A Far Cry From A No Thing Psychoanalytic Perspectives on Women and Secondary Amenorrhea Danielle Fortunée Redland Goldsmiths University of London 2018 PhD in Psychoanalytic Studies Department Social, Therapeutic and Community Studies 1 Declaration of Authorship I, Danielle Redland, declare that this thesis is my own and that it has been generated by me as the result of my own research. Where information has been derived from other sources, I confirm that this has been referenced. Historical clinical case studies have been sourced from published material and new cases have been presented in this thesis with the consent and support of those involved. 2 For Sarah, Evie, Jonathan and Benjamin 3 “Wait without thought, for you are not ready for thought: So the darkness shall be the light, and the stillness the dancing” (Eliot, Four Quartets: East Coker). 4 ACKNOWLEDGEMENTS My thanks go to Christopher Hauke, my PhD supervisor whose psychoanalytic thinking and craftsmanship renders him a master builder. He has enabled me to create this thesis autonomously and yet I have never once felt alone. Thanks also to Tina Simmonds who supervises all of my clinical work: Experience counts. Thank you to Christopher Bollas, Riccardo Lombardi and Cynthia Rousso for their correspondence: So to, “Mary,” “Belinda,” “Rachel” and their families who gave me permission to share their stories for the first time here in this thesis. Francis Grier and Andrew Balfour helped me at crucial checkpoints in my own analytic wanderings and to Rabbi David Mason and Mr Demetrios Economides, thank you too. At present, my weekly conversations with Michael Brearley are valuable. Difficult, yes, but there is much to be gleaned from “the talking cure.” Change can be both a blessing and a curse and I wish to acknowledge and thank Adam and our children for the camaraderie, continuity and connections maintained and created during this process. To my parents, I am grateful for their continued love and support. To Sharon, Dani, Jessa, Yael and Carolyn thank you. Last but by no means least, to my canine companion Toby who knows the wild woods much better than I ever could. 5 ABSTRACT Secondary amenorrhea is predominantly viewed outside of the social norms, somehow beyond the natural order of things. It might appear to reside in the shadows of its menstruating counterpart, viewed as that which is lacking, but this thesis will prove otherwise. Secondary amenorrhea is a very powerful and present symbol that makes its mark in medical, cultural, social, anthropological, political and religious life. Narratives of womanhood and statehood dominate. Examples will be draw from women in war and the Holocaust, hysterics of the late nineteenth century, prominence of patriarchy, gynecology, psychogenic trauma and eating disorders. What though for the individual? What does it mean when a woman of menstruating age stops bleeding and what does it matter to her or to us? This thesis considers how the mind weighs heavily on the body. Through the application of psychoanalytic thinking, this thesis will link the cessation of menses to the unconscious registers suggesting that there is a communication of the psyche that looks to the body to find expression. Issues of symbiosis, inter- dependency, individuation, alienation, separation and loss are themes that recur in cultural and historical narratives worldwide and in the clinical work. These are discussed using examples from the consulting room. Psychic conflict and the search for resolution will be demonstrated in a psychoanalytic review of Ovid's Pygmalion and Shaw's retelling of the story. We shall also consider the role of the analyst by studying Freud's failed treatment of Emma Eckstein. The purpose of this thesis is to show just how much presence there is in this supposed absence. 6 CONTENTS pages Introduction and Chapter Summaries 8-22 Chapter 1 Far Cry From a No Thing: Commentaries on Secondary Amenorrhea 23-68 Chapter 2 Currencies of Blood and Laws of the Land 69-122 Chapter 3 Nazi Blood Ideology, Menstruating Women and War Amenorrhea 123-137 Chapter 4 The Body Boundary, the Ego Boundary, Non Menses and Patterns Of Relating in Eating Disorders 138-177 Chapter 5 (Parts I & II) Metamorphosis – Ovid and Shaw’s Retelling of the Pygmalion Myth, The Process of Change in The Psychoanalysis and Treatment of Secondary Amenorrhea 178-253 Chapter 6 A Bloody Affair - Freud, Fliess and Emma Eckstein: A Psychoanalytical Re-examination with Amenorrhea in Mind 254-291 Conclusion 292-304 Notes to Chapters 305-311 Appendix 312-314 Bibliography 315-357 7 INTRODUCTION The purpose of this PhD is to elucidate and validate the exploration, thinking, understanding and treatment of secondary amenorrhea as seen through a psychoanalytic lens. The study of secondary amenorrhea from a psychoanalytic perspective is designed to reveal just how much presence there is in this supposed absence. It is a rich terrain, as yet unexplored. Amenorrhea, by definition, describes a woman’s absence of menstrual bleeds. Primary Amenorrhea is the failure to start having periods by the age of sixteen. Secondary amenorrhea describes a cessation of periods in women of menstruating age and it is with secondary amenorrhea that this thesis concerns itself. On a physiological level, the reasons for secondary amenorrhea can be linked to genetic patterns, endocrine systems and hormonal imbalances. A woman’s menstrual physiology can also be influenced by race and / or ethnicity with differences in cultural attitudes and beliefs mirroring differences in menstrual cycles. All this will be examined to illustrate the ways in which we as individuals and as a collective engage with secondary amenorrhea. We shall explore its symbolism and demonstrate its usage and its value in the realms of both conscious and unconscious thought and motivation. Whilst there are some written works on the menstrual cycle, one might question to what extent the subject of amenorrhea is taboo. Often, the word amenorrhea does not feature in the indices of some of these books on menstruation and it’s lucky to get a mention at all. When it features in medicine, obstetrics and gynaecology it is frequently dismissed as an error, solved by overriding the body’s system with medication or intervention. In the consulting room, psychotherapists often “forget” about their patient’s menses. The opportunity to think about that which has been “lost,” is lost to both analyst and patient. As eminent psychoanalyst and writer Christopher Bollas reflects 8 “it is curious (odd, unconsciously significant?) that the menses is rarely discussed not only in the literature, but actually in the “course” of an analysis” (C. Bollas, pers. comm, 13th Sept 2016). My thesis intends to identify and locate the many different places in which secondary amenorrhea does feature, both alongside its menstruating counterpart and in its own right. As far as I am aware, this thesis is the first of its kind to bring together all the different strands and to present them in one body of work. On a biological level, the female menstrual cycle and the female reproductive system depend on a coordinated interplay between a quartet of organs – the hypothalamus, the pituitary, the ovaries and the hormonal priming of the endometrium. This interplay either results in a successful embryo implantation or it results in the onset of menses and the start of a new reproductive cycle. Failure of one of these components to play their role in this organisational set-up causes disruption and can result in amenorrhea. More specifically, it is the hypothalamic – pituitary ovarian axis that receives and integrates external incoming information such as light, pain, temperature and smell alongside internal information such as blood flow that brings about a menstrual bleed: And if this information is not successfully processed, the function of the axis becomes disrupted and amenorrhea will result (Santoro & Neal-Perry, 2010). Let us suppose now that this bodily disruption is mirroring and being mirrored by a similar organisational state of mind in the psyche of the amenorrheic patient. In other words, there is disharmony in her internal world and the way in which information is communicated, distributed and processed is sent off kilter. A dislodging might perhaps be the result of a trauma, a fear or a neurosis. It might reside in the place of fantasy (known) or phantasy (unconscious). Whether it be real, imagined or what we term “as real,” a disturbance comes into its own. As a result, her psychic axis is no longer in a state of equilibrium and unconscious, conscious, external and internal communications are interfered with. Thus, both her mental and menstrual flow are shored up and halted. Over time, perhaps this state of secondary amenorrhea becomes a friend to the patient rather than a foe, as it defends against the complexity and mess that is normally associated with 9 the bodily menstrual process and the mental maturational process. One of the difficulties in the treatment of these patients comes about when the body supposedly betrays the mind and the patient’s menses returns. Of the case studies I have included, the reader shall see how some patients who have come to psychotherapy with amenorrhea “miraculously” start to menstruate and continue to have regularly monthly menstrual bleeds. Some become pregnant: This, without any medical interference. The shift in the bodily mechanism is often mirrored by an internal shift in the psyche but all this comes with its own health warning. Carefully managing the patient’s metamorphosis, safeguarding a fragile ego and maintaining her psychic equilibrium are no mean tasks but they are imperative in ensuring the successful outcome of these analytic encounters. If the patient experiences a rebirth, “shedding a skin” as one patient described it, what must be foregone? It was in the unearthing of these case studies that my own seeds of curiosity took root and it is hoped that this PhD will arouse the curiosity and interest of clinicians and patients in all fields of therapeutic work.