The truism that in any clinical encounter patient and clinician are both sexed and embodied was once linked to the inescapable materiality of consultations in which clinicians saw, touched, heard, smelt, and occasionally tasted their patients’ bodies. If we assume that sexuality is not behaviour, but an essential experience of embodied selfhood and relatedness, the traditional clinical encounter will inevitably, then, be in some sense sexual. The inherent sexuality of the encounter has been difficult for medicine, because for very good reasons to do with an imbalance of power between the parties, sexual enactment in the clinic is usually disastrous for the patient. The traditional response to this difficulty has been to attempt to expel completely all manifestations of the sexual from the clinical transaction. It may be thought that this is unambiguously a good thing when the medical event has a strictly physiological cast, concerns a broken bone, for example (though I will in fact argue against this idea), but it is clearly problematic to attempt to expel the sexual from the clinic when the event which brings the person to the clinic is intrinsically of psychosexual significance. The ‘logical’ move to get around this problem is for biomedicine simply to redefine such an event as one devoid of psychosexual meaning: some elements in obstetrics, for example, construct childbirth as an expulsive operation of the female pelvis, a mechanical event of no sexual significance (for discussions of the sexuality of childbirth, see, for example, Cohen and Estner, 1983; Kitzinger, 1986). In this scenario, it can make no difference to the patient whether the baby is born vaginally or abdominally, under the mother’s steam or via forceps, with or without perineal shaving and so on. The issue is represented as a technical matter which involves ‘operator convenience’ (Beischer and. Mackay, 1980, p.254) rather than patient experience, and the intrusion of embodied response, particularly in the highly charged form of sexuality, becomes unimaginable.
A further development in the process of disembodying the medical encounter is that clinical examination need no longer be negotiated through a body-to-body interface. A ‘reading’ of a patient provided by radiation, ultrasonography, or an electro-magnetic resonance may seem to constitute a perfect solution: the representation of the patient in the clinician’s mind can be created by technology, rather than by potentially awkward interpersonal means. Pregnancy, and birth, for example, almost inevitably find themselves overtaken by the once-removed ‘gaze’ of medical technology which may replace the physician’s multi-sensoried assessment. Instead of looking at, talking to, palpating, or otherwise addressing the patient’s body, the physician may look at the image produced by the tool which has ‘looked’ at the patient. The now very familiar ultrasound experience of early to mid-pregnancy, especially where it involves some further procedure like chorionic villi sampling, for example, typically has patient, family and medical attendants gazing at a monitor above the patient’s body. But at some point the ghostly simplicity of the image has to be brought back to the messy, non-compliant, maybe seductive, maybe repellent, patient ‘site’, and being in 4D (3 dimensions plus time) rather than 2D (or 2D plus time in the case of real-time monitoring), the body is bound to make a nuisance of itself.
Medical technology, predicated on the one-body model of selfhood, where the patient can be considered in severe isolation from the person who is examining her, rigorously excludes the pleasures, fears and embodiment of the interpreting clinician from consideration. There is more to bodies, however, than fleshly materiality. Live bodies have minds, and minds affect physiology. Embodiment involves both physiology and psychology, and, as I will argue, psychology (and thus physiology) involve the interpersonal. Interpersonal processes change when direct embodied contact is replaced by embodiment mediated by technological representation. Blood pressure rises or falls, perceived pain alters, depending in part on what is going on between individuals. Physical contact, and even talk, may minimise the need for analgesic.
Reliance on technology in the clinical encounter thus provides a useful opportunity to consider the operations of the sexual in the clinic, unfeeling as it may seem to say so, precisely because of the efforts to factor them out. I argue that as the mind, and perhaps the body, of the clinician affects, and might even be thought to produce, the mind and the body of the patient in the clinical encounter (and vice versa), the exclusion of one party, the clinician, from the clinical picture must distort the data. It is essential in thinking about the clinical encounter, to have a systematised way of understanding and analysing interpersonal transactions.
Psychoanalytic theory can shed some light upon what it is that happens when the embodied patient is not met by the embodied clinician. It is the one area of clinical exchange where the contemplation and analysis of the interpersonal and sexual is explicitly ruled in rather than out of the clinical encounter. Even more rigidly than other branches of clinical practice, psychoanalysis proscribes any form of physical contact whatsoever between patient and clinician. Hands are not held, bodies are not examined (eg Casement, 1990, pp.155-167). Sexual thinking, however, is very much on the agenda, and in fact provides a good deal of the basic data of the psychoanalytic clinical exchange. What might comprise the sexual, however, is very much more open to question in the psychoanalytic encounter than in everyday discourse. Sigmund Freud first established that the sexual is extremely fluid and unruly, and only gets forced into conventional channels under social pressure (Freud, 1962). Psychoanalysis is less interested in sexual behaviour than in sexual possibilities and fantasies, and it explicitly analyses the role of the clinician in this exchange. The raw material of the psychoanalytic consultations is the transference-countertransference shuttle, that is, the interpersonal situation as it exists in the consulting room (Hinshelwood, 1988, pp.255-262). Via the contemplation of the countertransference, that is, the clinician’s response to the patient’s material, the analyst is obliged to use her responses, sexual or otherwise, to consider what is happening in the clinical encounter (though she would rarely if ever disclose these to the patient).
Psychoanalytic theory thus addresses explicitly what other ways of thinking about the clinical encounter address only implicitly, or may attempt to deny. ‘How does this person react to me? How do I react to her? What difference do our reactions make to her well-being? To mine?’ are the basic issues in the psychoanalytic transaction. Psychoanalytic theory allows us to consider exactly what happens when the wish to understand issues of interpersonal embodiment (the sexual as it exists in the ethically proper consulting room) is stymied by the interpolation of the machine.
I want to address these questions by considering the model of selfhood developed by recent psychoanalysis, specifically one advanced in the work of the post-Kleinian theorist W.R. Bion. Post-Kleinian theorists explicitly reject the idea that subjectivity is a matter of individual split-off consciousnesses, acting independently from other such consciousness, insisting that subjectivity is both created and experienced interpersonally. Bion argues that the task of ‘cold booting’ a self, that is, beginning to move from a biological base to a psychological organization cannot be accomplished alone (Bion, ‘A Theory of Thinking’: 1993). This is an idea which Bion’s contemporary, the psychoanalyst-paediatrician D.W.Winnicott, famously summarized in his exclamation that there is no such thing as a baby, that infants do not exist outside a maternal environment (Winnicott, 1964, p.88). Moreover, such care cannot be understood as no more than the provision of physical services, as Nazi experiments demonstrated (Henry and Hillel, 1976). Babies quickly die if they are not psychologically as well as physically ‘handled’. It is infinitely preferable that the psychological interaction be loving but, as child abuse cases make only too clear, babies will readily use abusive psychological handling to construct a self. It is the interaction that is absolutely essential: the quality of the interaction determines whether or not the outcome is satisfactory, not primary survival.
Bion extended the Kleinian concept of projective identification, that is, the interpersonal transaction where ‘parts’ of self are in fantasy put into the other, who duly accepts the gift and acts as if it were fact (Hinshelwood, 1988, pp.179-208). Before Bion’s work, projective identification had been considered a defensive and mostly pathological mechanism, allowing the preservation of a ‘safe’ version of self, and the creation of a demonised or idealised figure in the other. The marital bargain where the wife carries all the nurturing skills and the husband all the practical skills is an example of this sort of projective identification. A man places his nurturing qualities in his wife, and admires or despises them there (Morgan, 1995). She picks this up, and in return puts the ruthless or competitive parts of her personality into her husband, and similarly loves or hates them in him. It is generally argued that that this sort of projective identification leaves the personality relatively fragile and depleted. The more that is projected, the more mutilated and psychologically vulnerable the personality left behind.
Bion, however, developed the reverse of this idea: a theory of normal projective identification, or what is usually called empathy. He argues that that one might put part of the personality into another for what might be thought of as prosthetic reasons, to temporarily strengthen a weaker personality, rather than to hunt them out of the self. He uses it to explain the fundamental need for psychological contact, because the theory of normal projective identification underpins his explanation of how the normal neonate can make use of maternal care (some infants obviously cannot do so: autistic babies are an example). A baby does not initially know it has a mind: it must use the shelter of the mother’s mind if it is to develop its own mind to the point where it can exist independently, exactly as it once used the shelter of her body to develop its own. Bion outlines the process thus: the baby feels it is dying, makes the mother feel that feeling, which (if she is not too anxious) she can modify with her own more developed thinking apparatus, and ‘give back’ to the baby in modified form. An anxious mother who cannot initially manage this might be able to be ‘contained’ herself (as Bion terms it; Hinshelwood, 1988, pp.246-53), perhaps by a midwife, her own mother, a partner, so that she can receive and modify her baby’s projections. This is the familiar feeding exchange: a distraught newborn, who apparently equates hunger with annihilation, is fed and calmed down by her mother, who is sympathetic, but not unduly upset herself. After many such exchanges, the baby begins to have a thought, rather than a mindless experience of horror: the thought is that a sensation of boundless terror and pain can be experienced and modified by another (that she can be hungry, fed, and made comfortable).
The central issue is not the physiology, but the psychological processing offered by the mother. Gavage feeding can stop the hunger, but only another mind can process the panic. The experience of a baby who, like the ones in the Nazi child-rearing experiments, has the horrible experience, and is duly fed, but not interacted with in any way, is unimaginable. What happens to the fear? An overwhelming experience of horror that produces no obvious catastrophe is a Beckettian absurdist experience: ‘I can’t go on, I’ll go on’. In fact, Samuel Beckett had a period of intensive psychotherapy with Bion in the 1930s, and the connections between the work of the two men are suggestive (Simon, 1988; Souter, 1999). Bion describes the experience of the baby in this situation in terms which bring Beckett’s characters to mind: to reintroject unmodified projections is to ‘experience not the fear of dying made bearable, but a nameless dread’ (Bion, 1993, pp.116). The consequences of this are profoundly familiar. Pain is easier to bear when someone is with you: the dental nurse holds the hand; the midwife tries to stay with the labouring woman until she delivers. Isolation is the unnatural punishment that torturers know it to be.
For the capacity for interpersonal selfhood to develop, the emerging self has to tolerate the construction of what Bion calls a ‘link’ between itself and environment. Well-functioning adults must be able to continue to tolerate it. Bion notes that the prototype of all links a model of interpenetration of self and other. This is an idea based, he says with his typical outrageous nonchalance, on the image or image-memory of the ‘primitive breast or penis’, an imaginary representation of a body part that can provide the self a connection with the environment-other (Bion, 1993, p.93). He describes a patient for whom
Projective identification makes it possible for him to investigate his own feelings in a personality powerful enough to contain them. Denial of the use of this mechanism... leads to a destruction of the link [between self and environment] (Bion, 1993, p.106).
Medical technology, high or low, might in this sense be read as an attack on the Bionian link, a refusal to allow intersubjective processes to elaborate the selves in the clinical encounter. Instead of two or more selves, the encounter would be between one self and one machine or tool. If the sexual is considered to be not merely the drive towards genital arousal and orgasm, but the essential underpinnings of the drive to establish an enlivening and anxiety-relieving ‘link’ with others (via an unconscious model of ‘the primitive breast or penis’), the re-routing of the clinical encounter through the machine has far-reaching consequences. Certainly, the patient would find it harder to use the person of the clinician for reassurance (how do you seek comfort from someone who is reading a printout?). The more important issue, however, is how the patient is represented in the clinician’s mind. How does this affect the encounter?
My contention is that when the clinician is dealing with a patient via high or low tech tools, the sexed and embodied nature of the interaction does not simply vanish, but instead takes on some of the characteristics of the mechanical interposition. A perineum massaged with the midwife’s (gloved) fingers is likely to be recognised as similar to the hand that touches it, a fleshly and sexually significant body part. A perineum accessed with scissors may assume, in the mind of the person wielding the scissors, a complementarity to the tools: perhaps more like a bolt of cloth or a sheet of paper than flesh. A perineum on which forceps are used may be thought of more like a mechanical fulcrum than a genital area. (Note#1). In the case of the birth of Giulia, discussed below, the mother’s attendants use a step-ladder to enable them to climb up and use knees, arms, and even feet to force the baby out. If one uses a stepladder to access a patient, does the patient become something like an elephant? a truck? a house? Patient and clinician are certainly linked in these instances, by scissors, forceps or stepladder, but rather than allowing the tolerance of a lively interpersonal link which encourages development and connectedness, these tools create mechanical links and the interpersonal exchange, therefore, also becomes mechanical. The link in the mind is with ‘breast’ or ‘penis’ as machine, not flesh, and takes on the characteristics of the tools which give access to the other: the inevitable wish to experience selfhood through the other modulates to the (autistic) wish to experience selfhood in oneself while reacting to the other as machine. Thus the consultation mediated through the scalpel, for example, will not alter to become a disengaged inquiry into biochemistry and physiology rather than an interpersonal transaction; rather the experience of embodiment and communication will take on a surgical, anti-flesh quality.
These are the sorts of reasons which explain why psychoanalysts so rarely use tools: most medical analysts will not even prescribe drugs to analytic patients, but refer them to another practitioner if treatment with drugs become necessary. The tool the analyst needs is her psychoanalytically trained selfhood to access the selfhood of the other. Like the mother Bion describes, the analyst must make herself available to process her patient’s psychological products: to make herself available to process the products of a machine transforms the humanized and humanizing link into a dehumanized and dehumanizing one when it finally loops back to the patient. A fully detailed study of the perversion of normal projective identification by reliance on technology is rare, partly because examples are typically kept to the brisk form of the conventional case history that appears in medical case-notes, and often are kept hidden from the patients’ relatives.
In a recent book, Wrongful Death, Sandra Gilbert describes her family’s attempt to reconstruct the cause of death of her husband Elliot from subpoenaed case notes of this sort (Gilbert, 1997). Elliot Gilbert’s doctors refuse his family any information about why this otherwise robust sixty year-old man died after surgery for prostate cancer, and his widow, with the help of family, medical friends and lawyers, pursue the matter till, on legal advice, it is settled out of court for what she describes as ‘a modest sum’ (the terms forbid her to reveal it). The Gilbert family never is told what killed him: the autopsy report notes ‘no anatomical cause of death’; his death certificate suggests ‘liver failure’. My own reading of the book suggests that Elliot dies of a series of complications (anaesthetic difficulties, internal bleeding which remains undetected for reasons of negligent recovery-room procedures, and lethally inappropriate resuscitation attempts). I think it is possible to argue that the institutional callousness with which this unexpected death was treated plunges the Gilbert family, and especially Sandra Gilbert, into an agonised denial of Elliot’s mortality. When the hospital claims no individual malpractice, but ‘an institutional systems failure’ about which the family had previously heard nothing (ibid., p.9), although Elliot ‘bled to death’ (ibid., p.175), how can the bereaved focus their minds on the inevitability of ‘ the death prepared for us’ (ibid., p.335)? The language of defensive medicine, the case-note chart, forces the bereaved into a situation where death or injury is irrelevant to outcome. ‘We did the right thing’, says Elliot’s doctor. He is referring to the decision to do a radical prostatectomy; he is not thinking of the ‘total management’, in which the patient is allowed to bleed to death post-operatively.
Elliot Gilbert had an idiosyncratic anatomy which makes him almost impossible to intubate: in a previous episode of attempted intubation, had nearly died, and threatened to sue if failed intubation had wrecked his vocal cords. When intubated again, Elliot finds himself the victim of what Bion describes as ‘curiosity, arrogance and stupidity’, the characteristics of the interpersonal transaction in the presence of a dehumanizing link (Bion, 1993, p.101). Thus dehumanized, he loses his status as meaningful embodiment, a man with a history, a profession, a family, a future, and becomes merely a complicated technical problem, a site into which tubes have to be jammed with increasing force. The final shock to Sandra Gilbert’s sensibilities is the amiable doctor’s use of the word ‘terminating’ to describe Elliot’s dying. In the long review of these events which constitutes the book, Gilbert ponders the ethical issues they entail. She is particularly pained as she believes that the doctor who sent the family away from the dying man’s bedside actually seemed to like Elliot. The insensitive and ethically questionable actions of the doctors only make sense if we realize that the body of Elliot Gilbert has, by virtue of the technical complications that assail them all, been transformed in the minds of his medical attendants to brute materiality. The link provided by embodied contact, in which Elliot and his doctor may have feelings for each other, is replaced by a link created by tubes. The tubal link, low-tech as the technology might be, works towards dehumanizing this patient. It produces the image of the patient as one half of a mechanical connection: you pull the tube, it terminates. There is no room for a living man in that link. When the patient is accessed through multiple surgical and biochemical procedures, his humanity disappears, his body becomes monstrous.
Gilbert’s book, however, allows us very little access to the subjectivities of Elliott’s doctors, who, we are told, keep reflection about their disasters, partly for fear of litigation, to the ultra-private clinical forum of what the family are not pleased to find is called the ‘M and M’ (mortality and morbidity) meeting. One work which does explore the effects on the clinician of accessing the patient through technology ¾ though this is by no means its intention — is a study undertaken by Alessandra Piontelli, a Milanese psychoanalyst, From Fetus to Child (1992). This work attempts to consider and observe the continuum of personality between fetal and post-natal life. The project in itself is a fascinating one which depends on an idea familiar to mothers everywhere, as Freud said of infantile sexuality: that newborns have a past, and that they are born with personalities. It is the technical issue, of how to ‘observe’ the fetuses, which interests me here. Piontelli believes, with all psychoanalysts, in the primacy of the clinical encounter, in the fetal case (she argues), a version of
... the method of Infant Observation described and taught by Esther Bick … which is close to the method of ‘participant observation’ used by anthropologists and ethnologists... The frame of mind of the psychoanalytic observer of infants is close to the ‘free-floating attention’ recommended by Freud. (ibid., p.14)
The argument goes: if we wish to investigate pre-natal existence, we must observe the fetus directly, as observers do with the infant, and not attempt to ‘reconstruct’ or imagine its experience. To support her case about the need to observe the fetus ‘directly’, Piontelli cites atriumvirate of eminent psychoanalytic authorities (Sigmund Freud, Anna Freud and Hanna Segal) who all recommend ‘direct observation’ of children and infants. The problem with Piontelli’s argument is that it skates over the differences between a fetus and an infant: the fetus is merely an ‘unborn child’, as the anti-abortion lobbyp uts it .
Piontelli’s decision to ‘observe the undisturbed fetus in its natural environment’ (ibid., p.8) does not, therefore, mean talking to and otherwise interacting with its mother. Rather, like most Western providers of obstetric care, she means to monitor it via ultrasonography, specifically to bring the fetus’s ‘inner’ world into focus. The fetal ‘subjects’ are monitored for periods of one hour at intervals during pregnancy, and then are periodically observed with their families up until four years of age. There are a number of issues, not considered very carefully in her book, that follow from Piontelli’s decision to rely on technological visualization of the fetus. She does briefly address the (crucial psychoanalytic) issue of whether such protracted observation (five or six one hour sessions) might interfere with the mother’s fantasies about the child, but decides, conveniently for her purposes, that it might just as well ‘facilitate bonding’ (Note #2). In this, however, she is thinking mostly of the woman's actual visualization of the fetus. More important is the group interaction over the prostrate body of the pregnant woman: the hour-long ultrasound observations, during which the mothers lie flat on their back for an extended period (dangerous in late pregnancy) and are exposed to the obstetrician's boredom, complaints and fantasies about the babies before the mothers can even feel fetal movements. To want to ‘observe’ a fetus without observing it-and-its-mother is to enter into the fantasy of the independent fetus, one which has no confusing interrelationship with its mother’s tissues, much less with its mother’s mind. As E. Ann Kaplan notes, such an approach ‘represents the fetus as an entity in its own right, unattached to the mother, or at least rendering her irrelevant to what is going on in the womb’ (ibid., p.209).
It is interesting to speculate about a research project which might attempt to investigate fetal experience by addressing the subjectivity that the observer can interact with, the pregnant woman, that is, mother-and fetus. What would follow if the investigator used her subjectivity to access the woman's subjectivity, which was accessing the fetus's 'subjectivity? At that stage, what does it means to think about a fetus's 'experience', if its experience is its mother's experience? Do the mother's fantasies allow access to the fetus's experience? Do the psychoanalyst's countertransference responses allow access to the mother-and-fetus's experience? These are interesting questions, but Piontelli gives them no space. Our society does not regard mothers as useful sources of information about their fetuses’ ‘personality’ or well-being (although there is considerable ‘hard’ evidence that they make very good fetal monitors), and Piontelli is no exception in this matter.
In this study, Piontelli argues convincingly that some aspects of personality and behaviour patterns are fixed before birth. It is hard to imagine a more persuasive interpretation than the one Piontelli suggests for a little girl said to look like a snake or a Martian: that this psychotic child, with her frenzied games of wrapping ropes and cords around her neck, is constantly reenacting a horrible birth and pre-birth experience in which she was born black in the face with the umbilical cord wrapped around her neck. Likewise, I am convinced by the charming vignette of the brother and sister pair who Piontelli calls the ‘kind’ twins, observed by ultrasonography to ‘stroke’ each other through the dividing amniotic sacs in utero, and seen to play a similar game with a curtain at one year of age. The representation of ‘the independent fetus’, however, seems to militate against an intersubjective model, where maternal/fetal subjectivity is a shared experience, and appears to require a corresponding degradation of the mother.
The effect of the technological ‘link’ on Piontelli’s response to the women in her study is clear. The pregnant mothers are all represented as physically repulsive, and as either too libidinal or anti-libidinal: either slags or drags, as children used to say when I was at school. It is a sort of primitive splitting of possibility, in which each extreme is represented as grotesque. Normally, one would expect the interpersonal sensitivity of psychoanalysis to direct the analyst ¾ via ‘normal projective identification’¾ to more variegated possibilities of selfhood and the perception of embodiment. The pregnant woman’s fears about her looks and physical safety would be introjected by the clinician, modified, and made bearable for re-introjection, as the mother does for her distraught infant in Bion's theory (Raphael-Leff, 1995, pp.177-182). In this study, emotionally removed from the pregnant women by her technological focus on the visualized fetus, Piontelli seems to be unable to perform anything like this function, and to have been pushed back to where ‘normal projective identification’ will appear in the pathological form dictated by the mechanical link, with stupid and arrogant dehumanizing. In this state, the world can only be split along crudely narcissistic lines where self is beautiful, and absolutely distinct from other, about whom one may be curious, but who is disgusting. Pontelli’s book is unusual in that, unlike Gilbert’s patient-centred account, it provides us with the thought processes of the medical attendant who perceives the patient with whom the mechanical link is formed, and we can see that that, almost regardless of the intentions and orientation of the clinician, the consequences of a techological link have their own imperatives.
In each of her case studies, Piontelli begins her accounts of the fetal observations with unsympathetic descriptions of the mothers. The researcher’s attempts to get past the mother's inconvenient flesh so as to observe her fetus as a separate subject results in the mother being attributed with a sort of intrusive and dehumanized sexuality. With their inconvenient husbands and clothes and wishes to have relationships with the researchers, the pregnant women seem to constitute indecent barriers to her work with the fetus-subject, as if fetal observation could proceed in a much less cumbersome way if there were no maternal body. All seven of the women whose fetuses are visualized are, without exception, described as inferior to the observer in a range of unpleasant ways. The inferiority is primarily (but by no means exclusively) physical. The first parents, Mr and Mrs A, are described in this extraordinary way:
She] looked enormous in her wide maternity dress...[she] was rather heavily but also clumsily made up, with bright red lipstick emphasizing her already fleshy lips and bright blue eyeshadow and silvery pink blush smeared carelessly on her lips and cheeks. Her old-fashioned yet rather vamp-looking, low-necked black velvety dress, together with her smeared and bright make-up, made her look quite ‘whorish’ though in an outdated and clumsy way, like a character in a Fellini film... Mr A looked provocatively comfortable showing off his grotesque wife. Being so short, he too looked like a caricature...like a malicious gnome. (Piontelli,1992, pp.40-1)
This apocalyptic representation of the subhuman parents seems to emerge from Piontelli’s appalled (primitive and unconscious) sense of the grotesqueness of the huge sexual body of the mother surrounding her innocent and vulnerable child, and the more Oedipal horrors of the father's frightening complicity, experienced apparently as procurer-like, in her sexuality.
This pattern (of which I can detect no consciousness in the text) continues through the alphabet of Piontelli’s subjects, from Mrs A to Mrs G. In contrast to the mother’s body, the doctor’s embodiment is represented like that of the visualized fetus: small, delicate, friendly, genteel, and without appetite; the patient’s is greedy, whorish, hairy. In rupturing the oneness between mother and child, the technology also allows the doctor’s experience of the mother to be represented as entirely a matter of the mother’s characteristics, nothing to with a sexualized exchange in which the doctor might project her dirty sexuality (and the fetus’s) into the patient. Doctor and fetus are figured in an ultrasonographic relationship, virtual mother, and no-trouble virtual child. This is the nearly inevitable result of treating a human being as no more than what one caller to talk-back radio describes as ‘ big bags to carry [a] kid’, especially when the ‘kid’ is regarded as precious to the observer (Kane, 1990, p.274). The tool turns the mothers into dehumanized research sites, whose repeated attempts to remind the attendants that they have bodies, as Mrs B does, or minds, as Mrs G does, simply disgusts the doctor. The intrusion of embodiment, integrated psyche-soma, into a space mediated can only be registered by the mechanical link as a perverse sexuality.
The emphasis on the exclusively intra-psychic hypothesis rules From Fetus to Child. The only exceptions are found in the discussions of the psychotic toddlers, none of whom are ‘seen’ as fetuses by the researchers, which is surely significant. The mothers of these children are described with empathy by Piontelli. Tilda's mother, for example, is described a pleasant, warm-hearted person, with a ‘crazed appendage’ in the form of her psychotic child (Piontelli, 1992, p.203). The case of Jacob (ibid., p.18) seems to show a child whose problems are at least as much to do with repressed mourning in his parents as with his own prenatal experience of the death of his twin. Piontelli inevitably prefers the intra-psychic to the intersubjective explanation of a child’s situation. Even the most obvious interpersonal issue, the treatment of the pregnant women by their obstetric attendants, is not considered when Piontelli thinks about fetal 'personality'.
Yet the birth of Giulia to Mrs A (the only birth of the observed fetuses that Piontelli attends) clearly shows how important it is to be able to consider the institutional, interpersonal and social construction of maternal-fetal sexuality, as well as the intra-psychic. Mrs A’s appearance, previously described as ‘whorish’, modulates to something animal-like as her labour progresses: she is described without a trace of empathy as she screams, belches, and makes ‘loud vomiting noises’ during the almost unimaginably brutal birth of her child. Although vomiting and belching are normal, and indeed diagnostic, signs of impending second stage (see Kitzinger, 1986), Piontelli shows no sign of considering whether they might be other than idiosyncratic psychological responses to the process of birth, representing them as typical of Mrs A’s gross behaviour. During the long labour, Mrs A is neglected, interfered with, washed with cold water, examined internally during contractions (‘Mrs A screams “No... it hurts too much”’); she is told to push harder by the midwife (‘Mrs A screams “I can’t do it... it hurts too much”’) but told to stop pushing by a nurse who wants to take blood during expulsive contractions (‘How can I do that... it’s not up to me whether I push or not’). Finally, when a Caesarean section seems likely, the Professor startles the observing psychoanalyst by calling for ‘the stepladder’ to be tried first:
(.. I really don’t know what he is talking about; I have never heard of a stepladder being used in obstetrics …) [They climb on the stepladder]…The Professor… is using his foot and sometimes his knee to push against her stomach. His assistant does the same... Mrs A screams non-stop, sounding both terrified and in pain, and practically everybody is now on her stomach. The Professor almost jumps on it... [Dr R later] says ' I can't stand seeing women treated like that... a woman literally stamped upon!... and it's not different with the children either' (Piontelli,1992, pp.55-6)
This account of violence with which Mrs A is treated during her labour may provide an interpersonal aetiology for the ‘greed’ of Giulia and her mother which so occupies Piontelli’s attention in her discussion of the family. That is, this family may use oral satisfaction as compensation for institutional attacks on their sexuality. Or perhaps Mrs A’s ‘grossness’ might be thought of as an appropriate equivalent to the grossness of her medical treatment. Giulia’s birth exemplifies the dehumanizing effect of technological contact with the patient: when the object of the doctor’s attention is a stepladder, the mother may be visualized as a large obstacle to which force must be applied, and problems of embodiment such as obesity or inhibited second stage of labour cannot be thought about intelligently. The disavowed sexuality of interpersonal contact will appear as ‘curiosity, arrogance and stupidity’. This accurately describes the medical behaviour in the birth of Giulia, when the Professor uses his foot to squash Mrs A’s baby out of her vagina.
In a world where normal interpersonal channels are ruled out, physicality cannot be understood as a sensuous experience of mutual pleasure, either between mother and fetus, parents and children, or between friends. It is all one way, and generally persecuting. The fetus is imagined to be variously poisoned, starved or overfed in utero. Piontelli’s study has received a considerable degree of approval from the psychoanalytic establishment. Her first two reports of her findings appeared in The International Journal of Psycho-analysis, and Frances Tustin, probably the most eminent British psychoanalytic child psychotherapist of her generation (and an analysand of Bion), praises From Fetus to Child in her Autistic States in Children (1997, pp.130-1). In view of its unpsychoanalytic dehumanising of the pregnant women, such approval seems surprising, but it mirrors the text’s apparent unconsciousness of the reality of the pregnant women. I think it emphasizes the fact that even the psychodynamically well- informed, those whose method is based on a belief in the embodied integrity of the other, find it difficult to maintain this belief when accessing the other through technology, rather than with a clinician’s own embodied capacities.
Literary explorations of the opposite, the humanizing, effect of the interpersonal registration of embodied sexuality on the medical encounter are common. One major writer who repeatedly shows how the registration of the sexual humanity of the other has a humanizing effect on the clinical transaction is William Carlos Williams. Carlos Williams’s stories typically show the shift from disgust to a rush of empathic feeling which follows the physician’s entering into the embodied predicament of his patients. In ‘A Face of Stone’, for example, the young doctor initially describes his patients very much in the terms that Piontelli uses describes her pregnant subjects and their spouses:
He was] a small stoutish individual in a greasy black suit... She, on the other hand, looked Italian, a goaty slant to her eyes...She looked dirty. So did he. Her hands were definitely grimy, with black nails. And she smelled... People like that belong in clinics, I thought to myself. I wasn’t putting myself out for them, not that day, anyhow. Just dumb oxen. Why the hell do they let them into the country. Half idiots at best. (Williams, 1987, p.78)
Williams’s doctor reveals his dehumanizing of the couple much more directly than Piontelli does. Her description of the A’s as Felliniesque, for example, masks her horror with the gentility of the cultured film-goer, where the young doctor simply abuses them coarsely, as ‘dumb oxen’. This story catalogues at length the irritation the doctor feels at having to deal with these people, but concentrates on the dehumanizing effect the transaction has on him, his growing brutality in the face of their demands. The erosion of his ‘normal’ decency startles his wife: ‘ Who in the world are you talking to like that... You mustn’t do that’, she objects when she hears him yelling at them (ibid. p.81). The parents nag him to check their baby (‘his body isn’t so good’), and when he finally does so, it is in an agony of disgust: ‘I picked the thing up by its feet and the back of its neck’(ibid., p.83). But the physical contact, and the eye-to-eye interaction with the baby changes his mode of relating to this family: he finds the baby is no merely disgusting ‘thing’ after all, but quite another thing: ‘a smart looking little thing and a perfectly happy, fresh mug on him that amused me in spite of myself’. But the parents then demand that he check the mother. This outrages him: ‘What a creature. What a face. And what a body’. His examination of the mother reveals some awful deformities, particularly to the legs. They are ‘bowed, really like Turkish scimitars and somewhat rotated on themselves...’: the doctor, examining her, holds ‘one [leg]... on the palm of either hand’. He learns that they are the result of her traumatic childhood as a little Jewish girl in Poland during the war, the only survivor of her family. The doctor’s sense of the woman’s selfhood shifts as he hold the ugly legs and thinks about her as a whole person: ‘So that’s it... No wonder she’s built the way she is, considering what she must have been through in that invaded territory. And this guy here... ’ (ibid., p.87). He begins to register what the crazy fussing about the baby’s health means for the parents, what the man’s love for his wife means, and is finally able to respond to the woman with some genuine professional care: ‘I showed a few of the pills to her in the palm of my hand’. In effect, this means he has entered in to this charmed circle of family love, where beauty really is in the eye of the beholder. The woman responds by smiling ‘for the first time since I had known her’, and agrees to take the pills: ‘Yeah, she said, I swallow him’.
These words finish the story triumphantly, and show something of the therapeutic power of the interpersonal in the clinic. Throughout this story, the woman has been represented as non-compliant. She refuses to wean her child, she refuses to change her shoes. She refuses to be reassured. For her to take these big green pills with a smile, in the blurry shadow of her wartime history, seems to mean that she has accepted that the doctor knows that she is no subhuman, is not seeking to exterminate her kind (although initially he was pretty close to something like the wish to exterminate her, with his response of ‘dumb oxen’). The young doctor’s recognition of the family’s terrible history, the baby’s potential, and the meaning of her embodiment allows him to understand something of the man’s ‘half shameful love for her and at the same time the extent of her reliance on him’. His sense of their specifically sexual humanity allows the establishment of a good link, a good feed in Kleinian terms, symbolised in the pills she accepts from the doctor’s open hand (“Yeah, I swallow him’). Stone turns to flesh: the ugly woman smiles and opens her mouth; the hate-filled young doctor offers oral aid lovingly. The hand that touches the baby, holds the legs, shows the pills, is what makes the difference here. Without that, this doctor does not register the embodied complexity of the family, no lively link is possible, and the encounter remains ‘stupid and arrogant’.
Many of Carlos Williams’s stories show this move from a cruel stereotyping of the other which precludes a therapeutic exchange to an openness to the patient’s embodied aliveness. In an essay, ‘The Practice’, Carlos Williams describes coming to such a position of surrender as gaining ‘the peace of mind that comes from adopting the patient’s condition as one’s own to be struggled with’, and notes that under these circumstances work would actually reconstitute him mentally, even when exhausted. This is a close approximation, it seems to me, of Bion’s idea that the mother’s peace of mind (reverie, he calls it) provides the space to take in the baby’s projections and deal with them. No sense of complex, interpersonal psychosomatic contact is possible when one party’s mind is full of his intentions to do a job on the other, regardless of the other’s response. Whether the job is to feed the other, to teach the other or to give the other medical attention is not significant. A sense of elaborated embodiment can only be experienced when interpersonal space is provided to experience it in: peace of mind, reverie. This interpersonal struggle can be, as Carlos Williams suggests, revivifying for both parties. In the clinic it develops out of the clinician’s capacity to recognize sexual potential, even in the most unpromising individuals. Gilbert and Piontelli show how a reliance on technology interferes with and perverts the creation of a link with the patients’ sexual and embodied subjectivity; Carlos Williams shows the reverse. In these representations of the medical encounter, it is clear that medicine must find some way of taking cognizance of the embodied, and thus necessarily sexual, potential and experience of the patient, however alien or infuriating she might seem, if a therapeutic outcome is to follow. Elliot Gilbert’s anatomical peculiarities baffle and infuriate his medical attendants, but outside that site of struggle they know very well that there is more to him than an outrageous upper respiratory tract. Mrs A’s family love and value her, however grotesque she seems to those who want to check out her fetus. A technical link seems to militate against the interpersonal experience that mutuality provides, and is likely to be experienced as dehumanizing. There is no substitute for the clinician’s embodied self as a diagnostic tool, however, narrowly physiological the issue may seem to be. To remain conscious of one’s own embodiment, as more than tool user, when accessing the body of the other seems to be the trick of finding a way of using the scissors, the drainage tubes, the ultrasonography, without losing sight of the patient’s reciprocal embodiment. It may, of course, be a very difficult trick.
