged. Her non-verbal presence cannot be the same. It does not feel the same because we are not in the same space. I feel anxious and wonder how to hold her without using too many words that would serve to reassure, to negate the silence rather than transform it into meaning. At times of prolonged silence when it feels I am too deaf to hear I notice that it has become a part of my technique to tell her that it is not clear to me where she is at. In part, it contains mutual anxiety. 'You have not given up on me, you are still looking for me' responds the patient. It also has a more anxious connotation: 'you are not dead'.

This time, during the long and anxious silence, I turn my attention towards the interior of my body. I hear my racing heartbeat, something is moving, curling up inside me; it is tight. Then it all unfolds, and my lungs feel free. I get hold of the baby within myself. The baby screams! I feel it is an impossible task to distinguish whose scream it is, mine or my patient's. Instead, I draw my attention to imaginative holding. I surround my arms around the internal baby and stay still. Next, I remember Edvard Munch's painting of a screaming mana silent scream. Then, I hear myself saying:

A: The silence that screams.

There is an immediate affective response: P: I am just remembering my favourite object on your bookshelf. It is a deer and her baby feeding on her.

My gaze has found the dyad on the shelf that Amadea is missing. Now imaginatively she is here with me in the consulting room.

A: They are attached by a piece of land. They constitute an inseparable unit. P: They are? I always thought that they were separate, and you put them together, so that she could be fed.

The poignant recognition of the work my mind has done. The feeding couple has been reconstructed and with it the representational capacity has been recovered. I feel warmth within my body.

Philip is talking to me over the phone. There is a noise down the line. He pauses and says: P: It is a helicopter.

A: I can hear. P: You do? Through the phone?

A: From the sky. P: We are under the same sky! The illusion of being in the same space has been recreated if only for an instant. The joy of proximity! This exchange feels profound against the background of the loss of the couch, the mother's lap (Winnicott, 1949) . Philip, who speaks to me from his car, drives around his neighbourhood to try to park in the same spot. Today he feels dislodged: even the parking space cannot be kept! This time there was another car parked there and he was raging. Next thing he complains about is the pain in his back. His back is missing the couch. He insists that he just wants to stretch his body. I imagine a baby slowly waking up in his cot in the presence of the mother.

'Under the same sky' or 'on a piece of land'what my patients have been trying to recreate is the common holding space that allowed some degree of illusion of physical togetherness to be established. Winnicott used the notion of holding to conceptualize the importance of maternal arms. Mother through holding gives her baby bodily warmth and framing structure, while imaginatively perceiving him/her in her mind. At this early stage of human development, mother's psycho-somatic presence is fundamental for her infant's survival both physical and psychic. The concept of holding reflects this dual property, which has transpired to be so relevant during the loss of physical union. I noticed that the need for holding was especially acutely expressed by regressed patients who were psychically fused with me, re-living this early phase of psychic development and ordinarily needed silent presence in the room. It was the physicality of the room with its sensual dimension of smell, temperature, light, small objects, that constituted the essential element of analytic experience. During this phase of analysis, an analyst is the background and the room is the foreground. This mode of being is necessary to be worked through in its own time, before such patients can gradually move towards more separate psychic existence. This is crucial for the development of mental space that can survive separate bodily existence.

One of my patients told me: 'if you are human, you must be affected too!' I would like to reflect here on how I have been affected and what I have learnt in this mutually disturbing situation marked with the loss of the shared room in the context of existential uncertainty.

Milner wrote about the importance of the gap that is framed (Milner, 1952) . The frame marks off outside from inside, and what is inside needs to be taken as a metaphor. Analytic sessions are framed in space and in time. During the period of working by remote means, what has been lost is the spatial frame and we rely on the temporal one. We cannot be together in the same space, but we can be together in the same time-gap. Thus, the nature of holding has changed. The room has been replaced by the technology. What was around us, is now between us. There was an abrupt shift in which the physicality of togetherness was lost. Sound is now only perceptual real, the only flesh linking an analytic dyad. Hearing becomes hyperactive like a hypertrophied organ to compensate for the lack. The question I pose is: how is this change in frame and in perceptual impoverishment affecting my analytic listening?

First of all, I am both wary and weary of hyperactive listening. It is anxious and results in acoustic overload that is exhausting. I have found myself unusually tired and frustrated. Only when I began to direct my listening to the interiority of my bodily space did I recover something essential to my analytic work. It felt almost like re-finding my own body, perceptually recovering its depth.

VISCERAL ATTENTION Milner (1960) spells out what I am grappling with in her paper 'The concentration of the body' (1960):

What I mean by body attention or body concentration in the analyst is this: it is a state in which the direct proprioceptive body-self awareness, which I suppose is best called the body presentation, as distinct from the body representation or body image, becomes the foreground of one's consciousness rather than the pre-conscious background. As I see it, this kind of attention in the analyst differs from the free-floating kind that, when I first practiced as an analyst, was the only kind I thought appropriate and which most neurotics seemed able to manage with. It differs because it is not 'in the air'; it deliberately attends to sinking itself down into a total internal body awareness, not seeking at all for correct interpretations, in fact not looking for ideas at allalthough interpretations may emerge from this state spontaneously (pp. 239-40 my emphasis).

Milner understood the importance of this bodily attention in particular when working with patients suffering from early maternal deficiencies. These patients lack a sense of in-dwelling in their own body and she observed that they need 'to achieve an intuitive awareness of an unanxious mother figure contentedly anchored in her own body and in happy communion with it' (p. 240).

Regressed patients benefit more from this kind of state in the analyst which must mainly be transmitted on unconscious to unconscious level than from verbal communication. As Milner describes, it is a total letting go of thinking in ideas, to achieve unmindfulness. The object of this attention is: 'one's own internal body perception, [that] is inarticulate, dark and undifferentiated', the inner unknown. That is why I choose to call it a visceral attention and rather than contrasting it with the attention in the air, I consider it as the non-verbal aspect, the corporal counterpart of free-floating attention. It is through concentrating on our bodies we free our mind to attend to the primary process and widen the scope of our receptivity. In other words, the mind surrenders to the body and it is a mindful body that listens.

Previously, I might have been using this type of attention as part of my listening. However, it was more of an unaware drifting within me due to relaxation than an act of immersion. Recently, it seems to have been my own anxious state that accentuated the need for the active awareness of inner holding. In the face of impaired analytic frame and the loss of my patients' bodily presence, I must have lost the sense of safety to carry on with what is so fundamental for analytic listening: surrendering to one's own unconscious, the unknown within myself. The inner analytic frame of mind was also shattered. Therefore, I actively had to carry out the process of holding, something that goes unnoticed in the usual analytic situation. When reflecting on what I did, I think I gave up the patient in the external world and willingly attended to my own inner body-self. Paradoxically, it resulted in re-finding my patient. Milner writes:

What looks like a turning away from the object and the outside world does in fact seem to result in the opposite from turning away, that it results in an increased perception of the nature and significance of the external object, in this instance the patient (1960, p. 240).

To describe this state would be to say that I would follow my internal body contours, as if I was drawing my own bodily frame. In fact, I am creating the missing boundary between the inner and the outer realities with my attentive inner gaze. Moreover, Milner observed that this mooring of one's attention within the sea of one's own body, a visceral attention in my words, 'bring(s) about a change in the analytic situation and freeing of the patient's material ' (1960, p. 240) .

As the brief clinical encounter shows, it freed my patient's mind to the point of re-finding an object that stood for our togetherness. The memory of feeding deer, a mnemic image (Freud, 1900 ) of a satisfying feeding situation, restored the much needed illusion of safety that is necessary for a symbolic work of analysis to be carried out. Milner, whose lifelong preoccupation was the creative use of a meeting of mind and body, points out that it brings the affective changes in the analyst's mind. In my experience, it certainly engages the mind to perceive the very essence of our vitality. It feels like a journey within one's own internal organs. This must be reminiscent of our visceral being, what it might have been like to be in the mother's womb so close to her organic aliveness. Is it not also about the importance of the analyst's body awareness in re-finding the missing body of the patient? The analyst's voice that stems from the visceral space must carry the mark of its origin and potentially enable patients to reconnect with their own bodies. It might also be an attempt to frame the unbound immaterial uncertainty by focusing on its counterpart within ourselves that is framed by our own bodies.

Freud stated that the conscious ego 'is first and foremost a body-ego' (1923, p. 27) to emphasize that the thinking ego is underpinned by a double perceptual reality; that it is the interface of the inner and outer realities. Attention is the function of the ego that is the principal tool we use whose deepest feelers can distil the information needed for perceiving a mental state of another human being. SOME CONSIDERATIONS FOR TECHNIQUE When Freud (1912) outlined his recommendations on analytic technique, he referred to his earlier paper in 1909 in which he stated a fundamental rule for clinicians, a counterpart of free association. There, he suggested examining the case of Little Hans, recounted by his father without trying to understand the case at once, but first of all to be open to be impressed and '… give our impartial attention to everything that there is to observe ' (1909, p. 23, my emphasis) . Later, Freud (1923) gave a more comprehensive summary:

Experience soon showed that the attitude which the analytic physician could most advantageously adopt was to surrender himself to his own unconscious mental activity, in a state of evenly suspended attention, to avoid so far as possible reflection and the construction of conscious expectations, not to try to fix anything that he heard particularly in his memory, and by these means to catch the drift of the patient's unconscious with his own unconscious (p. 239). Botella and Botella (2005) elaborated the concept of regredience, the analyst's regression towards more primary mode of functioning to represent something inarticulate in an analysand's psychic material. However, the emphasis is on the evolution of the representation. The under-focused aspect remains to be how to do it. How to surrender to the unknown, give up the area of secondary elaboration and get closer to a primary mode, to inarticulate in Milner's words. Perhaps, in part, it is so because as Milner (1950) put it 'We are trying to talk about a process which stops being that process as soon as we talk about it' (p. 161).

Our own personal analysis equips us with an intimate practice of surrendering to our own unconscious in the presence of the other. Through the process of internalization of it, we continue self-holding in the physical absence of the other and it becomes the background matrix of our mental space. The challenge arises in circumstances of intense anxieties in the analyst caused by the major life events such as the current COVID-19 pandemic. In my understanding the capacity for visceral self-holding is a fabric of being a psychoanalyst which is hardly noticed like our breathing and heartbeat that gets consciously registered when disrupted. The anxiety of psychic survival disturbs this body-mind unit that holds us, and we need to attend to its awareness or active restoration. Visceral attention through in-dwelling in our own bodies comes as a part of the technique that is available to facilitate holding the self and the other.

It is my contention that albeit the scale of it may vary, in every analysis there is a phase dominated by uncertainty in which analytic listening confronts us with a high degree of anxiety that threatens our psychic survival. I believe that every analyst is familiar with the experience that might last for weeks and is characterized with the sense of despair and frustration in an analytic pair with the concomitant pressure on the analyst to make sense, to do something about it. Coltart (1993) called it a phase of bafflement in which all that is needed is a 'perpetual bare attention'. She borrowed the concept from Buddhism to highlight the quality of profound 'opening of oneself to another person' (p. 182).

Milner's emphasis is on the analyst's own body and how to achieve this bodily attention. It is, in part, to challenge the mystery of it 'just happening'. There is an aspect of active engagement using the will to create the frame of mind to hold the attention inwardly and wait. The mysterious component, the passive aspect is about having no control over the outcome of a meeting of the mind and the body which initially is represented by a metaphor of gap.

In this light, the technique of listening consists of active and passive components. The will performs an active turning of the attention to the interior of the bodily self that I argue is crucial for achieving a state of free-floating attention. Only the attention that is anchored in the body can freely float. When I grasped this paradox, I have realized that visceral attention has a rhythmic quality to it, perhaps thanks to its closeness to breathing; it submerges into the body and emerges out of its depth.

The will and visceral attention create a frame of mind, a mental psychoanalytic room that holds the analytic dyad. Milner delineates the limited function of the will that 'has to wait in very active present mindedness and be content with being a frame, holding the empty space if something new is to emerge, something that has never been before ' (1952, p. 82 ). THE FRAMED GAP: BLANK PAPER AND VISCERAL SPACE I suppose that doodling is the part of body concentration on paper that is the framed gap. Being also an artist, Milner studied the importance of the surrender to the body in the process of painting. It is a kind of deliberate filling out of one's whole body with one's consciousness, so that one perceived whatever one was trying to paint with a whole body attention, not just with one's eyes or one's head (Milner, 1969, p. 48) .

I wonder whether doodling has an additional freedom: it is aimless. It is not about drawing an external object but one's inner feeling state. It is more about the process that is primary in its mode than a product; more of a mental gesture than an artistic expression. What it succeeds in is giving form to something inarticulate within us. It certainly helped me to achieve the un-anxious enough state described by Milner and reconnected me with my patients. Perhaps, my unconscious search for a blank page to doodle derived from the need for a negative surface where representative activity could be recovered and representations could begin to emerge. The blankness of a piece of paper must have allowed the attention to be held. Perhaps unmindfulness is akin to a 'no memory, no desire' state of mind that Bion (1967) recommended. Ultimately, visceral attention denotes the quality of an analyst's engagement with one's own corporeality which in its perceptual presence hardly leaves room for memories and desires to take over. For perception-consciousness and memory are mutually exclusive (Freud, 1896) . One of the ways to be devoid of one's own memory and desire is to give up a mind via 'some sort of active direct feeling contact with a primary body awareness' (Milner, 1960, p. 235) .

As I took more interest in these free-flowing drawings, I have detected the pattern in the process itself. I would begin with a dot unfolding into a spiral which then took on a quality of life of its own. It is as if the first circular lines engaged my eyes and my hand in a way that followed the inner search for forms. I have also noticed that in fleeting moments I would see that these various bends and loops were shaping into something familiar. Challenging to be articulated, this non-verbal process is reminiscent of the experience of utter concentration during 'a cloud journey' I would take with my 5-year-old daughter as a part of home schooling during the lockdown. Whenever I perceived a bunny or a bear amongst swimming clouds, I wished she could see it before it disintegrated into a shapeless white.

Gradually, I began to see the theme in my doodles. Some depict dreaming human bodies with their eyes closed emerging from the background (Figure 1 ). I am wondering whether I have unconsciously been recreating the physicality of togetherness with my patients. However, most of the doodles are seashells (Figure 2 ) … seashells cast ashore evoke Tagore's (1912) poem 'On the Seashore', quoted in Winnicott (1966) :

On the seashore of the endless worlds children meet …They build their houses with sand, and they play with empty shells.

Doodling must be a type of playing through which I recovered transitional space where empty seashells are created-found objects. 3 And maybe, I have created and found an acoustic container, the framed gap that receives the sound: if you put your ear close enough to a seashell you hear the waves whispering about its unknown inhabitant …

when emerging out of the first national lockdown due to the pandemic of COVID-19. In July, I presented it to the British Psychoanalytical Society

uses a term trouvé-créé [found-created] for Winnicott's conception of primary creativity. It is more accurate to say créé-trouvé [created-found] as Winnicott's baby finds what s/he has already created

The Complete Works of W.B. Bion, volume VI

The Work of Psychic Figurability. Mental States Without Representation

Slouching Towards The Bethlehem … And Further Psychoanalytic Explorations

The Complete Letters of Sigmund Freud to Wilhelm Fliess 1887-1904

The Interpretation of Dreams

Analysis of a Phobia in a Five-year-old Boy

Recommendations to Physicians Practising Psycho-analysis

Les animaux maladies de la peste, Fable 1. livre VII dans le deuxième recueil des Fables de La Fontaine

On Not Being Able to Paint

The framed gap. In: The Suppressed Madness of Sand Men Forty-Four Years of Exploring Psychoanalysis

The concentration of the body. In: The Suppressed Madness of Sand Men Forty-Four Years of Exploring Psychoanalysis

Psychic reality, negation, and the analytic setting

Winnicott's deconstruction of primary narcissism

Mind and its relation to the psyche-soma

Primary maternal preoccupation

The location of cultural experience

 Winnicott, D. (1971) Playing and Reality. London: Tavistock Publications.MAIA KIRCHKHELI is a psychiatrist and an IPA psychoanalyst. She worked as a specialist in a drug and substance misuse clinic in Georgia before moving to the UK, where she first