Psyche-Soma Disturbances: Working Psychoanalytically with Visual Impairment and the Dilemma of Recognition

Isolde Keilhofer, LP

“I would be most thankful for a sheltering

shadow of an incognito.”

~ Charlotte Bronte

Oliver Sacks, a neurologist, naturalist and author, whose writings are currently much in the air, brings and kindles a respectful fascination with unusual neurological conditions.  His curiosity, at times, is based on personal vulnerabilities.  Sacks can be drawn upon as both a model for openness and for his empathic interest in the complexities of perception.  Sacks himself suffered from prosopagnosia, also known as face blindness, a neurological condition resulting in the inability to recognize faces.  Although non-neurological visual impairments are the focus herein, Sacks gets to the heart of the matter: the agony of missed visual recognition, social isolation, and communicating awareness, including self-awareness, of such vulnerabilities.


A word about definitions.  Visual impairment, vision impairment, vision loss, or low vision is distinct from blindness, and includes a spectrum from mild to moderate to severe.  Not all visual impairments fall into the category of legal blindness, a government definition that varies from country to country and has more to do with benefit entitlement than describing functionality.  Various functional demarcations do exist, one especially around the ability to read print, in other words, being able to function in some sighted way in a sighted world.  Other important distinctions must be borne in mind, such as congenital, or lifelong, versus later-in-life eye diseases, some leading to blindness and others not.  A multiplicity of eye conditions exist and involve varying degrees of vision loss and function, with varying types of adaptive possibilities, often contradictory, and with varying degrees of psychological, often devastating, impact.


It is these in-between states, not fully blind, not fully sighted, that are of particular interest to me; it is a state I live in.  The questions of self-disclosure are important ones, there are assets and liabilities of a hidden, or partially hidden, disability, or of hiding a disability, and from whom, including or excluding hidden pain, sudden exposure and the improbability of relief.


How does psychoanalysis fit into this mix?  Psychoanalysis came into being as a treatment for hysteria often associated with physical maladies with no known physical causes.  Yet, Freud’s libido theory, the theory of instincts, is a frontier concept between the physical and the mental, imbued with ambiguity (Freud, 1915).  Freud’s bodily ego is the bedrock of psychoanalytic theory, and, although as a therapy it is focused on the psychological, there is no escape from the limitations of the body (Freud, 1937).  Freudian theory is not one-sided in the understanding of symptoms, for example, and a very fitting one, Freud writes in an early case history: “Frau Emmy was extremely short-sighted and astigmatic, and her hallucinations may often have been provoked by the indistinctness of her visual perceptions” (Freud, 1893, p. 64).  As Freud indicates, actual physical symptoms can take on symbolic meaning, involve secondary gain and become entwined in fantasy life in complicated ways.


Marginally, there has always been psychoanalytic interest in actual physical limitations.  Anna Freud and Dorothy Burlingham did extensive research on blind infants at the Hampstead Child Clinic, albeit as part of their far reaching project, the conceptualization of normal developmental lines (Burlingham, 1961; A. Freud, 1965).  Rene Spitz (1965) brought the study of direct observation to infants.  In terms of vision he surmised that perception, as opposed to visceral reception, had to be learned and was much dependent upon object relations and the reciprocity between infant and mother, a pre-verbal dialogue.  Spitz, however, was most interested in psychogenic diseases.  From Georg Groddeck to Franz Alexander to Joyce McDougall, it seems that psychosomatic interest and theory, invaluable in many ways, generally prevails.


The complexity of symptoms, however, can lead to the danger of mistaking a physical one for a symbolic one.  The most infamous case of this involved the composer George Gershwin in the 1930s.  For years he suffered from terrifying headaches, attributed to psychogenic causes by his analyst, a medical doctor, by the way.  In actuality, the headaches were caused by a growing brain tumor from which he died in 1937 at the age of thirty-eight.  Scholars have argued that had he been diagnosed in time, his particular type of tumor could have been eradicated (Leffert, 2011).  This can be taken as warning against the poeticizing of symptoms and an analytic omnipotence of cure.


Nancy McWilliams in an important chapter, “Assessing What Cannot be Changed,” in Psychoanalytic Case Formulations, writes:


When supervising or consulting on the work of other therapists, I am often struck by the extent to which physically limiting conditions are ignored or dismissed—even by practitioners with medical backgrounds who have presumably more training in diagnostic evaluations for what was until recently called organicity.  (McWiliams, 1999, p. 52)


For example, turning back to Oliver Sacks, he did not realize that his inability to recognize faces was a cognitive disorder until 1985, when he was then in his fifties.  A realization enabled, in part, by the many responses to his writings by those sharing a similar, painful fate.  I wonder, was an SOS, a signal of distress, finally received.  In fact, prosopagnosia is greatly under-diagnosed.  Prior to diagnosis, Sacks blamed himself, his absent-mindedness, his character (Sacks, 2011).  He writes:


But I think that a significant part of what is variously called my ‘shyness,’ my ‘reclusiveness,’ my ‘social ineptitude,’ my ‘eccentricity,’ even my ‘Asperger’s syndrome,’ is a consequence and misinterpretation of my difficulty recognizing faces.  (Sacks, 2010, p. 37)


One can imagine a therapist missing this ‘organicity.’  Indeed, Sacks relates an episode that took place after an analytic session in the lobby of his analyst’s office building, when he did not recognize a man waving at him.  It was his analyst, a psychiatrist, a medical doctor, with whom he had worked for many years.  Sacks adds parenthetically, and one wonders why parenthetically:


This failure to recognize him came up as a topic in our next session; I think that he did not entirely believe me when I maintained that it had a neurological basis rather then a psychiatric one. (Sacks, 2010, p. 37)


One wonders if anguish was present and perceived.  This brings to mind Bion’s notation: “…communication depends for its efficacy on the capacity for receptiveness of the receiver…”  (Bion, 1992, p. 271).


McWilliams shows an empathic understanding of the therapist, eager to bring about change, when she writes, “something that cannot change may seem less exciting as a therapeutic goal than exorcising one’s dispensable neurotic demons…[.]”  Yet, adamant about catching on to denial, collusion and the need for realistic assessment, she continues, “the adaptive process is crucial to human well being” (McWilliams, 1999, p. 49).  In other words, limitations must be recognized.  And, of course, mourned.


It is Winnicott, the great British object relations theorist, who opens mind and heart to the intricate dance of psyche-soma and directly addresses the impact of what he calls physical abnormalities.  To begin with, for an infant, whatever is, is normal.  Winnicott gives the idea, in his illuminating, yet elusive way, that if a baby or child is accepted as a self, as is, the later, also necessary acceptance of having something wrong somewhere can be achieved on a healthy basis.  A mother is constantly introducing and reintroducing a baby’s body and psyche, an attitude of shame, fright, guilt, fear can distort self in body integration (Winnicott, 1989).  Winnicott stresses the mirroring that a mother provides, he writes: “‘I am seen or understood to exist by someone […] I get back (as a face seen in a mirror) the evidence I need that I have been recognized as a being’” (Winnicott, 1965, p. 61).  What can go awry, I wonder, for the visually impaired infant who lacks this mutual gaze or mirroring?  And, what can go awry for a mother whose infant does not quite see her?  I imagine Winnicott imagining that particular mother who can help her infant find another means of exchange and also imagining that particular mother who cannot.


The tone of loss that emerges when working with patients who have congenital visual deficiencies is significantly different from patients beset with vision loss later in life.  It brings to mind the distinction Winnicott makes between privation and deprivation: with privation there is absence, longing perhaps for a stillborn capacity, and with deprivation there is something once possessed, now gone (Winnicott, 1965).  It is doubtful, in either case that a one-time mourning process can lead to a newly minted self; many disabilities present ongoing, or unrelenting, challenges.  To borrow an image, a bit out of context, from Bion, borrowed from Milton, the blind poet, mourning in these cases is like the mythical river Alpheus, it flows underground and reappears, pops up, in “extraordinarily different places” (Bion, 1978, p. 35).
As surveyed on the vast PEP Web Archive, physical impairment seems a foreign concern in psychoanalytic writing in general, and papers on visual impairment are particularly sparse.  A striking omission, given the central role vision plays in psychological development.  Concurrently, the counseling available in the low vision world is often confined to mobility training, to social work, or is often lacking altogether for those that do not fit into the legally blind category.  Vision counseling is an important component, it takes a village after all, but deeper psychodynamic therapy is needed and calls for your involvement.
In one of the PEP articles, “Analyzing the Traumatic Impact of Childhood Visual Impairment,” Hertel discusses three such adult cases.  In the first, a patient, on the verge of ending a six-year treatment, makes a passing, almost missed, hint at a silent childhood struggle with severe myopia, that only then became available to be worked on in therapy.  Hertel’s honesty in reporting a treatment that almost ended without addressing a central trauma is laudable.  Bringing Winnicottian play into the mix, one might wonder if this patient created the acceptance of himself as whole before revealing that something wrong somewhere part of himself for deeper regard (Winnicott, 1989; Eigen, 2002a).


In another of Hertel’s cases, the patient had an accumulation of eight or more years of work with other analysts in which his strabismus, or double vision, and its daily stressful toll, was not once discussed.  Hertel indicates how the trauma itself of visual impairment is gravely compounded by going unrecognized; missing this again in analysis re-traumatizes.  McWilliams amplifies this danger of therapeutic re-traumatization to include a wider range of patients with physical and mental limitations of all sorts.  The historical misdiagnosis and mistreatment, both medical and social, of dyslexia is another such example.


Hertel’s important thesis is as follows:


Children with visual problems cannot “see” the ego trauma caused by looking through their damaged eyes. Significant others usually do not “see” the children’s trauma either. Thus, a silent, insidious undermining of the self ensues. It will likely continue throughout life unless there is an “other” to reflect the damage to them and help them work through its traumatic effects. (Hertel, 2003, p. 913)


This impossibility of self-recognition, with untold developmental consequences, differs from the denial that McWilliams cites as a very common response to physical limitations.  The difference is expressed succinctly in Hertel’s epigraph, from Shakespeare’s Julius Caesar, “…for the eye sees not itself, But by reflection, by some other things” (Hertel, 2003, p. 913).


For Winnicott the mother’s face is the first reflector.  Michael Eigen takes this to a universal scale, he writes: “The centrality of the human face as symbolic of personality permeates the fabric of human experience” (Eigen, 1980, p. 425).  In mythology, a face “…launch’d a thousand ships. And burnt the topless towers of Ilium.”  Love and hate, Freud’s primal forces.


Disabilities, limitations, are an assault on the psyche, and are often responded to with primal rage.  Shakespeare’s Richard III twists the self-hatred of his hunchback deformity to murderous action, “determined to prove a villain” (Shakespeare, 1974, p. 703).  Melville’s Ahab is in a “quenchless feud” (Melville, 1851, p. 155), a monomaniacal quest, for revenge against the great white whale for his lost leg.  Shelley’s (1818) Frankenstein monster, shunned at every turn, pained and lonely, seeks revenge against his creator.  “Rage,” writes Eigen, ”often indicates a break or failure of emotional digestion and rises as something that ought not or cannot be digested” (Eigen, 2002b, p. 168).  “When rage strikes, feel it,” he advises.  In other words, live through the experience.  Rage, defiance, is it always destructive?  I hear it in Beethoven’s symphonies.  Yet, in the face of helplessness, rage can contain elements of Bion’s nameless dread and Winnicott’s primitive agonies.


Private agonies abound.  One would not guess from the intense imagery in the novels of Charlotte Bronte that she suffered from eye troubles.  Her extreme short-sightedness most likely contributed to her being labeled quite eccentric.  Slight glimpses of these troubles come from her first biographer and friend, Elizabeth Gaskell.  Gaskell is sensitive to a silent ache, she writes: “It is probable, that even her sisters and most intimate friends did not know of this dread of ultimate blindness which beset her…” (Gaskell, 1996, p. 222).


The wish to hide, to shelter vulnerability, is a longing perhaps as strong as the wish to be recognized.  Such a struggle is often found in the agonizing transition to blindness when the use of an identity cane becomes pressing.  In some cases, harrowing accidents are endured before that public symbol, and display, of blindness is accepted.  Oliver Sacks, when presenting his book, Mind’s Eye, then in his seventies, having suffered further vision loss, made a passing but telling remark as he was fumbling, or visually stumbling, through notes at the lectern: “I am distressingly visible and wish I were not” (Sacks, 2011).


The impact of visual impairment, like a silent explosion, is far reaching.  The social language of visual cueing, visual expression, even visual cooing, is a wordless and wondrous dimension.  The inability to participate in this swirl of wordless communication is a fathomless loss.  Not to be recognized by a visually impaired friend, colleague, or lover, leaves unintended visceral stings, despite one’s knowing.  Visceral stings that do have social consequences.


Mishaps and anecdotes of misrecognition are exchanged by Oliver Sacks and Chuck Close, the American artist, in a Radiolab piece, “Strangers in a Mirror,” about their shared prosopagnosia, a condition returned to so often herein for it isolates, puts in relief, the dilemma of recognition.  Good humor prevails in the interview, but Close ends on a very realistic, down-to-earth, note, saying: “Unfortunately there are no real answers to coping, you are not going to lessen the deficit by having a good attitude, or trying harder.  It is what it is” (Radiolab, 2010).  Sacks calls on us to bear witness, to make public, to broadcast experience, to share adaptations.





Beebe, B. (2004). Faces in relation. Psychoanal. Dial., 14:1-51.

Bion, W.R. (1978). The Tavistock seminars.  London: Karnac, 2005.

Bion, W.R. (1992). Cogitations. London & New York: Karnac.

Burlingham, D. (1961). Some notes on the development of the blind. Psychoanal. St. Child, 16:121-145.

Eigen, M. (1980). On the significance of the face. Psychoanal. Rev., 67:425-439.

Eigen, M. (1981). The area of faith in Winnicott, Lacan and Bion. Int. J. Psycho-Anal., 62:413-433.

Eigen, M. (2002a). A basic rhythm. Psychoanal. Rev., 89:721-740.

Eigen, M. (2002b). Rage. Middletown, CT: Wesleyan University Press.

Freud, A. (1965). Normality and pathology in childhood: assessments of development.  New York: International Universities Press.

Freud, S. (1893). Frau Emmy von N, case histories from studies on hysteria. SE 2, 48-105.

Freud, S. (1915). Instincts and their vicissitudes. SE 14, 109-140.

Freud, S. (1937). Analysis terminable and interminable.  SE 23: 209-53.

Gaskell, E. (1857). The life of Charlotte Bronte.  New York: Oxford University Press, 1996.

Hertel, R.K. (2003). Analyzing the traumatic impact of childhood visual impairment. J. Amer. Psychoanal. Assn., 51:913-939.

Leffert, M. (2011). The psychoanalysis and death of George Gershwin: an American tragedy. J. Am. Acad. Psychoanal. Dyn. Psychiatr., 39:421-452.

McDougall, J. (1974). The psychosoma and the psychoanalytic process. Int. Rev. Psycho-Anal., 1:437-459.

McWilliams, N. (1999). Psychoanalytic case formulation. New York: Guilford Press.

Melville, H. (1851). Moby-Dick: a Norton critical edition (H. Hayford & H. Parker, eds.). New York: Norton, 1967.

Radiolab (2010 June 15).  Strangers in a mirror.  Podcast audio.

Sacks, O. (2010 August 30). Face blind. The New Yorker.

Sacks, O. (2011). “Dr. Oliver Sacks on the mind’s eye.”  YouTube video, 1:23.  Posted by American Museum of Natural History, October 20, 2011,

Shakespeare, W. (1974). The tragedy of Richard the Third. (The Riverside Shakespeare, ed. G. Blakemore. Evans et al.).  Boston: Houghton Mifflin, pp. 708-764.

Shelley, M. (1818). Frankenstein. (James Rieger, ed.). Chicago: University of Chicago Press, 1982

Spitz, R.A. (1955). The primal cavity—a contribution to the genesis of perception and its role for psychoanalytic theory. Psychoanal. St. Child, 10:215-240.

Spitz, R. A. (1965). The first year of life. New York: International Universities Press.

Torre, J.D. (2002). The psychoanalytic method working with mental and physical impairment. Int. J. Psycho-Anal., 83:675-677.

Winnicott, D.W. (1965). The maturational processes and the facilitating environment.  London: The Hogarth Press.

Winnicott, D. W. (1971). Playing and reality.  London: Tavistock Publications.

Winnicott, D. W. (1989). On the basis of self In body.  Psychoanalytic Explorations. Harvard: Harvard University Press, 261-283.




Isolde Keilhofer can be contacted at:

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: