PSYCHOANALYTIC STUDY OF THE CHILD (1986), Volume 41: Pages 209-219.


Signs and Sequelae as Seen in the Analysis
of an Adolescent


Peter's analysis lasted for six years and started at the age of 13. Early traumatic and disturbing events played a striking part in his pathology and were vividly reexperienced in treatment. This short paper describes some of these reenactments and gives reasons why the experiences from which they derived might properly be described as "traumatic."

In spite of Peter's long and in many ways successful analysis, he remained a rather depressed young man, dominated by pervasive feelings of inadequacy which he tried to escape by sexual activities. During treatment, his compulsive masturbation, accompanied by sadomasochistic fantasies and his tendency to enactment, increasingly forced me to think of his disturbance in terms of sexual perversion.

During his masturbatory practices, he needed to create, simultaneously or in quick succession, sexual excitement, pain, and anxiety. He masturbated from early childhood, but in adolescence he enhanced his orgastic pleasure by tying a plastic bag over his head. In this way his fantasy was that a female partner was castrating and suffocating him was give an added dimension of reality.

A connection can readily be made between these sexual fantasies and practices and experiences in his third year of life, when he suffered intermittently from painful infections of the penis. These involved the mother in repeated examinations and manipulations of his genitals. Phimosis eventually required circumcision at 2 years, 8 months. His mother stayed with him in the hospital but could only report his bad reaction to anesthetic. In analysis Peter claimed to have memory of mother driving him to hospital for the operation, but this memory lacked any affective coloring.

There can be no doubt from Peter's analytic material that these events were crucial in the formation of his psychopathology and that, at least retroactively, they were experienced as vengeful attacks and punishments by his mother. By the time he entered analysis, his masturbatory conflicts were firmly linked with his feelings about his damaged penis and the conviction that he was an inadequate person in every respect. This narcissistic vulnerability and depleted self-esteem had, of course, earlier roots.

Peter was a disappointment to his mother from the day he was born. She was an inexperienced, anxious, rigid mother who was quite unable to cope with an infant whose behavior failed to match her exact expectations. The pregnancy proceeded according to plan until Peter arrived 12 days too early and had to be extracted by forceps. He cried a great deal during the first few months, which upset his parents' regimental household and lifestyle. He did not feed according to his mother's schedule, and her worry about his poor weight gain and slow physical growth led her to "force food into him." She probably became even less responsive to Peter's needs when she became pregnant, for a second time when he was only eight months old. All these circumstances reflect an unsatisfactory early interaction between mother and child, and the inadequate and curtailed symbiotic phase formed the core of Peter's disturbed self and object relationship.

In the second year of life, Peter's interaction with mother was dominated by what she described as "their great battle over toilet training." A battle which started when she was only 1 year old went on until well into this third year of life. when daytime bladder control was finally achieved. Contributory factors to this long delay included a stressful 2-week separation from mother and home at the time of the brothers birth, and the onset, some months later, of the phimosis.

The mother's narcissistic hurt and guilt in relation to Peter's imperfections may well have been compensated by her pleasure and pride in the new baby who seemed to thrive both physically and psychologically. Both parents described this younger brother as more satisfactory in every way. Not surprisingly, Peter's development began to lag, and according to his mother, his younger brother talked before he did. Irrespective of the accuracy of this information, it does suggest that Peter could not express his feelings in words at the time of the circumcision.

The unfavorable comparison with began on the day his brother was born became a bane of Peter's life. He felt that his brother was not only better loved but was superior in every respect. Two years before his referral for treatment, which was obstensibly was for learning disabilities in spite of his good intelligence (IQ 120+), Peter had suffered the ultimate humiliation of this younger brothers advance to a class above him at school.

He envied but also idealized this brother, casting him in the role of a genius - a second Einstein - whom he could never emulate. His revengeful hatred of the brother, an ever recurring theme in this analysis, was understood as a displacement of feelings he harbored for his mother for producing the brother and for favoring him. Later in treatment this also appeared as an oedipal displacement from the father who "possessed' the mother.

I have discussed the transference developments in Peter's analysis (1980). They led to a very clever recasting of his psychology in terms of double identification with the clever Jews who were nevertheless discriminated against and circumcised, and with the powerful, sadistic, get morally despicable Nazis. This expressed both the ambivalent investment of self and object relationship. It provided immense opportunities not only for the development of the analytic process, but also for resistance and stagnation in the analytic work when he used the treatment to gratify his sadomasochism. Even the most careful monitoring of countertransference cannot prevent a sadomasochistic patient from exploiting the analytic situation for perverse gratification. At all times Peter worked hard to get himself into a state of sexual excitement which served to ward off his depressive feeling states.

I hope this brief overview will provide sufficient background to give perspective to the analytic material which follows. This is unavoidably selective but I hope it indicates the significance of Peter's experiences around the phimosis and circumcision.

Both anxiety and guilt helped to make Peter a secretive boy, who, throughout the first year of analysis, deliberately withheld and distorted material. But at the beginning of treatment the anxiety was so pervasive that he could hardly communicate verbally. When he talked at all, his speech was difficult to understand and he was reduced to muttering under his breath such comments as "What is going to happen?" or "I haven't told you anything about my sins." I felt at the time that he was reacting to analytic situation as if it represented the Day of Judgement. In retrospect it is not difficult to see that the intimacy of the analytic setting, of being alone in the room with a woman who was immediately cast in the role of dangerous castrator, was both terrifying and seductive. Affectively, it seemed to have revived the traumatic childhood experiences in the most dramatic way.

In the early weeks of treatment he would silently draw maps of the London Underground system and respond to any comment I made by blotting them out. He would do so with such ferocity that big holes were all that were left on paper. This, while my attempts to establish contact through verbalization always mobilized fears that I might discover what he was deliberately trying to keep hidden, his sexual preoccupations were betrayed by his actions and concomitant affect.

Intense anxiety about his damaged penis was evident from the way he treated the felt-pens he used for drawing. He often handled them roughly and the anxiously looked at the tips for damage.

As if to underline his derisive rejection of my cautious and carefully worded interpretations, he also rejected my felt-pens and brought his own from home. This led to a strange enactment of the third week of treatment. He selected a red pen and found that the protective cap was stuck so he could not use it. He began to push and pull the cap with a mounting excitement and anxiety. Once or twice he held it out to me, apparently to elicit my participation, but then mistrustfully withdrew it. His face was flushed and his hands were covered with red paint. when he finally succeeded in pulling off the cape He anxiously inspected the tip, hitherto protected to see if it was damaged; and he disparagingly declared that his mother would jolly well have to provide a new one. While this material opened up the analytic work on his masturbation conflicts, and his view of the mother as responsible for his damaged penis, the full significance of this enactment in terms of his childhood experiences when his penis was sore and he had difficulty in urinating was recognized only some months later in connection with another, more dramatic, enactment.

Following his brother's visit home from boarding school (week 36) we had an unusually good session. For once Peter seemed in touch with his unhappiness and was able to talk about anger and resentment with his parents for being interested only in his brother. He complained that the whole weekend was spent in praise of his brothers good examination results and is making plans for his brother's future privileged education. He had experienced all this as a deliberate humiliation and reproach from his parents and throughout the weekend had felt an unwanted outsider in his own family. I had commented on the long-standing nature of such feelings and how they had contributed to his pervasively low self-esteem. Peter replied that the brother was the cause of his trouble and that he wished him dead or, better still, that he had never been born. Right at the start of this session it emerged that the weekend had also been the celebration of the brother's birthday.

He arrived the next day in a completely different state of mind. He was regressed; his communications were again non-verbal; his nose was blocked by an attack of hayfever, and he was desperate about the discomfort. He considered phoning his mother for advice, but reproachfully demanded instead that I do something about his agony and provide him at least with tissues. This I did. He started to attack his nose in a most sadistic manner. He placed a paper tissue on his lap, leaned over it, and tried to force mucous from his nose. He pulled, pushed, poked and blew, using both hands for these manipulations. He was totally self-absorbed in this frenetic activity which went on for quite some time until I intervened. I suggested that his concern about, and vicious treatment of his nose really referred to his penis and that he might be remembering something of what happened to him when he was a small boy and had phimosis. I tried to to put into words some of the discomfort and pain he must have suffered at the time, especially when urinating or when his penis was touched by his mother. Peter listened attentively and smilingly and said that I saw sex in everything. But he at once stopped attacking his nose and showed no further signs of discomfort from the hay fever.

Similar material reappeared on many subsequent occasions; it was particularly telling when we explored his compulsive need to masturbate. He explained that every time he failed to ejaculate he would have to try again. As this sometimes happened 10 to 12 times a day, it made his penis so sore that he feared permanent damage. In this way he was also attacking himself, while in his fantasies he was raping a girl.

The equation of ejaculation and urination, as a means of attack on the female object, persisted from his toilet- training battle with his mother. This battle was the background to his somatic and psychological experiences at the time of the phimosis and circumcision. This was also the psychological content of enactments during the early months of treatment, when he wanted to use his felt-pens on me, tried to squirt drops at me with his nasal dispenser, and left little pools of water all over the floor of my room. Later, when verbalization replaced acting, he would just threaten to piss on me when he felt he needed to counterattack. There was a mounting excitement and triumph at the height of the attack, but his was at once followed by fear of retaliation. But eventually we learned that an important motive for the attack had been the wish to engage the object - even if it was only in battle.

This sadomasochistic mode of relating was evident in all of Peter's relationships outside the analysis as well. He provoked others to counterattack though his non-verbal attacks and abuse.

With his mother, he still achieved closeness though his body. While she was quite impervious to his psychological needs, she always appeared concerned about his physical ailments and imperfections. The slightest complaint of pains in his neck or back secured the mother's immediate attention, and she would start to massage him. She repeatedly drew attention to a minor impairment in the movement of his left arm for which she gave him physiotherapy. She often dragged him to doctors. e.g., for a verruca which she thought should be excised rather than treated medically as the doctor suggested. There were endless battles about cleanliness and about he need for Peter's hair to be "trimmed" (a term he also used to describe circumcision).

In this way the mother reinforced Peter's castration anxiety, and she communicated her view of him as imperfect. But her physical ministrations sexually excited her adolescent son and in this way she perpetuated and compounded his difficulties. When the doctor suggested prophylactic injections for the hay fever, the mother persuaded him to let her give Peter the course of injections herself. Although he feared that she might hurt him or ever kill him, he submitted to her without protest. In the analysis he spoke of using the experience as a stimulus for new variations of his sexual fantasies.

I can see with hindsight that this material was also enacted in the transference, long before the full implications were understood. In the eight week of treatment he developed a sudden pain in his back and wanted me to do something about it. Instead of exploring with me what something could mean, he quite literally stripped to the waist, ostensibly to see what his mother could have put in his vest to cause the pain.

There can be little doubt that the somatic and psychological experiences occasioned by the phimosis and circumcision were experienced by Peter as abuse and victimization. Child abuse by mothers and medical experimentation by Nazi doctors on the sexual organs of concentration camp victims were recurring topics in the analysis. He also emphasized that such brutalities left the victims physically mutilated, mentally retarded, or even dead. He, of course, saw himself both as physically mutilated and mentally retarded.

It would seem that the traumatogenic experiences in his second and third year of life also unleashed massive aggression which his disciplinarian parents met with condemnation, physical beatings, and further assaults and abuse. Peter's "sins" and "guilty crimes," to which he alluded at the beginning of treatment, referred to quite violent, aggressive attacks on animals and children. He "accidentally" killed a kitten; he hit a boy over the head so he needed six stitches; and he almost drowned a girl in the swimming pool. These episodes must have occurred between the ages of 4 and 8. He was riddled with guilt about these murderous attacks. After his banishment to boarding school, his behavior was reversed. Though, in more subtle ways, he himself soon became the butt and victim of others.

Primitive aggression threatens to destroy the object and self and mobilizes massive anxiety. It may well be that for Peter the anesthetic concretized and dramatized self destruction, death, and suffocation. The mother had told us that Peter reacted badly to the anesthetic, but was unable to remember anything else about the circumcision. It may be speculative to suggest that Peter brought into analysis somatic memories of the panic he experienced when given the anesthetic, but the idea was prompted by the following events.

From time to time Peter froze into a motionless state and sat for several minutes with fixed staring eyes and a masklike facial expression. He would emerge from this trancelike state, either spontaneously or in response to my intervention, only after a violent jerking movement of his head, which was suggestive of a deliberate effort to rid himself of something compelling and terrifying. In discussion various hypotheses were suggest to account for these puzzling episodes. Did they indicate a kind of petit mal caused by organic impairment? Did they suggest a kind of hysterical twilight state or even some kind of hallucinatory experience? Did they represent attempts to immobilize his body in order to control sexual excitement and terrifying fantasies?

As soon as Peter's fear of treatment lessened and he could begin to permit himself to convey his feelings and fantasies, these trancelike states disappeared and an organic basis seemed unlikely. But a defensive "withdrawal into fantasy" in the face of anxiety, or painful effect mobilized by any kind of internal or external impingement, remained. At such times Peters was always difficult to reach.

It is of interest that in the third year of treatment the trancelike state made a brief reappearance in one of the sessions. I noted that it was a dramatization of the early states because by that time Peter's self-observing capacities were sufficiently developed to prevent precipitation into panic. He could also acknowledge what had happened and explore it a little. He recalled the frequency of such panic states in and out of analysis and thought of them collectively as "my madness." He thought now that it was his way of "shutting off" the outside world and concentrating exclusively on fantasy. I was doubtful whether he really had this degree of voluntary control. We were able to link the heightened state of anxiety in this particular session to a transference fantasy that his sadistic attacks would really destroy me, bring treatment to an end, and leave him totally abandoned. It was this "painful realization" he must of tried to "shut out."

I have always harbored the fantasy that the anesthetic was given by a mask and a bottle. If this were so, it would make sense of Peter's perception of death as suffocation, and his use of a plastic bag, in later adolescence, to support his fantasies of castration and suffocation by a big woman. It is a fact that fantasies of being victimized, passively overwhelmed, and cruelly punished to the point of death were sexually exciting just because the aggression was turned against the self and alleviated guilt.


The events surrounding the phimosis, the concomitant interventions, as and subsequent operation profoundly affected Peter's development. Self and object representations were crystallized around these experiences, and the relationship locked in a sadomasochistic battle for survival. The perception of his mother as malicious attacker, whose longed-for attention an concern could be obtained only by suffering pain and be relinquishing his penis, absorbed, restructured and organized a whole range of earlier experiences and conflicts.

His unrequited longing to be loved, his envy of his brother as usurper of his rightful place, the dangers stemming from his heightened aggression - nurtured by unmet early needs, forced feeding, and rigid toilet training - all became organized around the experience engendered by the phimosis and circumcision. The anal phase battle for power and control acquired a particular potent input from hurting an being hurt and became focused on the penis. The mother became all important as the provider of pain and sexual excitement - a sadistic attacker and seducer - and a powerful model for identification.

All this colored the way Peter came to experience his rivalry with the feared and oedipal father, his highly ambivalent relationship to his brother, his banishment from home at the age of 8, and his relationships with to teachers and peers at boarding school. What was so striking in Peter's analysis was the way in which all the avenues pursued led to the experiences surrounding the circumcision.

How do we conceptualize the nature of such an "organizing experience" (Yorke, 1986) which not only shapes what Herzog (1985) has called "the developmental line of personal meaning" but also propels the psychosexual development along a deviant path and generally constricts ego functioning?

Of course the analysis only gradually and laboriously unraveled the various layers and developmental transformations of Peter's masturbation fantasies and conflicts. But how do we explain the emergence of specific and and apparently encapsulated memories, through the most primitive, symbolic, and concretized enactments at the beginning of the analysis?

Do these unconscious enactments of the manipulations of the penis, the difficulties in urinating, and the experiences of the anesthetic reflect the the "traumatic" impact of these events? Affectively they were all charged with an admixture of excitement, pain, and panic. Are we to interpret them as signs of "trauma" in the classical sense, that they mobilized a degree of affective excitation which overwhelmed vulnerable ego functions; could not be dealt with at the time, became encapsulated as primitive memory structures, until they were reworked and raised to a higher level of integration in the course of the analysis?

There were also some technical implications concerning reconstruction, which arise when working with a patient like Peter. I found it useful to organize my reconstruction around the "trauma of the circumcision" because this was the most meaningful in terms of Peter's current experience. But in the view taken of an intrapsychic "organizing experience," reconstructions of this kind may also be more meaningful in terms of the childhood past. Reconstructions must be intrapsychically meaningful rather than be historical or developmentally accurate.


Hertzog, J. M. (1985). Early somatic illness and pain. Presented at the Anna Freud Centre Colloquium.

Kennedy, H. & Yorke C. (1980). Childhood neurosis v. developmental deviations. Dialogue: J. Psychoanal. Perpectives, 4:21-33.

Yorke C. (1986). Reflections of the problem of psychic trauma. Psychoanal. Study Child, 41:221-36.

       Codirector of the Anna Freud Centre, London, which is at present supported by the G. G. Bunzl Charitable Foundation, London; The Freud Centenary Fund, London; The Anna Freud Foundation, New York; The New-Land Foundation, Inc., New York; The Leo Oppenheimer and Flora Oppenheimer Haas Trust, New York; and a number of private supporters.
       Presented at the International Scientific Colloquium on "Repeating: Enactment and Verbalization in Different Stages of Development" held at the Anna Freud Centre, November, 1985.

(File revised 19 October 2006)

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