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A plea for affirmation Relating to states of

unmentalised affects
a
Bjørn Killingmo
a
Sköyensvingen 12, 0375 , Oslo , Norway E-mail:
Published online: 21 Jan 2013.

To cite this article: Bjørn Killingmo (2006) A plea for affirmation Relating to states of unmentalised affects,
The Scandinavian Psychoanalytic Review, 29:1, 13-21, DOI: 10.1080/01062301.2006.10592775

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A plea for affirmation

Relating to states of unmentalised affects 1

Bjern Killingmo
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In some patients, among them the so-called psychosomatic patients, somati-

cally-experienced affects are not transformed into words and symbols. Due
to deficient mentalization, affective arousal is not linked to a meaningful and
emotionally experienced self-representation. These patients do not experience
affects as their own, and the analyst does not get through to their self-state by
way of interpretation. The aim of this paper is to elaborate on the concept of
"affirmation " and to argue in favour ofaffirmative interventions, supplement-
ing classical interpretation, in the treatment ofpatients with deficient affect
mentalisation. It is further argued that intonation and the sound quality of
the analyst's voice play a decisive part in conveying affirmative messages to
the emotionally isolated patient.

Key words: affirmation - deficit pathology- mentalisation of affects

Perhaps Anna Freud is the one who most consistently
has insisted on the limited application of psychoanalysis
as a treatment procedure. She reserves psychoanalysis
for the neurotic conflict proper, refusing to allow that it
may have a corrective effect on developmental pathol-
ogy. By this, she also is on a par with a tendency to pre-
serve the distinct quality of psychoanalysis by restrict-
ing it to interpretation: "The pathogenic sequence of
frustration, regression, internal incompatibility, anxiety,
defence by repression, return of the repressed and com-
promise formation - the sequence which is characteristic
for the neurosis - is relieved by analytic work which
lifts all partners in the process to the same level of con-
sciousness and thereby enables the patient to find dif-
I A Spanish version of this paper has been published in
Maladevsky, A., Lopez, M. B., Ozoraes, Z. L. (2005). Psi-
cosomatica, Aportes teorico-clinicos en el siglo XXI, Lugar
Editorial S. A., Buenos Aires.
ferent, healthier and adaptive solutions for his conflicts.
Developmental pathology, on the other hand, does not
respond to interpretation. Even if confronted with the
details of their aberrant development and the reasons
for it, children or adult patients remain quite unable to
alter what has happened and what is, after all, the very
basis for their personality structure." (Freud, A. 1981,
p. 118).
Anna Freud's restrictive position seems rather dogmatic
and will hardly be accepted as common ground to-day.
Certainly, conflict and interpretation should still be con-
sidered central in psychoanalytic thinking. However,
contemporary psychoanalysis is first of all marked by
diversity. The so-called mainstream of psychoanalysis
gradually faded out in the 70s and 80s, and a number
of psychoanalytic sub-cultures have emerged with their
preferred vocabulary. There is no longer consensus,
even as to what are the core concepts of psychoanaly-
sis. Clinical material, technical devices as well as the
psychoanalytic situation itself are conceptualised in
 different ways. Taking clinical practice, and not theo-
retical presuppositions, as a starting point, it is obvious
that psychoanalysis to-day encompasses a wider range
of interventions than interpretation in a narrow sense.
Terms like empathic understanding, containing and
holding demonstrate this. Contemporary psychoanalytic
practice also covers a much wider scope of psycho-
pathology than that of the classical neurosis. To-day
we may even speculate whether the neurosis proper
really exists or ever has existed. The last two decades
of clinical experience and progress in psychopathologi-
cal understanding make it more reasonable to count on
developmental unevenness also in the so-called good
neuroses. This is on a par with Zetsel (1968) discuss-
ing the notion of the "so-called good hysteric". From a
structural point of view, we may expect to find devel-
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opmental failures and intra-psychic conflict combined
in a multitude of ways.
Finally, it would be an unacceptable option to analyse
the neurotic part of the patient while leaving the devel-
opmental failure untreated. This would be incompatible
with an overriding Gestalt conception of personality.
Personality acts as a dynamic unit, changes in one part
affect all the other parts. Thus, modem psychoanalysis
is a many-coloured spectrum, a curative discipline aspir-
ing to be helpful to a widening span of patients. Among
them are patients who suffer from somatic symptoms,
which are considered to have a psychological origin.
In this paper, psychosomatic pathology will not be dis-
cussed as such. However, I shall take the stand that
psychosomatic symptoms can be seen from the point
of view of unrnentalised affect, and that on the whole,
the so-called psychosomatic patients' affective arousal
is not linked to a meaningful and emotionally experi-
enced self-representation. The patient does not experi-
ence affects as his own. Neither is affect expressed in
words and symbols. Certainly, this point of view does
not form a conclusive formulation of the dynamics and
structure of the psychosomatic patient. Nor do patients
with a low degree of affect mentalisation always suffer
from psychosomatic symptoms. Hyperactivity, chronic
restlessness and empty depression are examples of other
forms. However, my point is that the concept of mentali-
sation is helpful in dealing with what Anna Freud calls
developmental pathology and which I shall call deficit
pathology. Due to the incapacity to express emotional
experiences containing self-representation in words and
symbols, traditional psychoanalytic verbal discourse
does not come to grips with the subjective experience
of these patients. They will remain in an experiential
domain, which does not correspond to that of the ana-
lyst. The analyst does not get through to their self-state
by way of interpretation. Thus, on a deeper level they
14
are emotionally isolated and the analyst is not available
to them.
This is certainly a challenge to psychoanalytic tech-
nique. We have to develop concepts and ways of think-
ing which can help us to address and relate to states of
unmentalised affect. In this connection I shall present
the concept of affirmation. The main aim of this paper
is to enlarge upon this concept and to argue in favour
of affirmative interventions as a technical means, sup-
plementary to classical interpretations. Within this per-
spective the following issues will be discussed.
(1) Lack ofmentalisation as a psychological deficit.
(2) Psychological and therapeutic effects of affirmative
responses.
(3) Intonation as a vehicle in conveying the quality of
affirmation.
(4) The theoretical connection between affirmation and
mentalisation.
DEFICIENT MENT ALI SA TION
The concept of deficit is not part of the conceptual
framework of classical psychoanalysis. Not till the end
of the 201h century, did the concept of deficit enter the
theoretical stage. This was due to influences from dif-
ferent sources. Kohut (1977) contributed substantially
to the idea of deficient self-structures and Mahler et al.
(1975) to deficient separation of inner self and object
representations. Infant research has supplied an enor-
mous amount of information, specifying how quali-
ties of parent - infant relationship play a decisive role
in forming lasting emotional patterns towards oneself
and others. Stem's (1985) concept of affective attune-
ment between mother and child may serve as an exam-
ple. Attunement refers to a kind of sharing of affective
experience, prior to the development of the capacity for
mentalisation and symbolic representation. Experiential
qualities from this pre-verbal level constitute the core of
an affective pattern, which the individual may repeat all
through life to uphold a feeling of continuity of exist-
ence. Failure in attunement would be an example of
what the concept of deficit refers to. It should be added
that the increasing interest in borderline states, personal-
ity disorders and narcissistic disturbances of recent years
has also contributed to putting the concept of deficit on
the theoretical agenda of psychoanalysis.
The term deficit refers to failures in the caregiver's
emotional feedback, leading to structural incapacities
in the infant. On the level of principle, we can speak
of three classes of failure: (1) lack of stimulation; (2)
over-stimulation; (3) misplaced stimulation. Pine (1992)
has proposed that we distinguish between deficit and
 defect, the first referring to properties of the environ-
ment, the second to the effect of the deficiency in the
personality. In the clinical situation, the problem has to
be approached from two angles. On the one side, the
analyst has to understand, through the transference, the
specific nature of the empathic failure of the caregiv-
ers, and on the other side, how this failure has affected
the personality structure of the patient. Many possible
defects have been listed in the literature: Unreliability
in object constancy, low capacity for impulse delay,
failure in regulation of self-feeling, in affect modula-
tion, in frustration tolerance and in maintenance of a
stable experience of identity. After all, every aspect of
personality may be affected, more-or-less, as result of
emotional deficiency at an early age.
The concept of mentalisation has come to the fore
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in recent years and should be put on the list. Following
Lecours & Bouchard (1997), the concept refers to how
basic somatic, motoric or intersubjective excitations
" ... undergo a qualitative transformation into mental
contents within a human interpersonal and inter-subjec-
tive matrix." (p. 857). The transformation of somatically
experienced affects into mentally represented affects
probably involves a number of specific ego func-
tions. The process of mentalisation should therefore be
assigned an overriding position on the list above. Due
to deficient capacity to mentalise, the individual cannot:
(1) represent feeling states meaningfully in symbols
and words, (2) experience affects as his own, (3) relate
to himself as an agent. The idea of "self as agent" is
central in the theory of mental development ofFonagy
et al. (2002). However, their concepts of self as inten-
tional mental agent and representational agent (p. 248)
seem to describe cognitive aspects ("understanding" and
"comprehending" properties of intentional mind states),
while my concept of agency emphasizes experiential
qualities, that is an inner feeling of a "strategic I". In
patients with a low capacity for mentalisation, the cog-
nitive-meaning aspect of affect is diminished while the
somatic-excitational one is increased. An example here
would be the so-called empty depression, a state of sad-
ness without experience of associative links to objects,
images and memory traces - only an endless gnawing
feeling of unrest. As affective arousal is compelled to
find outlet beyond words and symbols, bodily functions
are likely to come up as a means of expression.
By referring deficient mentalisation to an early period
oflife, prior to internalised self- and object-representa-
tions, inter-systemic conflict and symbolic expression,
one might come to think of deficit related problems as
a kind of non-dynamic phenomena. At least three rea-
sons weigh against this. First we have to assume that
whatever the injury, it has always been perceived in a
specific way. The coding and later interpretation of the
happening is the individual's own construction and has
to be addressed by interpretation in due time. Secondly,
if we by "dynamic" mean moving forces caused by anxi-
ety and defensive strategies, deficit pathology is a truly
dynamic phenomenon. However, in deficit related states,
the underlying motive is of another kind than in typical
conflict pathology. In the latter, the motive is the indi-
vidual's own prohibited wishes (libido and aggression),
while in the former, the motive is one of maintaining
an experience of identity. The quality of anxiety too is
different. In the context of conflict, anxiety is associated
with the content of an unconscious wish, while in the
context of deficit, anxiety is tied to loss of one's self.
Thus, we might distinguish between meaning-related
anxiety and being-related anxiety. Thirdly, an organising
process must be understood as continually taking place
in psychic life. In the adult, derivatives of early deficit
and conflict are combined in such complex patterns of
character that it is almost impossible to distinguish the
one sharply from the other. "Often an emotional cluster
has initially to be interpreted on a conflictual basis. Next,
elements of the same cluster have to be affirmatively
responded to until, at last, the pattern as a whole is again
interpreted as an expression of conflict" (Killingmo,
1989, pp. 74-75). According to subtle nuances in the
transference, the analyst has to oscillate between two
therapeutic strategies, that of searching for unconscious
meaning and that of constituting meaningfulness in the
patient's self experience. (As to characteristic signs of
conflict transference and deficit transference, see .Kill-
ingmo (1989)).
As long as a patient functions on a level of impaired
mentalisation, his ability to profit from interpretative
interventions is reduced. To be allied with the analyst,
searching for underlying meaning, presupposes a rather
high level of ego functioning. The patient must be able
to postpone needs for immediate gratification in favour
of an anticipated goal, and he must experience the very
mode of searching as meaningful. However, in the expe-
riential mode of deficit, the patient has not sufficient
capacity for delay and no motive for "finding out". Nor
has he the ability to mentalise affect on a level, where he
can experience himself as an agent. The most importu-
nate need of the patient is that of experiencing a quality
of being. This need constitutes the emotional centre of
his relation to the analyst as long as an impact of defi-
cit material prevails. Instead of revealing meaning, the
strategy of the analyst should be that of assisting the ego
in experiencing meaning in itself. To this end, I shall
argue that interventions of an affirmative type may be
helpful.
15
 THE AFFIRMATIVE RESPONSE
I shall take as my vantage point that the human being
has an underlying need for meaningfulness in his self-
experience. This need is ever present, but does not
come to the fore till it is threatened. The experience
of meaningfulness is achieved by way of affirmative
responses from outer objects as well as from inner object
representations. Affirmation can take place both on a
conscious and on an unconscious level. An affirma-
tive response can be defined as a communication to the
subject from an object or object representation which
removes doubt about the validity of the subject's expe-
rience. To affirm does not mean to evaluate, praise or
give credit to a person's performance or self-image. An
affirmative response simply states and validates, in an
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empathic way, the quality of the person's self experi-
ence. An experience of meaningfulness in the self-state
is not obtained by way of words, logic and cognitive
reasoning. It is well-known that patients can speak of
themselves, even reflect upon their inner self-image,
without having a feeling of self. Due either to unmental-
ised affect or defensive isolation (Killingmo, 1990), the
patient displays nothing but an intellectual performance,
using empty words lacking an embedded affective mode.
This way of speaking tells the analyst that the patient
does not communicate from a position of an own, and
owned "I". On an experiential level, strengthening the
feeling of "I" is the very aim of affirmation.
To understand how affirmation can be helpful, we
have to examine the concept more closely. The act of
affirming can be analysed from four points of view, each
focusing on a specific mode of self-object relationship.
The four modalities are:
(1) The experience ofbeing seen.
(2) The experience of being understood.
(3) The experience of being listened to.
(4) The experience of being agreed to.
Each of the four modes is supposed to contribute in a
specific way to the patient's subjective experience of
self. The affirmative response of the analyst serves as
an emotional feedback from an object or object repre-
sentation, with the aim of strengthening weak spots in
the foundation of the patient's self-state. Taking into
consideration the actualised transference, the analyst
may emphasize one mode above one other by the way
he formulates his response or by the intonation of his
speech. However, in the clinical situation, an affirmative
response will mostly occur as a global phenomenon, i.e.,
all modes being involved simultaneously (as to exam-
ples of affirmative responses, see Killingmo (1995)).
16
In a general way, these modes refer to early states
of deficit, which also persist as motives in object-seek-
ing in later life. From this point of view, the patient
is recurrently looking for an object able to provide a
relationship which matches the quality of his special
infantile deficit. However, as this object is unlikely to
be found in real life, the patient is endlessly searching,
trapped in an illusion of "the one and only" object. In
analysis, the deficient need-state should be responded
to by affirmative interventions while the illusion has to
be interpreted.
To account for the psychological effects of the above
relational modes, I shall propose a meta-logical sequence
taking place in the patient on receiving an affirmative
response. For each mode, the logic is as follows.
(1) I am seen: "He sees me, so I must be visible, there-
fore I am." This mode sustains a feeling ofbeing.
(2) I am understood: "He understands me, so I am
someone that can be understood by another, thus I
am related to someone." This mode sustains a feel-
ing of relationship.
(3) I am listened to: "He bothers to listen to me, so I
must be worth listening to, then I am something."
This mode sustains a feeling of substance.
(4) I am agreed to: "He agrees with me, then my point
of view does not come out of the blue, then I have
a reason." This modality sustains a feeling of jus-
tification.
The intended experiential impact of the four modes
could be amalgamated in a kind of inner self-declara-
tion: "I am someone, in a relationship to another, with
my own value and with the right to be so." That would
express an attitude of agency. In his 1960 film, Sasom
I en spegel (Through a glass, darkly), Ingmar Bergman
furnishes a striking example of this kind of meta-logic.
In the last scene of the film, the charming but narcissistic
father suddenly turns towards his adoring but rejected
son, and for the first time speaks directly to him. The
decisive thing for the son is not what the father says, but
the very fact that the father addresses him. The boy is
noticed and registered in the census. It is as if he could
tell himself: "Now also I am." His feeling of revelation
is expressed in the last line spoken in the film: "Father
spoke to me." It should be underlined that experiential
qualities as those mentioned above are not mediated on
a conscious level, nor is the process one of cognitive
rationality. As we also know from daily experience, a lot
of information is processed and meaningfully acted upon
without passing through a conscious reflective process.
Thus, the "conclusions" the patient draws from the ana-
lyst's affirmative response come about as spontaneous
 emotional coding. The patient simply feels it. After-
wards, the affirmative statement, the feeling itself and
the context as well, can be reflected upon and digested
in the therapeutic dialogue.
The psychological effect of affirmation can also be
described from the point of view of self-representa-
tion. The concept of self-representation refers to an
inner organisation of ideational content, a mixture of
images, fantasies and beliefs about oneself. However,
the affirmative response does not aim at the content of
self-representation. Rather, it furnishes the self-repre-
sentation of the patient with qualities like existence,
attachment, value and legitimacy, which refer to basic
relational and structural constituents of the self-repre-
sentation itself. I shall call them constituencies beyond
dynamics. This means that if they are not fairly well
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established, the self of the patient will not function as a
representational agent and a stable centre of reference.
The patient will not grasp and relate meaningfully to
the analyst's interpretation of unconscious wishes sim-
ply because he has no access to the experiential quality
of" I wish". In this situation, the analyst is faced with
a structural deficit, which has to be addressed before
the dynamic derivatives of intersystemic conflict are
attended to. To summarise so far: the aim of affirmative
intervention is two-fold.
(1) To sustain an inner feeling of a strategic "1".
(2) To sustain self-representation as a stable centre of
reference and agency.
THERAPEUTIC EFFECT OF AFFIRMATION
What are the therapeutic effects to be expected from
properly-mediated affirmative interventions? As has
been stated previously, the patient in a deficit transfer-
ence may not have words at his disposal, that can con-
vey the quality of his experiential state. Nor is he able
to grasp the emotional impact of the analyst's words.
Thus, the therapeutic dialogue becomes empty, leaving
the patient in a wordless isolation and further therapeu-
tic progress is blocked. In this situation, an affirmative
strategy may be helpful. By conveying to the patient an
experiential quality of "I can understand what it is like
to be you," the analyst contributes to making the feel-
ing state of the patient less private. It becomes some-
thing that has shape, can be shared with another and
eventually be put into words. To be understood, breaks
isolation and restores a feeling of being inside, being a
member of an including "we", as if the patient would
say to himself: "I have come in from the cold". The
emotional contact with the analyst restored, the patient
may be ready for further therapeutic exploration. This
is the most immediate therapeutic gain from an affirma-
tive response.
Affirmation may also be helpful in removing paralys-
ing doubt. Here we should talk of two kinds of doubt.
One is a doubt, which has its origin in intersystemic con-
flict. An example here would be the obsessive-compul-
sive state where the superego has assumed an impulsive
force balancing derivatives of id impulses in an ongoing
back-and-forth movement. Another is doubt due to an
unreliable feeling of existence. The first is related to
unconscious conflict, the second to impaired ego func-
tioning. Sorting out and deciding upon the status of
present sensory impressions normally takes place auto-
matically on a pre-conscious level. These ego functions
form a structural foundation for a reliable self-experi-
ence. When impaired, the very identity of the patient
is at stake, and he will desperately need the analyst as
an object who can remove doubt and restore a sense of
reliability in self-experience. In order to meet this need,
the analyst may put in a cause-and-effect sequence in
his affirmative reply. An example would be: "I realize
that you call my acceptance in question and that you
are sceptical. You never felt that someone close to you
took you quite seriously - nor did father - and now you
doubt that I do. That I can understand". This formula-
tion offers the patient the possibility of seeing himself
in perspective legitimising his doubt historically. Seen
in a context of reasonable, natural events, his self-state
may appearjustifiedto him. In this way, the experiential
quality of doubt is likely to disappear, and the quality of
the transference is changed. To sum up, the immediate
therapeutic effect of affirmation is two-fold.
( 1) It alleviates isolation, bringing the analyst back into
a position of emotional availability.
(2) It reduces doubt, restoring a stable self-state as a
background of reference.
The joint action of the two is to bring the analysis into
process again and to raise the level of reflective dif-
ferentiation in the therapeutic discourse. This is what I
shall call the dynamic gains of affirmation in the thera-
peutic process.
As I see it, affirmation may also contribute to more
long-term or structural changes. What I shall call misat-
tribution of causality is one example. Initially, a child
has no intentional participation in a trauma or depriva-
tion, but as an act of later organisation, he may uncon-
sciously transfer bad intentions and guilt feelings from
other conflictual relations to the traumatic context. This
is done simply to give an otherwise confusing and ter-
rifying experience meaning. Thus, misattribution of
responsibility is a kind of survival strategy. In a deeper
17
 sense, however, the patient has no experience of being
an active agent in the first place. What the analyst has to
focus on, is not the dynamics of guilt, but on the prevail-
ing feeling of confusion, blocking access to an authentic
self-experience. For the patient, the first step is to have
his inner feelings stated and validated. This paves the
ground for a correction of cause and effect. Only then
can the guilt feeling be examined and understood by the
patient as a defensive measure.
Bleichmar ( 1996) has explained how parents transmit
subtle messages to the child, which reflect their own
unconscious fantasies and how they see themselves and
reality. "There are people who are raised from a very
young age with messages, both conscious and uncon-
scious, of the type 'we can't do that' or 'we will never be
able to attain that' (p. 946). This may serve as an excel-
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lent example of deficit in parental mirroring. When the
parents transmit attitudes like hopelessness, impotence,
emptiness, worthlessness and lack of meaning in their
unconscious self-image, the child will identify with the
same negative affective qualities on a preverbal level.
They will be part of an enduring self-state affecting
the individual's experience of existence and identity
throughout life.
In the analytic situation, such attitudes will mostly
be in the background, like a modest melody in a minor
key. They may even be so subtle, or overlaid by counter-
phobic activity and demonstrative joie de vivre, that they
may slip out of the analyst's grasp. Thus, the analyst
risks doing analytic work on the top of an unrecognised
pervading feeling of hopelessness. The analyst's invita-
tion to search for underlying meaning has no appeal to
the patient. It is experienced as an impoverishing bur-
den which one has to carry, or a lip service which has
to be paid while waiting desperately for the real thing
to come. Again, the therapeutic rule is: first things first.
The underlying feeling state acts as the most immedi-
ate driving force and has to be brought to the surface.
It should be gently pointed out to the patient along with
an empathic sharing of the quality of the patient's feel-
ing state and understanding of what it is like feeling that
way. The feeling of hopelessness validated, the patient
may be open to examine how this feeling came about
in the first place, how he has identified with his parents,
and how he has continued to feel like that, in spite of life
experiences which repudiate his negative outlook on life.
Probably, the reason for this repetition is that the early
internalised self-state is upheld in order to consolidate an
inner feeling of continuity in the experience of existence.
This is on a par with Sandler's conception of safety.
Man will always consciously or unconsciously look for
a background of safety (Sandler, 1960). However, what
makes a relationship safe is not primarily benevolence or
18
stability, but the element of familiarity. Being familiar
means that the person has developed strategies to deal
with the situation. That is what makes him secure. Thus,
we have to think that even if painful, the feeling of hope-
lessness brings about a kind of meaning, guarding the
self-representation against discontinuity and despair. In
due time, however, the defensive function of the self-
state has to be addressed by way of interpretation. The
analyst should also interpret how the patient uncon-
sciously may use hopelessness in the transference to
induce guilt in the analyst and thereby take revenge on
an object representation he has projected on to the ana-
lyst. As we are dealing with possible long-term effects
of affirmation, we cannot expect changes to appear all
of a sudden. On the contrary, alternating affirmative and
interpretative measures have to take place again and
again for a long period of time. Only very reluctantly
will the subject give up the defensive restriction of his
experiential realm and open up for new kinds of object-
related feelings in the relationship to the analyst.
THE VOICE OF THE ANALYST
How shall the analyst affirm the patient's self-state in
the clinical setting? To answer this question, I think it
is helpful to see human relationships from the point of
view of communication. The subject is always in an
affective dialogue, exchanging meaningful messages,
with external and internal "others". The dialogue takes
place on a conscious as well as an unconscious level and
may be expressed by way of words, intonation, facial
expression, gestures and patterns of bodily tension. The
"speech" of the subject always addresses another as
well as another speaks to the subject in the subject's
own speech. The listening perspective of the analyst is
aimed at unconscious dialogue scenarios in the patient,
deeply rooted in the past, which are actualised in the
transference in the dialogue between the patient and
the analyst. The analyst is listening to dialogues behind
dialogues (Gullestad & Killingmo, 2002).
What kind of message from the analyst will then
tune in with the underlying dialogue scenario of the
patient who is in a deficit transference? First of all,
we can ascertain that questioning the patient is not the
way to go. The question, as a linguistic form, has many
psychological implications. Here I shall only mention
two. Firstly, by asking somebody a question, the one
who asks, takes the active part in the dialogue while
the one who is expected to answer, is assigned a passive
role. By putting a question to the patient, the analyst
may easily appear in the transference as demanding
or overbearing, reviving a dominating internal object
representation which passes on to the patient's self-
 representation a feeling of dependence, weakness and
lack of agency. Secondly, the question as a linguistic
form has a narrowing effect on the associative course.
Placed in an answering position, the patient is given a
task to fulfil. He has to concentrate, select and decide
upon alternatives. This is a process of cognition, which
is contrary to opening up for a more disengaged course
of associations, which eventually may lead to the true
self-state of the patient. Questioning does not mediate an
affirmative quality. Rather it puts across a kind of rela-
tionship and a kind of cognition which block access to
the subtle nuances of self-experience what is at stake.
Analysts are used to communicating by way of
words. We almost take for granted that the patient will
grasp the content of an interpretation transmitted at a
semantic level. Certainly, affirmative responses may be
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conveyed by the content of the words. However, to have
a real affirmative effect, the words of the analyst should
be simple and straightforward. Extensive explanations
are likely to pass beyond the self-state of the patient
and leave him even more emotionally isolated. A plain
statement like "I understand" may come through to the
patient. But this formulation may also easily become
an emotionally empty cliche bringing no affirmative
feedback to the patient. The important point is that the
patient in deficit transference is not prepared to receive
or share declarative messages. This level of communica-
tion is nothing but a social form to him. His need is to
communicate his special quality of experience to another
and to receive a response from the other, which brings
meaningfulness to his self-experience. It is a matter of
inter-subjectivity, of sharing experience with another
human being who lives in a desolate inner landscape
lacking in a deeper sense the feeling of I am. Thus, for
an affirmative response to function therapeutically, it
cannot be only a phrase or a technical artifice, it has to
express an authentic experience in the analyst. The atti-
tude of the analyst should communicate that he agrees
with the patient's self-state as if he would say: "I ask for
nothing. I do not even listen to what you are saying. I'm
just listening to you." The analyst listens to the patient's
potential self. The emotional presence of the analyst has
to be one of calm, ruminative and containing form of
listening, free from any kind of explorative meta-com-
munication. In metaphorical terms: The linguistic sign
of an interpretation is the question mark, while that of
an affirmative response is the full stop.
Lecours & Bouchard (1997, p. 857) state: " ... all
psychic contents can be situated on a continuum of
increasing "mental" quality, for example between the
poles of somatisation and insight". Transformed by lin-
guistic regulations, symbolic representation and cultural
codes, semantic declarative language comes close to the
pole of insight. For the patient in deficit transference,
this level of communication is too distant from the bod-
ily pole. This is where the intonation and sound quality
of the analyst's voice come to the fore. Every analyst
can testify to the importance of "mhmm", perhaps the
most frequent of all therapeutic interventions. Depend-
ing on the sound quality, this simple vocal utterance
can convey to the patient an affirmative response rather
like this: "Yes, that is how you feel, that is how one can
feel, I agree to that. That I accept without reproaching
you. That's how one is to be allowed to feel in a world
like this. I'm still on your side. I don't leave you alone"
(Killingmo, 1995, p. 513). The point is that this com-
plex emotional message would not have been received
by the patient if it had been expressed in words. Only
the very tone in the analyst's voice can break through
to the unmentalised self-state.
Fonagy (1971) has provided a theory embracing
relatedness of the speech sound and affect. Speech is
composed of phoneme-sequences expressing messages
encoded by a linguistic code. This code is arbitrary,
implying no emotionality a priori. However, speech is
also encoded upon a paralinguistic code which, contrary
to the linguistic code, is supposed to represent universal
ways of emotional expression. Thus, the speech sound
also represents an independent attitudinal message. Fol-
lowing the Fonagy theory, we may assume that the
infant, through the medium of intonation, is able to
communicate affectively with its surroundings a long
time before intentionality can be expressed by differen-
tiated phonemes. Intonation may be conceived of as an
archaic language consisting of emotional experiential
states tied to acoustic images and muscular tone. From
this, we can conclude the following.
( 1) Intonation is a kind of somatic communication of
affective messages.
(2) Intonation is a kind of communication, which passes
on affective meaning directly without taking the
devious route to semantic language symbols and
culturally coded meaning.
In clinical practice, the analyst may use intonation as a
means to strengthen the affirmative effect of verbally-
formulated responses. This seems to be on a par with
Steiner: "The intonation one chooses to adopt, in its
positive aspects, therefore, greatly contributes to the
building up of an affective core of new internal objects
or states of being, to the revitalisation of old ones in
order to allow new links to be forged" (1987, p. 269).
Through intonation, both participants in the therapeutic
discourse use a language where affect to a large extent
is represented as somatic sensations and where affective
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 meaning is communicated in the sound quality itself,
not in semantic content. The essence is that both ana-
lyst and patient share their mode of affect communica-
tion. I shall conclude that intonation comes forward as
the most apt way of addressing experiential states of
unmentalised affect.
THE THEORETICAL CONNECTION
BETWEEN AFFIRMATION AND
MENT ALI SA TION
How does mentalisation come about? According to
Freud, a process of linking (Bindung) has to take place
(Freud, 1911 ). Somatically experienced affects are
linked to mental representations. However, the con-
cept of Bindung, in Freud's explanation, seems to be
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a rather loose term, mostly referring to drive energy,
not to affect. One can also speculate as to whether the
notion of linking reflects a mechanistic way of thinking:
Two kinds of properties exist as separate elements in
the first place. To have them connected, the term linking
is coined. Today this seems to be an outdated way of
thinking. Instead of presupposing an initial separated-
ness between somatic and mental representations, I shall
take the stand that from the beginning, the two consti-
tute a global unit. This unit differentiates gradually. An
ongoing process of organisation permits " ... the emer-
gence of mental contents and structures of increasingly
higher levels of complexity, leading to symbolisation
and abstraction." (Lecours & Bouchard, 1997, p. 857).
This is on a par with a general developmental principle
that increasing levels of ego functioning imply qualita-
tive changes both functionally and experientially. Tak-
ing this stand, we may argue that there is no need for a
concept of linking. Nor is there a special point where
somatic feelings of excitation change into mental rep-
resentations. In addition, affect representation and self-
representation develop from the same matrix and take
place gradually in an ongoing process of ego differentia-
tion within an inter subjective relational field.
In the preceding, I have ascertained that the primary
task of affirmation is to validate the patient's self-state.
However, by offering an affirmative response, the ana-
lyst does not simply equal the experience of the patient.
As an object who is able to formulate, either by words or
by intonation, a precise recognition of the patient's feel-
ing state, the analyst is also a step ahead of the patient's
level of mentalisation. Thus, the analyst serves as a
model for the patient's spontaneous identification with
a more differentiated level of ego functioning, furthering
his mentalising capacity. This seems to be in agreement
with the developmental view ofFonagy et al. (2002, pp.
288-289): "In order to move the child from the mode of
20
psychic equivalence to the mentalizing mode, analytic
reflection, of whatever orientation, cannot just "copy"
the child's internal state- it has to move beyond it and
go a step further, offering a different, yet experientially
appropriate re-representation" A main point here is that
affirmative interventions do not address ideational con-
tent as is the focus of interpretations of conflict. Affir-
mation is related to how the mind works, that is to basic
constituents of affect experience and self-representation.
As far as psychoanalytic treatment promotes structural
differentiation of self-representation, we should expect
that a process of mentalisation may take place slowly
and gradually in, and as a function of, the therapeutic
interaction, in which an affirmative mode has to be
included.
CONCLUSION
Depending upon the quality of the transference, the
analyst has to oscillate between two strategies, that of
interpretation and that of affirmation. In clinical prac-
tice, these strategies should not be too sharply distin-
guished. Derivatives ofunmentalised affect and deriva-
tives of affect organised on a conflictual level may be
intertwined in complex patterns. Therefore, we should
not think either interpretation or affirmation. The ana-
lyst must be open to relational modes in between, that
is interpretations with an affirmative flavour and vice
versa. Nevertheless, whatever the mixture of the two, the
most direct way of conveying this affirmative flavour is
by way of intonation. At times, the very quality alone
of the sound in the analyst's voice can break through to
the isolated self-state of unmentalised affects.
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