Community Consulting Group, New York City

Mark B. Borg, Jr. PhD
[AUTHOR'S BIO]

Borg, Jr., M. B. (2005). A Zombie Storms the Meathouse: Approximating Living and Undergoing Psychoanalysis in a Palliative Care Culture. Psychoanalysis, Culture, and Society, 10 (1): 1-22.

Author's Note. I would like to thank Jennifer McCarroll, Eve Golden, and Jon Lindemann for their helpful comments and suggestions.

Enactments of palliative care entail an excess of dissociated pain and anxiety that conforms with the unconscious injunction of our liberal individualist society to "Be Well." In this paper, I suggest that palliative care rituals serve as society-level unconscious defenses that Westerners use to ward off any form of emotional discomfort. This paper follows a patient, starting with a "zombie" dream presented in her initial session, through the first six years of her psychoanalytic treatment as she moves through this palliative care system.

A FASCINATING AND PERPLEXING ASPECT of our society is the proliferation of remedies — social, personal, and cultural — for just about anything that might cause discomfort. This includes not only pain and anxiety, but also their derivatives: irritation, frustration, sadness, anger, and so on. Human — that is, emotional — responses to everyday stimuli are increasingly pathologized, and we are increasingly promised the obliteration of all personal suffering. Yet at the core of all these human responses to suffering that need remedy is a deep sense of empathy with the struggles associated with simply existing at this time in this society, in a state of perpetual dread over the immense social problems that infect those around us, and that seem (and often are) insurmountable. It seems that in our society it is the experience of empathy that is most feared, most defended against, and most abstained from — as if compassion is the ultimate contagion that, if experienced in full force, would lead to break down.

The list of potential remedies for our discomfort is long enough to allow us to create an infinite number of personal treatments for every imaginable malady, thus removing us from the emotional experience of painful and anxiety-provoking stimuli. In this state of amputated emotions and self-experience we can become zombie-like, unable to impact or be impacted by our world or by each other. Eventually, we run the risk of approximating living by defending ourselves against the discomfort induced by threats (both actual and perceived) without acknowledging the power that they hold over us. I believe that these remedies — which serve as culturally-sanctioned symptom-management techniques — meet the World Health Organization's (WHO) definition of palliative care:

Palliative care is generally confined to individuals with terminal illnesses (Barraclough, 1997, p. 1367; Field, Clark, Corner, & Cooper, 2001, pp. 8-10; Portenoy & Bruera, 1997, Ch. 2). There is a vast literature on palliative care — that is, symptom and pain management — for patients with such diseases as cancer, AIDS, and dementia (Greipp, 1993, p 126; Lipman, Jackson, & Tyler, 2000, pp. 1-11; Paice, 2003, p. 95). In the United States, palliative care prescriptions for morphine and other narcotics are strongly associated with hospice care.[1] Perhaps an equally compelling description of the palliative care society is captured by the science fiction writer Phillip K. Dick. He writes, "Life itself was unendurable and hence had to be ameliorated. As a thing in-itself it could not be actually lived. There had to be some way out" (Dick, 1965, p. 90).

The characteristics of what I will call our palliative care culture are consistent with the sociological analyses of Bellah, Madsen, Sullivan, Swindler, and Tipton (1985, pp. 2-6), who described a general American movement toward liberal individualism. They asserted that the definitive aim of life in such a society is to promote fulfillment (in the form of increased satisfaction and decreased discomfort or pain) for individuals instead of communities (ibid., pp. 34-42). Other authors have analyzed the pervasiveness of this perspective in many social and cultural institutions (including psychotherapy and the social sciences in general) in capitalist societies, particularly the United States (Richardson, Fowers, & Guignon, 1999, pp. 18-21; Taylor, 1992, p. 6). As a character defense on a societal level, liberal individualism allows us to avoid acknowledging the social consequences of a sanctioned perspective that supports fulfillment for some and suffering for others (Richardson et al. Ch. 2). As this perspective becomes rigidified, it functions as an ideology. By ideology, I mean, "those values and assumptions about the world which have implications for the control and allocation of limited resources" (Knox, 1995, p. 3). Consistent with such a notion of ideology, control and allocation processes are dissociated, problems and fulfillments become increasingly individualized, separated from their social and cultural influences and etiologies (Said, 1993, pp. 62-63). The inability to empathize with both self and other diminishes the potential for subversive or revolutionary processes to exert any impact on societal transformations or daily functions. The phenomenon is clearly expressed in the final volume of the Dune saga, when Frank Herbert (1985, p. 78) states that "Rules are often an excuse to ignore compassion." Today there are many examples of compassion being pushed aside in favor of rules and regulations that diminish our awareness of our collective fragility.

When awareness of pain and suffering — whether on the level of individuals, communities, or groups — is reduced through the use of palliative remedies, what remains is a form of chronic crisis that is so muffled that even those who suffer from it don't know how to respond. This process not only supports a "victim-blaming ideology" (Ryan, 1971, p xii), it also establishes a framework for defining social problems in terms of social conditions (e.g., poverty, racism, poor healthcare) and the groups that allegedly engender them (Seidman & Rappaport, 1986, pp. 1-3). These conditions concretize the split between the subjectified self and the objectified (or "inanimate") other (Fanon, 1968, p. 55; Freire, 1970, pp. 10-14).

I will suggest that this spilt leads to a scenario in which one's sense of self is defensively based on a mimesis of objectified others, one that rejects any awareness of internalization or introjection processes. The end result is a strong sense of an objectified self. Accordingly, the self is thought of as a copy of what is presented to the world on the surface of the other — that is, a copy of a copy, what Baudrillard (1994, p. 1) refers to as a simulacrum. Living in a liberal individualistic system filled with increasingly objectified others inevitably requires the mimicking of the defensive, palliated characteristics of others throughout one's development, producing objectified selves that are susceptible to the dread of isolation. Since it is an intolerable dread, individuals implement various defenses to dissociate their isolation within a monadic state of palliative care. In this state, cyst-like individuals become psychologically separated from the collective organism of community, society, and the world. The nourishment we might obtain through our connections with our own struggles and with each other is exchanged for our palliative rituals. As with any organ that is repeatedly attacked by toxins, the potential increases for a tumor to grow.

Out of this background has grown a system bound by implicit and explicit rules that control the commodification of palliative care. In this paper I will address the psychology of palliative treatment among individuals who want to avoid all forms of pain, discomfort, and anxiety, as well as within a world afflicted by so many perceived social ills, media-induced superficial self-criticism, and a sense of angst over our capacity for self-destruction. In many developed countries, this constellation has resulted in a broad range of activities that are used to alleviate our dread: consumerism, addiction, and fetishization are three examples of ritualized obsessional defenses that keep us from experiencing empathy for ourselves or others. The amount of palliative care we now ingest suggests the workings of a grand hospice in which we can collectively dissociate how our institutionalized pain management approach to life expands our inability to impact or be impacted by our own existence. The unconscious result: a sense of living in a terminal state.

Analysts regularly wrestle with the implications of a palliative treatment philosophy that supports an intolerance to the struggles, complexities, and experiences of everyday life; furthermore, we constantly struggle with separating this philosophical system from our patients' illnesses and emotions. It is my position that a personal or collective crisis can create a point of impact for penetrating the defensive character of our palliative care culture. In previous papers I have described how points of impact can create opportunities for making emotional contact with the circumstances that necessitate our disconnection from our individual experiences, our world, and each other (Borg, 2002, p. 348). These impact points occur when acute crises erupt within chronic crises, and thus retroactively allow for insights into the defensive operations that sustain the chronic conditions (Borg, 2003, p. 239).

Here I will explore the palliative care theme through an interpersonal psychoanalytic lens: a case study of a patient's first six years of thrice-weekly treatment sessions. Our work entailed a particularly powerful point of impact that was sufficiently painful to both patient and analyst so as to place an enormous burden on the treatment relationship. The patient's enactment of the palliative care philosophy was sustained through her connection to a deep wound — both actual and elaborated — born of a tragic accident that occurred when she was in her twenties. Her unconscious attachment to the accident and the pain that endured as its reminder/remainder served as a psychic black hole that pulled in all of her experiences and expectations.

During the first six years of our analytic relationship, I conceptualized Ms. X's treatment through an interpersonal psychoanalytic lens that reflects Harry Stack Sullivan's tenet that "everything that can be found in the human mind has been put there by interpersonal relations" (Sullivan, 1964, p. 302). Erich Fromm (1947, pp. 62-81) contributed to interpersonal theory by describing the workings of what he facetiously called "the sane society" (Fromm, 1955, p. 1) — a late capitalist society that induces receptivity, exploitation, marketing, hoarding character styles in its members who are acclimated to a bureaucratic and impersonal (social/political/cultural) environment that requires absolute conformity (Fromm, 1947, pp. 62-81). Sullivan, Fromm and other early interpersonal theorists such Clara Thompson, and Frieda Fromm-Reichmann thought of their approach as a "cultural model," in that it accounted for developmental process, personality and character styles, as well as psychopathologies not only on the intrapsychic level, but also as manifestations of living in a world where the primary source of satisfaction and security was related to actual others. According to Sullivan, the role of analysts is to observe, attend to, and appraise his or her own participation in the analytic process.

Freud and his followers — including many contemporary analysts — viewed (and continue to view) psychotic and borderline patients as "non-analyzable." In contrast, Sullivan viewed these conditions as human processes, and developed methods for working with such individuals (Sullivan, 1956, p. 125). His one-genus postulate, which states that "everyone is much more simply human than otherwise" (ibid., p. 32), was established from his work with such patients. He perceived psychotic states as existing at one end of a mental health and mental disorder continuum; unlike most theoreticians of his time, Sullivan (1940, p. 97) believed that human personality "tends toward the state [of] mental health or interpersonal adjustive success."

He also described schizophrenia and similar disorders as cultural phenomena resulting from early or ongoing failures in an individual's social environment (Sullivan, 1964, pp. 76-9). As the end products of acculturation to chaotic and traumatic family or cultural environments, he argued that such traumatic states are transmitted through empathic linkages between caretakers and infants in a process that is often repeated across generations.

Interpersonal theorists believe that anxiety serves as both a primary target for therapeutic intervention and a primary source of psychopathology. While they protect self-esteem and self-experience from being overwhelmed by anxiety, security operations such as selective inattention and dissociation also limit an individual's personal experience across domains of thinking, feeling, behaving, and interacting with others. Sullivan's "self-system" consists of all security operations that are developed to ward off overwhelming anxiety (Sullivan, 1953, p. 109).

Interpersonal psychoanalysts believe that experience and behavior take on meaning through interpersonal interactions that occur from the very beginning to the end of our lives (Stern, 1997, p. 148; Sullivan, 1953, p. 47). Through transference-countertransference interactions, a patient's intrapsychic and relational patterns (i.e., the workings of the self-system) are brought into the here-and-now of psychoanalysis for exploration, intervention, and understanding (Levenson, 1991, pp. 156-160). A commonly used approach is the analysis of patient-analyst enactments, which Hirsch defines as

What happens when the analyst unwittingly actualizes the patient's transference and, together with the patient, lives out [the] intrapsychic configurations … [enactment] is viewed as the patient's unconscious effort to persuade or force the analyst into a reciprocal action: a two-party playing out of the patient's most fundamental internalized configurations (Hirsch, 1998, p. 78).

According to Levenson (1972, p. 174), change is created via an analyst's ability to be "trapped, immersed, and participating in the system and then work his [sic.] way out." The experience of becoming embedded in and emerging from an enactment enables the participants in an analytic dyad to articulate the nature and depth of long-standing and significant areas of internal and interpersonal conflict, and use them as the basis for working through rigid defense patterns. Challenging ("working through") rigid patterns of thinking, relating, and behaving is aimed at loosening the tyranny of the self-system, which prefers to address anxiety by constricting self-experience and limiting the awareness of stimuli through dissociation and selective inattention. The interpersonal model relies on gathering data through a detailed inquiry into a patient's historical experience of self and others (see especially Sullivan, 1954). In the following section, I will present a history of my patient, Ms. X; it took three years for us to piece together this coherent picture.

Ms. X had been suffering for unknown reasons for many years before we met. Severe dissociative defenses had enforced a lack of awareness of her physical and emotional state, to the degree that she finally ended up in a hospital with back pain so severe that it caused her to collapse on the street. Her eighteen hours in emergency care included an intrusive interview and pointed questions about her psychiatric and drug abuse history. Ms. X was diagnosed as "psychotic," transferred to the hospital's psychiatric unit, and held for seventy-two hours. Upon her release, she was referred to the clinic where I work, just a few blocks away.

Wearing loudly clanging jewelry, coke-bottle eyeglasses, and a mop of brown-gray hair that covered her face, Ms. X arrived fifteen minutes late for our first session. I learned that she had participated in New York's punk scene, that she had been kicked out of her apartment ("struck homeless") while in the hospital, and that therapy was required by the shelter she had moved into. Self-described as a forty-five year old bisexual, she said that she had been very active in both grassroots politics and the city's drug world.

Her affects in this dream were disgust and overwhelming shame. She described feeling terror in her hope that she would not find her mother or sister in the factory, but also described a sense of belonging to the factory, as well as an irresistible urge to enact rites of passage that would affirm her as an integral part of its functioning.

Ms. X was born into a wealthy New England family. Her father inherited a janitorial supply business, but felt that his true calling was politics, and he and his brother held a number of local elected offices. Much of his time was spent in lobbying and fundraising activities. His wife, a registered nurse, reluctantly gave up her career when she became pregnant with Ms. X's older brother; the third child in the family was a younger sister. Ms. X, who claims to have very few pre-adolescent memories, describes her childhood as uneventful.

Her father, whom she views as a passive man, had a strong desire to mentor an heir to take over the family business, but Ms. X's older brother emphatically refused to participate in that dream. The father was strongly attached to the idea of a male heir, and when he started taking his 12-year-old daughter to his workplace, he gave her a male nickname. The brother has never been a central figure in our therapeutic work, but the sister has loomed large. While Ms. X was being treated as a son substitute, the sister (two years younger) was celebrated for her looks, encouraged to be completely feminine, and treated as a fragile girl in need of protection.

The one area in which Ms. X received equal encouragement from both parents was music. Her gifted mother taught her to play the piano at a very early age, and her father gave her a drum set and a guitar so she could play the raucous music that he felt suited her. During her whirlwind adolescence, the popular Ms. X was involved in a number of different bands, excelled in school, and "got no flack" from either family or friends for experimenting with bisexuality — for instance, when she rented a tuxedo and took a girl to her high school prom. Throughout these years, she continued to work for her father and proved to be, in her words, "a worthy heir." From childhood to early adulthood she was "fiercely independent," making every effort to ensure that she would "need no one." She also acknowledges an acute desire to be needed herself during that period, since she "only felt alive" in relationships such as the one she had with her father.

The military uses the term "friendly fire" when describing soldiers who are accidentally killed or wounded by their comrades. I've often felt that psychoanalysis is best viewed as the treatment of wounds caused by friendly fire. Patients often believe that the people responsible for their safety have let them down, even when their wounds were clearly inflicted by an "enemy" outside of their nuclear families. Acknowledging the friendly-fire casualties of one's family is a particularly powerful taboo in our liberal individualistic society, since it interferes with the pursuit of personal satisfaction and diminished discomfort. These psychological wounds therefore remain covert, sometimes gaining symbolic expression in physical problems associated with mental distress. Yet Racker seems to question what becomes of the guilty party, and speculates that patients must wonder in the transference, "What motive (in terms of the unconscious) would the analyst have for wanting to cure, if it were not he [sic.] who made the patient ill?" (Racker, 1968, p 146).

In many cases, psychoanalysts participate in this taboo; Freud's move to reject the reality of childhood sexual abuse (i.e., seduction theory) can be viewed as an important precedent. From his observations of various hysterical conditions, particularly paralysis, he developed his psychoanalytic thinking in terms of the mind's ability to govern physical realities (Freud, 1888, pp. 54-57). In the past three decades, however, some authors have questioned the comparative lack of psychoanalytic contributions to the issues of physical pain and psychosomatic illness (e.g., Anzieu, 1989, p. 13; Szasz, 1975, p. 75); others have taken the position that all pain is psychological (e.g., McDougall, 1989, Ch. 2; Taylor, Bagby and Parker, 2000, Ch. 4).

From the interpersonal perspective, Sullivan argued that psychosomatic illnesses are caused by the collective action of constitutional, environmental, and cultural factors (Sullivan, 1940, pp. 109-112). These causes are generally considered indigenous — that is, resulting from interactions among one's body, one's family, and one's society. He described how interactions with significant individuals (especially during early development) can lead to behaviors that might be perceived as medically (rather than socially) determined. These include strategic behaviors and rituals (often of a compulsive nature) that are unconsciously created to ward off anxiety. Emphasizing medical over social determinations, or the interaction of both, supports the taboo against acknowledging friendly fire — in other words, patients come to believe that their conditions are the fault of their bodies and not of their parents, or environments, or analysts.

It may be what we do with our pain and how we experience misery and suffering (consciously or otherwise) that marks us as members of particular communities or societies. Our bodies are transformed through damaging interactions with the world and with others — for instance, scars, amputations, AIDS, and cancer. For Adrienne Harris, "the body is a contested surface in which inner and outer demands get inextricably tangled … any body is thus a socially and historically specific site for psychic structure and meaning" (Harris, 1998, p. 44). We implement socially and historically determined dissociative-substitutive processes, psychosomatic psychopathology, and other forms of individualized enactments to navigate our way through our anxiety-ridden world. Such defensive processes make it possible to push aside awareness of troublesome psychological events and the feelings that attend them, as if pain, anxiety, and the circumstances triggering them could actually vanish. Symptoms (whether physical or psychological) serve as expressions of personal life patterns, and represent an individual's responses, reactions, and adaptations to interpersonal, familial, and cultural experiences.

It is also possible (as in Ms. X's case) that psychosomatic symptoms are used to enjoin ourselves with the sanctioned patterns that mark the palliative care system, thus dissociating — and therefore maintaining intact — the actual "friendly fire" wounds inflicted by our families and society. Ms. X's overt physical and psychiatric symptoms were primary intervention targets, while her real pain continued its symbolic and actual life unabated. It was as if her feigned acceptance of her status and her participation in the palliative care system were ruses to distract her treatment practitioners from interfering with — and helping her recover from — her actual wounds.

Character, as I am using the term, consists of repetitive interpersonal behaviors or interactive patterns that typify a person's sense of self, including one's sense of self-in-interaction with others and cultural institutions (e.g., family, community, government, media, and so on). Interpersonal theorists believe that adaptive and defensive patterns form a stable character structure for maintaining psychological security and for satisfying needs, especially in the presence of anxiety (Cooper, 1991, p. 725; Fromm, 1955, p. 12; Sullivan, 1953, pp. 329-331). Sanctioned patterns are established and reinforced through coercive interactions that threaten one's sense of security and satisfaction and sense of belonging to a particular family, cultural group, or society (Nancy, 1991, pp. 32-33; Sloan, 1996, pp. 85-6). These coercions can be subtly induced by ostracizing and secluding behaviors, and the sense of isolation can potentially grow to the point that it becomes an internal state represented by such institutions as prisons and psychiatric hospitals (as explored by Goffman, 1961). Patterns of reinforcement against such powerful taboos as acknowledging anxiety and pain are formed in the context of specific relationships (e.g., between parent and child) and maintained through the enforcement of cultural and community norms (e.g., prejudices, taboos, laws, and sanctioned rules of conduct).

Internalized (or mimicked) coercive interactions set the stage for transmitting culturally imposed, unconscious, and enacted sanctions that contribute to the establishment of characterological defenses — normalized patterns that serve as personal and cultural defenses against anxiety, empathy, and other potentially discomforting emotional states. By supporting the denial and enactment of an individual's encysted state, palliative care serves as a culturally bound character defense. Personal character defenses, bodily experiences, and their psychological underpinnings become dissociated and enacted through cultural rituals that further palliate our anxieties.

Since communities also develop characteristic ways of interacting in order to maintain security while dissociating awareness of internal anxiety, manifestations of the palliative care culture are also found at the group or community level (Borg, 2002, p. 348).[2] Community character is expressed through rules, regulations, taboos, and stereotypes; a number of individuals are required to serve as examples of what happens to rule-breakers. Fromm (1955, pp. 13-16) observed that character formation based on adjustments to a pathological society can produce psychopathology in two ways: via conformity to its rules and regulations and via rebellion against them. Within this no-win situation there are individuals who suffer from an inability to adapt and others who suffer from the compromises they make in the name of adaptation (ibid., Ch. 5).

The development of a palliative care culture has been accompanied by a shift in our definitions of "health" and "illness." Modern medicine has not only prolonged our lives, it has established a belief that life should be free of pain and anxiety. The most powerful disseminating agent for this concept is popular culture — especially the mass media, whose consistent message (or injunction) that defines the character of our liberal individualistic culture is: "Be well." The only acceptable response to "How are you doing?" is "Fine." We push aside the thought that we are anything less than well, even if we are suffering from enormous pain. To avoid the prohibited state of being unwell, we make increasing use of palliative treatments (aspirin, massage, Xanax, and a long list of diversions) to decrease our suffering and to dissociate incidents that remind us of our anxiety-ridden states. At the cultural level, palliative care is the enactment of excess pain and anxiety that is dissociated in conformity with the liberal individualistic injunction "Be well [ … or else!]."

With these societal defenses in place, we can use whole groups of individuals as repositories for projecting our deepest fears about our vulnerabilities and dissociated experiences of helplessness. The homeless, the impoverished, the "mentally disturbed," and drug addicts are used as examples of what we might look like if we surrender our collective defenses against "not being well." I have previously referred to these groups as "categorical scapegoats" (Borg, 2003, p. 237) whose individual members take on the emotional burden of our own dissociated anxieties about experiencing public vulnerability.[3] If empathizing with such conditions means putting ourselves into their associated emotional states, our general response is quite clear: "No, thank you!"

Is it possible that without such scapegoats — without an external target for the most dreaded aspects of ourselves — whole groups will split themselves and dialectically see themselves in fragments? Not only in every day clinical practice but also in political life, we see how an external threat decreases group fragmentation (Rendon, In Press). In a psychoanalytic context, our assessment of patient "analyzability" might indicate an institutionalized and politicized group resistance to the emotional dread, the potential fragmentation, that we might experience if we truly empathized with people in these groups. Furthermore, we risk using the term "analyzable" in response to our confusion over how to work with people in these conditions. Not to mention how the "analyzability" question allows us to dissociated our own racial and class biases, and other uncomfortable discriminatory tendencies. I will suggest that those who do not obey the "be well" injunction (reinforced by the standard wish/command of "Have a nice day") serve as scapegoats in their roles as "sick persons." Some find solace in counter-cultural movements built on the enactment and fetishization of breaking this rule — for example, bondage-dominance sadomasochism (BDSM) and the punk rock culture. In the punk culture, violating one's body via piercings, tattoos, and ("slam") dance style is accepted as a statement of rebellion, a political statement rejecting what has been done to one's self on a societal level. While some perceive these acts as pathological counter-cultural forms, they also confirm Fromm's point concerning the increasingly limited choice between personal pathology or adjustment to a pathological society.

And perhaps the whole "Be Well" process that I am attempting to describe is captured succinctly in the lines of the punk band NOFX (1997): "One thing's for sure, I'm all outta angst…Society don't bother me and there's something wrong with that." This is a society-level version of Sullivan's infamous distrust of a treatment that is going well. Ms. X maintained her commitment to a self-identity as an outlaw and a punk throughout all the pain and anxiety that she experienced, dissociated, and enacted — taking her side in the no-win situation Fromm described — and often tanking into dysthymia and hopelessness when she herself had run "outta angst."

At the age of 20, Ms. X was attending an Ivy League college, involved in the only heterosexual relationship she ever felt comfortable in, and was the leader of a band that signed a contract with a major record label. The bottom fell out of her world at the end of winter break, when she learned that her room, board, and tuition had not been paid. The next day, her father tearfully told her in his office that he and his brother had been found guilty of felonies related to their political activities, that he would have to give up nearly all of the family's financial assets (except for the janitorial business), and that he would be spending some time in jail.

The series of events that followed were not necessarily connected with this news, but are forever associated with it. Ms. X moved home to take care of her father's business while he was "away." Her mother reluctantly returned to nursing. Her brother disowned his family, and her sister announced that she was sleeping with Ms. X's boyfriend — a man who would eventually become her physically and emotionally abusive husband. Finally, two female members of Ms. X's band quit, leaving her with enormous contractual obligations.

One night her sister suggested that they talk about her affair with Ms. X's boyfriend. Under the influence of several drinks, Ms. X commented on how much she had always resented her sister's beautiful face. While driving home she lost control of her car and crashed into a tree, sending her sister through the windshield; the glass sliced through the sister's face from forehead to chin. Ms. X was pinned between the steering wheel and seat, but refused treatment for her injuries, which included significant damage to her back. At this point she committed herself to carrying the burden of her decompensated family, using her major wound to dissociate herself from a world that she could no longer tolerate. She felt like the priest in William Friedkin's (1973) film The Exorcist who exorcises the terrorizing demon out of the Linda Blair and into himself, and then makes a flying leap for the abyss — a scapegoat if ever there was one. It was also at this point that she began her long journey into an identity as a "categorical scapegoat," taking on a set of characteristics that would eventually qualify her as a member of several groups, including (but not limited to) psychotic, drug addict, and homeless.

In our discussions on the period immediately following the accident, Ms. X mentioned a "dull, thudding" back pain punctuated by occasional instances of acute pain. At the same time, she also felt a strong sense of exhilaration over her family's devastation, and maintained a sense of manic grandiosity accompanied by intermittent psychotic and delusional self-images as family destroyer and savior. Yet she never divulged her own pain and suffering — not even to herself. Over time, it became more and more clear that her psychosis was a function of this centripetal life event. The accident crystallized all of her painful experiences, pulling them together into a vortex of unmetabolized pain that took on a life of its own. The pain was also assiduously guarded by numerous "red herring"-type symptoms. In our explorations, the accident and its representation was experienced as an all-encompassing event that separated a fictitious but wonderful pre-accident family and self from a dreadful post-accident family and self — a shift that revealed the precariousness of her pre-accident adaptation.

Ms. X said that it was during the events that led up to and followed the accident that she realized how much hatred she had for members of her family, whom she variously described as her "fuck-up father," "passive, castrating mother," "abandoning brother," and "beautiful snake of a sister." She described other instances of eroticizing and fetishizing her family's wounds in addition to her meathouse dream. She had trouble elaborating on her experience of her own wound and its significant role in her self-experience, but over time we were able to speculate about how her actual wound served as a stand-in for the unmanageable immensity of failure that her family had suffered and for which she felt responsible. She also came to realize that the increasingly unsafe world that she had chosen to live in allowed for the actualization of additional tragedies — that is, she had effectively created a scenario for maintaining a somatic communion (meaning an emotional enmeshment through her most dramatic physical and emotional experiences) with her family and society.

However, in many ways Ms. X flourished during this period. She quickly overcame the initial disorientation that was associated with her family's breakdown — including what she later recognized as the first instance of what would become her long-term and intermittent psychosis. Her income increased sharply when she began working as an electrician. She wrote prolifically, became active in community events and political issues, and explored various romantic relationships and friendships. She also gained notoriety and status in the local punk scene. But at the same time, she also set the stage for her entry into a self-imposed palliative care system by experimenting with drugs and taking on a romanticized identification as an "outlaw." The self-destructive aspects of her life reflected her resentment over the insufficient care she had received from her family and the burden she carried for their failures.

In 1985, her mother was diagnosed with cancer. Over the next ten years, Ms. X gradually assumed financial and emotional caretaker roles for both parents. Toward the end of her mother's life, Ms. X was an easy target for the abuse that arose out of her mother's pain and delirium. Her mother began calling her "Your father's whore." She was repeatedly blamed for the family's collapse and described as a cancer that destroyed anything and anyone she touched. Toward the very end of her mother's life, Ms. X began stealing and using her mother's morphine, simultaneously increasing her mother's rage and her own hatred for her family. It also fed her need to address the pain that she was just beginning to acknowledge; the pain itself induced a strange sensation of meaning and enjoyment.

On the day of her mother's funeral, Ms. X's father caught her shooting up some leftover morphine; he accused her of killing his wife and demanded that she enter a psychiatric hospital. Upon her release, he gave her the address of a relative and a one-way ticket to New York City.

The term "scapegoat" was originally used to describe goats that were metaphysically burdened with the sin of an entire community and sent to the desert to die (Alison, 1998, pp. 95-96). Their deaths represented community cleansing — as dramatic an example of enacted dissociation as there ever was. Ms. X's role in her family was similar, and it grew into a role to be enacted within numerous domains. New York was her version of the desert, to which she had been banished to atone for the sins of her family and for the societal shortcomings that she perceived as having crushed it.

A scapegoat was never allowed to survive its banishment. Having performed its sacred duty in helping a community to cleanse itself of sin, the appearance of a scapegoat could no longer be tolerated, since it would symbolize a return of the repressed. So what would happen if the scapegoat did attempt to return, as, at least tentatively, was the case with Ms. X? Essentially the scapegoat has been severed from what Lacan called the "symbolic order" (Lacan, 1977, Ch. 20). That is, from all of her attachments to her community, as expressed through Law (prohibitions, taboos, etc.), placing her squarely in the realm of what he called "the space between the two deaths"(Lacan, 1991, pp. 231-2) — the place of the "undead." In Ms. X's case might exemplify this "space," as her body remained alive, but she had died in terms of psychic, emotional, and spiritual parameters. The result: her meathouse dream and her sense of living a zombie existence.[4]

And New York was this scapegoat's desert. According to Ms. X, her New York City relative was a heroin dealer. Almost immediately upon her arrival, she experienced severe migraine headaches and chronic pain that spread from her back to the rest of her body. Seeking relief from a sense of "going crazy," she began using what addicts call speedballs (a combination of heroin and cocaine), which led to a new round of psychotic episodes. In the two years between her mother's death and our first meeting, Ms. X was hospitalized at least ten times for psychotic symptoms, self-mutilating behavior, and suicide attempts of varying severity. By the time she was referred to my clinic, Ms. X had established a repertoire of psychiatric symptoms that completely subsumed her physical pain. She came to my office with a long list of diagnoses from different sources: schizoaffective, borderline personality disorder, opiate/cocaine dependent, and fibromyalgia. Still, the "psychotic" label seemed preferable to acknowledging her physical pain and its real and intrapsychically determined sources.

In terms of Ms. X's family, she felt she had "slipped off the planet" during her first two years in New York. With no family wounds or sins to sustain her, she lost her sense of being alive and turned into the zombie she described in her dream. She was horrified at the ways that her wound (in real life and in her dream) simultaneously symbolized her aliveness and her sense of being a dead person walking among the living. In her mind and through her enactments she created and sustained a family and a self that were much more cohesive in fantasy than they ever were in reality. But in the absence of her experience of and attachment to significant external others, Ms. X was left to feed on her own wounds.

When I began working with Ms. X, her only other consistent treatment team member was a neurologist to whom she was referred following her first psychiatric hospitalization in New York. The neurologist had extended Ms. X's palliative care regiment with prescriptions of Methadone, Percocet, Zyprexa, and Klonopin. Ms. X thus referred to her neurologist as a "croaker" — street terminology for doctors who write prescriptions in return for cash — perhaps an indication of her unconscious awareness of the palliative process of sustaining culturally-reinforced character defenses against all painful or uncomfortable experiences. It appears as though Ms. X was aware that her palliative care was similar to a virus that could infect an entire community: she portrayed her previous physicians as "falling for" the red herrings that her more overt symptoms represented, although in a highly dissociated state.

Our first two years of sessions consisted of bursts of uncontrollable affect and scattered descriptions of her drug regimen, her efforts to maintain her housing situation, and her overwhelming sense of hopelessness; she always appeared to be on the verge of another hospitalization. In the midst of these wild and often incomprehensible presentations, Ms. X gave unusually lucid descriptions of dreams that confirmed her feelings of being "a corpse among the living," but she quickly returned to her flare-ups of psychotic thinking. As her interactions with medical and social work staff increased, those individuals took on intensely hostile transferential meaning. Attempts to explore these relationships often erupted into screaming accusations of their alleged mistreatment of her.

During our second year there was a new exception to her scattered presentation. After a hospitalization for attempted suicide, she began using our sessions to describe her reactions to science fiction novels and philosophy texts in an extremely detailed, coherent, and intellectual fashion (she had been a philosophy major in college). These conversations included analyses of punk rock song lyrics, current political issues, and the many Star Trek[5] episodes that she watched at 4 a.m. on sleepless nights. She used her perceptions of my interested responses to bolster her idealization of me, our work, and her own sense of being likeable and interesting. Her focus on science fiction and technology indicated an obsession that served as a distraction from her cannibalized internal landscape. But her analysis still seemed to be the only relationship that was able to exist outside the wound/accident vortex that absorbed everything else in her life.

Staying on top of her labyrinthine offerings was tumultuous, frantic, and confusing, but never boring. In a single session she might scream about the dereliction of her "so-called caretakers" (always previous ones with whom she had lost contact), then burst into tears over her sense of helplessness, then ramble on about her day-to-day struggles in the shelter where she lived, then offer insights into Spinoza's metaphysics and its application to contemporary cybernetic innovation. She never questioned my ability to follow her — in fact, when I questioned her about this, she stated her belief that it was impossible for me not to "get it," without ever offering a definition of "it."

Excepting her hospitalizations, she never missed any of our sessions. Insisting that she was following her treatment plan by staying clean and sober, she worked her way through the homeless shelter system to the point where she had her own (case-managed) independent living situation. However, she was well aware of my occasional skepticism over whether or not she periodically abused her prescription drugs.

During the first four years of our relationship, Ms. X was hospitalized for two weeks every summer. She offered a vague connection between this pattern and a return to idyllic childhood summer vacations — the only times that she remembered as unblemished by family breakdowns. These events may have been connected to a desire for being taken care of. We attempted to take preventative measures during the second, third, and fourth years of our work, but to no avail. An especially discouraging incident took place in the fourth summer: when she was refused admittance at the hospital emergency room, she took a pair of scissors from her bag and slashed her wrists in front of the ER staff.

Upon her release one month later, Ms. X returned to therapy as a self-described "changed woman." Apparently the hospital staff was very confrontational about her abuse of benzodiazapines; her new intervention plan included significant increases in monitoring by her residence caseworker. Nevertheless, she described herself as "happy" — a word I had never heard her use before. She revealed that she had fallen in love with a woman she met at the hospital, a 29-year-old heroin addict who had been hospitalized for a recent overdose.

Ms. X's relationship with her new lover was similar to the one she had with her mother in the final stages of her mother's illness. Even though the lover was verbally and physically abusive, her "neediness" communicated a strong synergy built on their mutual wounds. In short, Ms. X felt needed again. Masochistically attached to her lover's palliative rituals, she was intoxicated by her lover's sado-suicidal enactments. Our treatment relationship had been threatened many times over the preceding years, but it wasn't until this relationship began that her analysis threatened to come to a complete stop. Not only was I overwhelmed by the sharp increase in her self-destructiveness, I was scared for her life. She was outraged that I couldn't simply "trust [her] on this one … and stop being such an asshole."

Four months into the relationship, her lover succeeded in killing herself. True to her previous role, Ms. X accepted her familiar scapegoat position by taking on the burden of and responsibility for her lover's death, and returned once again to the emotional desert of suicidal guilt and isolation.

Ms. X reacted to her lover's suicide with a combination of grief, pain, and terror. Acknowledging issues she had previously avoided, she expressed a desire to deal with "the possibility" that she abused her medications. Her romantic relationship had allowed her to give up her idealization of me and to replace it with a wish that I would "fuck off and die"; after the suicide, she profusely thanked me for my willingness to continue working with her. After one exceptionally difficult session, she apologized for any "painful repercussions" that her treatment had had on my personal life. She said this without the knowledge that I had started feeling acute pain from an old back injury; the pain was particularly sharp following this session.

After reflecting on the counter-transferential dimensions of this shared experience, I hypothesized that our work had exposed important aspects of my own cherished wound, which occurred during a parachute exercise while I was in the Army. Still in my teens at the time, I was certainly more of a "punk" than a soldier; I, too, had played in a punk band in high school. My compulsion to join the Army may have been based on my recognition that my father had been damaged by his two Vietnam duty tours as a helicopter pilot. After the session in which Ms. X apologized, I wondered whether my relationship with my own injury resembled hers, especially in their development, maintenance, and lack of medical attention. With this interpretation and a dissociated sense of how profoundly it might burden our treatment relationship, I incautiously headed toward its most important "point of impact." The chronic crisis we had been enacting became acute, opening the door to a more intimate (and hence frightening) way of acknowledging each other and the work we were engaged in.

At our next session, I explained the possibility that I might be experiencing a physical form of transference or somatic communion, and asked Ms. X whether she had any thoughts about my pain experiences. Her response was: "I think that you are nuts." I said, "And I think that your pain has been killing you slowly, like your mother's cancer, and like your mother's cancer, it will drive you completely crazy." After a few moments of silence, she started singing the lyrics of a song written by a long-forgotten punk band that we were both familiar with:

She then began screaming and begging me to not take "it" away from her; in the past, "it" had represented her relationships with her lover and her medications. She instinctively reached behind her to touch the site of her pain — the place where the laser-beam struck her in her dream, and almost the same place where I had sustained my injury. Crying, she fell to the floor and said,

In the transference, I represented the cultural forces that had transmitted the "be well" message to Ms. X. As a representative of this system, I was perceived as someone who could remove "it" (her wound, her pain, her scapegoated and isolated condition) and the multifaceted and interconnected relationships that "it" symbolized. However, I also had put her into a familiar position: would she feel that it was now her task (as a scapegoat) to take the burden of my pain and terminate the treatment? I had effectively worked my way into a most profound enactment with Ms. X — placing an immense burden upon her as she felt her family, and her society had done. It even went so far that I was actually considering termination! And like any good enactment, I not only did not recognize this crucial repetition, but I also had not a clue as to how we would work our way out of it. Yet during this process, the meanings and relationships that "it" represented began to surface.

After another silent moment, Ms. X gave detailed descriptions of her obsession with the physical aspects of her injury and her commitment to bearing her pain as a mark of the devastation of her post-accident family. She acknowledged making a vague link between the pain and the accident just prior to her first psychotic experience, and a later link with all of the emotional pain she had ever suffered. She described her view that many of the symptoms for which she sought treatment were potential "cover-ups" for maintaining these links — to her family, her deceased mother, and now her lover. She also admitted that, like a snowball, her core pain tended to grow by adding layers of painful experiences from the present to the internal wound that she alternately loved, hated, and suffered from.

The session marked the beginning of her mourning process. Over the next few months, Ms. X blasted me with her hatred and rage over what she believed to be my threat to take "it" away. Could I actually offer a viable sanctuary for a scapegoat who was considered dead? Was it even possible for the scaped goat to return from the desert? Her fear that her hatred might destroy me caused her to occasionally leave our sessions early and increased the uncertainty of her return. After considerable struggle and confrontation, she finally agreed to make an appointment with a pain management clinic — a suggestion I had been making for years — and to continue our efforts toward sharing her experience of her pain, responsibility for it, and recovery from it.

The doctors at the pain management clinic were astounded when they saw Ms. X's x-rays: her shoulder blade had been shattered in the accident, and they couldn't understand how anyone with such an injury could function with it for so many years. Her injuries required a series of major surgeries. As this paper was being prepared, she was continuing her pain management treatment — physical therapy, exercise, and collaboration with her analyst, but no narcotics. Her treatment program had made the transition from "palliative" to "reparative."

Over the past two years, Ms. X has made a steady effort in her analysis and physical therapy; over one year has passed since her last psychotic episode. She has willingly made connections between the general palliative care system (including her idiosyncratic enactments of it), her history of suffering, and the sense of loss associated with her giving up her scapegoat role. Her sobriety date is now considered accurate, and she has returned to her music and political activism. She is in contact with her father and sister, and is starting a relationship with a supportive woman who is willing to challenge Ms. X's old ways of denying her needs and absorbing the dysfunctional actions of others. While she still suffers from physical pain, it is no longer her sole focus, and no longer symbolizes her existence as a lonely, hungry corpse among the living. She sometimes misses the surreal worlds she encountered as part of her intermittent psychosis, and the desperate sense of urgency that drove her for so many years. She admits that she sometimes misses the pain that once served as the core of her sense of self.

Ms. X still struggles with some of the brandings that she picked up as part of her major role as a "categorical scapegoat": homeless, mentally ill, and drug addict. She now understands how difficult it is to shed the identifying markings of these labels — especially those that remain dissociated and are unconsciously enacted — once their respective wounds are inflicted. On the other hand, she remains ambivalent about her continued movement along the peripheral edges of the palliative care system. She recently gave me a demo recording of a song she wrote, one that could serve as a theme song for the last few years of her life. In the song's chorus she howls hauntingly over and over a bittersweet cry: "I couldn't cut it dying … "

1 Approximately 28% of all Medicare expenditures between 1990 and 1998 were spent on palliative care for patients in their last year of life; almost half of that amount was spent during the final two months. Although it contrasts sharply with the curative focus that otherwise dominates the American health care system, the expansion of palliative care is attracting increasing support (Marrelli, 1999, p. 2).

2 For a description of group-level defenses against anxiety used by institutions, see Menzies (1960).

3 This process parallels Holmes (1992) suggestion that "racial difference is probably as powerful a trigger and container for the projection of unacceptable impulses — with resulting prejudices toward the object of projection — as we have in our [U.S.] culture" (p. 2-3).

4 As an interesting contrast to this perspective, Deleuze and Guattari (1987, Ch. 12) present a romanticized vision of this "outlaw" condition, in which they describe "schizos" (such as Ms. X) as nomadic "war machines" that constantly elude late capitalism's hegemonic indoctrination and colonization efforts.

5 The irony of Ms. X being in treatment with a Borg (whose motto in the Star Trek television series was "Resistance is futile") was not lost on either of us.

6 "Guilt by Design," written by the unsigned punk band All Nite Rave in the early 1980s.

Alison, J. (1998). The Joy of Being Wrong: Original Sin through Easter Eyes. New York: Crossroads.
Anzieu, D. (1989). The Skin Ego. New Haven, CT: Yale University Press.
Barraclough, R. (1997). ABCs of Palliative Care: Depression, Anxiety, and Confusion. Journal of the American Medical Association 279, pp. 1365-1368.
Baudrillard, J. (1994). Simulacra and Simulation. Ann Arbor, MI: The University of Michigan Press.
Bellah, R., Madsen, R., Sullivan, W., Swindler, A., and Tipton, S. (1985). Habits of the Heart: Individualism and Commitment in America. Berkeley: University of California Press.
Borg, M. B. (2003). Community Group-Analysis: A Post-Crisis Synthesis. Group-Analysis 36 (2), pp. 228-241.
Borg, M. B. (2002). The Avalon Gardens Men's Association: A Community Health Psychology Case Study. Journal of Health Psychology 7, pp. 345-357.
Cooper, A. (1991). Character and Resistance. Contemporary Psychoanalysis 27, pp. 721-731.
Deleuze, G., and Guattari, F. (1987). A Thousand Plateaus. Minneapolis, MN: University of Minnesota Press.
Dick, P. K. (1965). The Zap Gun. New York: Galaxy.
Fanon, F. (1968). The Wretched of the Earth. New York: Grove.
Field, D., Clark, D., Corner, J., and Davis, C. (2001). Researching Palliative Care. Buckingham: Open University Press.
Freire, P. (1970). Pedagogy of the Oppressed. New York: Continuum.
Freud, S. (1888, 1964). Hysteria. The Standard Edition of the Complete Works of Sigmund Freud, Vol 1. London: Hogarth Press, pp. 37-57.
Friedkin, W. (1973). The Exorcist. Hollywood, CA: Warner Studios.
Fromm, E. (1941). Escape from Freedom. New York: Holt, Rinehart and Winston.
Fromm, E. (1947). Man for Himself. New York: Rinehart.
Fromm, E. (1955). The Sane Society. New York: Rinehart and Winston.
Goffman, E. (1961). Asylums. Garden City, NY: Anchor Books.
Greipp, M. (1993). An Ethical Model for Pain Management Practitioners. American Journal of Pain Management 3, pp. 125-130.
Harris, A. (1998). Psychic Envelopes and Sonorous Baths: Siting the Body in Relational Theory and Clinical Practice. In L. Aron and F. Anderson, (eds.) Relational Perspectives on the Body. Hillsdale, NJ: Analytic Press, pp. 39-64.
Herbert, F. (1985). Chapterhouse: Dune. New York: Ace Books.
Hirsch, I (1998). The Concept of Enactment and Theoretical Convergence. Psychoanalytic Quarterly 67, pp. 78-101.
Holmes, D. E. (1992). Race and Transference in Psychoanalysis and Psychotherapy. International Journal of Psychoanalysis, 73, pp. 1-15.
Knox, G. W. (1995). An Introduction to Gangs. Bristol, IN: Wyndham Hall Press.
Lacan, J. (1977). The Four Fundamental Concepts of Psychoanalysis. London: Tavistock.
Lacan, J. (1991). The Seminar, Book II: The Ego in Freud's Theory and in the Technique of Psychoanalysis. New York: Norton.
Levenson, E. (1972). The Fallacy of Understanding. New York: Basic Books.
Levenson, E. (1991). The Purloined Self. New York: Contemporary Psychoanalysis Books.
Lipman, A., Jackson, K., and Tyler, L. (2000). Evidence Based Symptom Control in Palliative Care. New York: Haworth.
Marrelli, T. (1999). Hospice and Palliative Care Handbook. St. Louis, MO: Mosby.
McDougall, J. (1989). Theaters of the Body. New York: Norton.
Menzies, I. (1960). A Case-Study in the Functioning of Social Systems as a Defense Against Anxiety. Human Relations 13, pp. 95-121.
Nancy, J.-L. (1991). The Inoperative Community. Minneapolis, MN: University of Minnesota Press.
NOFX (1997). I’m All Outta Angst. So Long and Thanks for all the Shoes. Los Angeles, CA: Epitaph.
Paice, J. (2003). Practical Palliative Principles. Journal of Pain and Symptom Management 25, pp. 93-102.
Portenoy, R. and Bruera, E. (1997). Topics in Palliative Care. New York: Oxford University Press.
Racker, H. (1968). Transference and Countertransference. New York: International Universities Press.
Rendon, M. (In Press). Beyond Community Analysis: A Response to Dr. Borg. International Forum of Psychoanalysis.
Richardson, F., Fowers, B., and Guignon, C. (1999). Re-envisioning Psychology: Moral Dimensions of Theory and Practice. San Francisco: Jossey-Bass.
Ryan, W. (1971). Blaming the Victim. New York: Random House.
Said, E. W. (1993). Culture and Imperialism. New York: Alfred A. Knopf.
Seidman, E., & Rappaport, J. (1986). Redefining Social Problems. New York: Plenum.
Sloan, T. (1996). Damaged Life: The Crisis of the Modern Psyche. London: Routledge.
Stern, D. B. (1997). Unformulated Experience: From Dissociation to Imagination in Psychoanalysis. Hillsdale, NJ: The Analytic Press.
Sullivan, H. S. (1940). Conceptions of Modern Psychiatry. New York: Norton.
Sullivan, H. S. (1953). The Interpersonal Theory of Psychiatry. New York: Norton.
Sullivan, H. S. (1956). Clinical Studies in Psychiatry. New York: Norton.
Sullivan, H. S. (1964). The Fusion of Psychiatry and Social Science. New York: Norton.
Szasz, T. (1975). Pain and Pleasure. New York: Basic Books.
Taylor, C. (1992). The Ethics of Authenticity. Cambridge, MA: Harvard University Press.
Taylor, G., Bagby, M., and Parker, J. (2000). Disorders of Affect Regulation. Cambridge, MA: Cambridge University Press.
World Health Organization (1990). Cancer Pain Relief and Palliative Care. Technical Report Series, 804. Geneva: WHO.