Living on the Border

Psychotic Processes in the Individual, the Couple, and the Group

David Bell, Aleksandra Novakovic, David Bell, Aleksandra Novakovic

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9780367325398
• eBook ISBN:
  9780429915772
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

This book centres on the problem of psychosis, understood from a psychoanalytic perspective, as it manifests itself in different contexts and different levels of organisation: from the individual psychoanalytic session, through work with couples, groups and institutions and wider levels of social organisation. Beginning with a discussion of the psychoanalytic approach to psychosis centring on the work of Freud, Klein and the Post-Kleinians, it goes on to cover individual, couple and group therapy with psychotic patients. It draws on clinical material and theoretical discussion to explore the links between psychotic processes on different levels. This work is aimed at different professionals working within the psychodynamic frame of reference: individual psychotherapists, couple and family and group psychotherapists; organisational consultants and trainees in different therapies. As well as this it will be a useful resource to nurses, doctors and social workers who work with very disturbed patients and wish to learn about psychotic processes.

Chapter One
The psychoanalytic approach to the treatment of psychotic patients

Hanna Segal

The psychoanalytic approach to the treatment of psychotic patients is based on the general assumption underlying all psychoanalytic thinking that psychological phenomena are amenable to understanding. The beginnings of psychoanalysis are in a way very modest. It starts with Freud listening to the communication of his neurotic patients. Up to that time, the patient was classified, manipulated, maybe treated, but his communications were listened to in a cursory manner only and were not considered material for examination. Psychoanalysis starts with Freud’s conviction that the verbal and non-verbal communications of his patient could be understood and should be examined with the intention of understanding. The pre-Freudian attitude to mental illness partly continues in many psychiatric approaches to psychosis. That is, they can be classified, diagnosed as schizophrenic or manic depressive, given treatment, and so forth, but their communications are considered either as not understandable or as only marginally relevant to the understanding of the patient. In fact, it is often considered to be a diagnostic point that the content of the schizophrenic patient’s psychotic communication is not understandable.

From the historical point of view, Freud tried to extend his attempts at understanding psychological manifestations beyond neurosis and into the area of psychosis, as evidenced by his well-known analysis of the memoirs of Senatspräsident Schreber (Freud, 1911c [1910]). However, he never deliberately attempted an actual psychoanalysis of a psychotic. Since psychoanalysis depends on working with the patient’s transference, and since psychotics are, as Freud understood it, wholly narcissistic and form no transference, he could not visualize how psychoanalytic work could be done with them. However, for many who worked with psychotic individuals in their ordinary psychiatric practice, Freud’s conclusion did not seem to fit the facts. To begin with, no one is completely psychotic—there are always areas of personality that function in a more neurotic way and so are capable of forming an object relation, however flimsy. So a number of analysts did undertake treatment of psychotic patients provided that the healthy area was sufficiently in evidence, and they tried to work on this healthier part of the patient’s ego, mainly in the positive transference with the aim of strengthening it enough to enable the healthier part of the ego to become dominant in relation to the psychotic part, a state of affairs that obtains in remissions. Frieda Fromm-Reichmann, Edith Jacobson, Harold Searles, and others in the United States continued and developed work with psychotic disturbance on a similar basis.

A completely different line of development was initiated by Melanie Klein, who continued Abraham’s pioneering work in the analysis of psychotic patients—namely, manic depressives. This work was pursued by analysts trained by her. Bion (1967b), Rosenfeld (1965), and myself (Segal, 1950, 1956, 1957), among others, have produced a number of papers relating to the treatment of both acute and chronic states, and this is the approach I shall concentrate on in this chapter, since this is the area in which I have direct experience.

Melanie Klein’s contribution to the theory and practice of psychoanalysis is rooted in her work with children. As a pioneer of child analysis, she had discovered that small children can develop a transference, both positive and negative, of great intensity. In her work with small children, she was impressed by the prevalence of the mechanisms of projection and introjection, more active and dynamic in the small child than the mechanism of repression. She also discovered that the infantile neurosis was a defensive structure, defending the child against primitive anxieties of a paranoid and depressive type bearing an obvious resemblance to those found in psychotic states. She herself did not analyse psychotic patients. However, she did analyse a 6-year-old child who today would be diagnosed as autistic, an analysis she described in the paper on “The Importance of Symbol Formation in the Development of the Ego” (Klein, 1930). In this paper, she shows how psychotic anxiety can block the process of symbol formation and the development of the ego and how the resolution of that anxiety can lead to a reestablishment of symbolic processes and ego development.

It is our contention that psychotic illness is rooted in the pathology of early infancy, where the basic matrix of mental function is formed. By projection and introjection, by splitting of the object into good and bad, followed later by integration, by introjection and identification with good objects, the ego is gradually strengthened and so acquires a gradual capacity to differentiate between the external and the internal world; the beginnings of superego formation and relation to the external objects are laid down. It is at this time also, in the first year of life, that symbol formation and the capacity to think and to speak develop.

In psychosis, all these functions are disturbed or destroyed. The confusion between the external and the internal, the fragmentation of object relationships and of the ego, the deterioration of perception, the breakdown of symbolic processes, and the disturbance of thinking, are all central features of psychosis. Understanding the genesis of the development of the ego and its object relationships and the kind of disturbance that can arise in the course of that development is thus essential to understanding the mechanisms of psychotic states.

In order to undertake a psychoanalytic investigation of a psychotic patient, certain requirements of the setting and management must be satisfied. The management of the patient outside the sessions must be assured. The patient has to live between the sessions, and his minimum needs, at least, must be satisfied. It is very helpful and at times essential that the management should be friendly to the analysis or at least neutral. It is part of a good management situation, for instance, to ensure that should the patient need hospitalization, the analytic treatment will not be interrupted just at the moment the patient needs it most—it is often because of a failure to arrange a sufficiently stable management that the analytic treatment comes to grief. The analytic setting must provide for the patient the kind of holding environment in which his relationship to the analyst can develop without being broken up by the patient’s psychosis. This obviously necessitates reliability and regularity of the hours, a certain uniformity of the setting, a feeling of physical safety if the patient is violent, and so forth. But the analyst himself is a very important part of the setting. He must remain constant and not vary his role, so that the patient’s phantasies of omnipotent powers over objects can gradually undergo reality testing. With secure management of the background and a proper analytic setting, the analysis can proceed.

Far from failing to develop a transference, the psychotic patient develops an almost immediate and usually violent transference to the analyst. The difficulty with the psychotic transference is not its absence but its character—the difficulty both to observe it and to stand it. The apparent lack of transference or its peculiar nature when it manifests itself is due to the fact that the psychotic transference is based primarily on projective identification. By the term “projective identification” I am referring to an omnipotent phantasy of the patient that he can get rid of unwanted parts of himself into the analyst. This kind of transference is both violent and brittle. The psychotic transference tries to project into the analyst his terror, his feelings of badness, his confusion, and his fragmentation. Having achieved this, he perceives the analyst as a terrifying figure from whom he may need to cut himself off immediately, hence the brittleness of the transference situation. The violence of this projective identification gives rise to a variety of phantasies and feelings. The patient may feel completely confused with the analyst and feel he is losing such identity as he still possesses; he may feel himself trapped or that the analyst will invade him in turn, and so on. As the transference is experienced concretely, interpretations are felt as actions. A familiar scenario is the experiencing of the analyst’s interpretation as projective identification in reverse—that is, to feel that the analyst is now putting into him, the patient, his own unwanted parts and in this way driving him mad. This concreteness of experience, in which he feels that he is omnipotently changing the analyst and the analyst concretely and omnipotently changes him, is a technical point of utmost importance. It is essential for the analyst to understand that, when he interprets an anxiety, the patient may feel that he is in fact attacking him, or if he interprets a patient’s sexual feelings, the patient may experience it concretely as the analyst’s sexual advances towards him or her.

At this point I cannot discuss further the various mechanisms that underlie this concreteness of experience, which arises from the failure of the patient’s symbolic function (see Segal, 1957, where I have elaborated this further). I emphasize this point here, however, in order to make clear that it is useless to interpret to the psychotic patient as though he suffered from a neurotic disturbance. For instance, ordinary interpretations of the Oedipus complex are so easily experienced as a sexual assault and thus make the patient worse. It is the schizophrenic patient’s language with its concrete symbolization and its confusion between object and subject—his psychotic transference—that has to be the subject of the analysis.

In the space of this chapter I cannot give a complete picture of the theory and practice of the analysis of a psychotic patient—the nearest I can come to it is to provide a model derived from Melanie Klein’s (1946) concept of the paranoid-schizoid position and Bion’s (1963) concept of a mother capable of containing projective identification. In this model, the infant’s relation to his first object can be described as follows: when an infant has an intolerable anxiety, he deals with it by projecting it into the mother. The mother’s response is to acknowledge this anxiety and do whatever is necessary to relieve the infant’s distress. The infant’s perception here is that he has projected something intolerable into his object, but the object was capable of containing it and dealing with it. He can then reintroject not his original anxiety but an anxiety modified by having been contained. Furthermore, through repeated episodes of this type, he also introjects an object capable of containing and dealing with this kind of anxiety. The containment of the anxiety by an internal object capable of understanding is the beginning of mental stability. This mental stability may be disrupted from two sources. The mother may be unable to bear the infant’s projected anxiety, and he may introject an experience of even greater terror than the one originally projected. It may also be disrupted by excessive destructive omnipotence of the infant’s phantasy.

From this perspective, there are two conflicting trends of development from the very beginning of mental life. One is based on the good container–contained relationship leading to growth, the other on a very disturbed relationship leading to psychosis. The two are in constant struggle—no one is quite mad or quite sane. In this model, the analytic situation itself provides a container. Into the setting, the patient projects his intolerable anxieties and impulses, but the setting itself cannot produce a change. The analyst, who is capable of tolerating and understanding the projected parts, responds by an interpretation that, at its best, is felt by the patient to contain the projected elements made more tolerable and understandable. The patient can then reintroject these “made more tolerable” projected parts, plus the functions of the analyst with which he can identify. This provides the basis for the growth of a part of himself capable of containment and understanding.

This is the ideal progress. But the countertransference is very hard to bear. Over and over again the power of the patient’s projective attacks shake our state of mind and we fail to function adequately. But such failures in themselves give us precious information about the nature of the interaction, if we can bear it long enough to understand it.

I shall give one short example from my paper “Depression in the Schizophrenic” (Segal, 1956). The patient, who came to see me aged 16, had suffered from schizophrenia from the age of 4 when her persistent hallucinations started. She had some remissions, but when she started analysis with me she had suffered for many years from chronic hebephrenic schizophrenia. In her first session she rushed around the room gesticulating, muttering, or shouting incessantly. I caught some references to vomiting and to ghosts. I suggested to her that she was trying to get rid of all the bad thoughts in her mind and body by leaving them in my room. Typically, the next day she was silent, obviously paralysed by fear. She hadn’t spoken in weeks, mostly lying on the couch and tearing threads from the couch cover. I want to report material from the second year of treatment.

The sequence that I want to describe occurred in October. She had come back from the summer holiday remote and hallucinated. From her behaviour I could gather that she was hallucinating God and the devil; they represented the good and bad aspects of the patient’s father, who had committed suicide when she was 15. At times it was clear from her gestures and expressions that she was having intercourse, now with God, now with the devil. There was a great deal of screaming, shouting, and attacking; at times she looked terrified. She was also continually picking threads from the cover of the couch and breaking them off angrily. I had interpreted to her mainly her relation to her father in terms of splitting, idealization, and persecution, and I related this to the transference, particularly in connection with the long summer holiday. I also paid a great deal of attention to her breaking off the threads from the couch cover, interpreting this behaviour according to the context as breaking the threads of her thoughts, the threads of analysis, the threads connecting her internal world with external reality. Her violence gradually subsided, and although she was still picking off threads and breaking them, and as usual she did a lot of biting, grimacing, and angry shaking, the change in her mood was noticeable. As time went on there was more skipping and dancing, more grace in her movements, less tension, and there was about her a general air of half-gaiety, irresponsibility, and remoteness. Then one day, as she was dancing round the room, picking some imaginary things from the carpet and making movements as though she was scattering something round the room, it struck me that she must have been imagining that she was dancing in a meadow, picking flowers and scattering them, and it occurred to me that she was behaving exactly like an actress playing the part of Shakespeare’s Ophelia. The likeness to Ophelia was all the more remarkable in that in some peculiar way, the more gaily and irresponsibly she was behaving, the sadder was the effect, as though her gaiety itself was designed to produce sadness in her audience, just as Ophelia’s pseudo-gay dancing and singing is designed to make the audience in the theatre sad. If she was Ophelia she was scattering her sadness round the room as she was scattering the imaginary flowers, in order to get rid of it and so make me, the audience, sad. As the patient in the past had often identified with characters in books or plays, I felt on fairly secure ground in saying to her: “It seems to me that you are being Ophelia.” She immediately stopped and said, “Yes, of course”, as though surprised that I had not noticed it earlier, and then she added, sadly, “Ophelia was mad, wasn’t she?” This was the first time she had admitted that she knew about her own madness.

I then connected her behaviour with the previous material and with my interpretations about her relation to her father and showed her how she had felt guilty about the death of her father-lover whom she wished to kill and whom she thought she had killed for his having rejected her. I also explained to her that her present Ophelia-like madness was a denial of her feelings about his death and an attempt to put these feelings into me. As I was interpreting, she threw herself on the couch and let her head hang down from it. I said that she was representing Ophelia’s suicide and showing me that she could not admit her feelings about her father’s death, as the guilt and distress about it would drive her, like him, to suicide. But she did not agree with this and said Ophelia’s death was not a suicide. “She was irresponsible, like a child, she did not know the difference. Reality did not exist for her; death did not mean anything.”

I then interpreted to her how putting into me the part of herself capable of appreciating the fact of the death of her father and the reality of her own ambivalent feelings and guilt resulted in her losing her reality sense, her sanity. She then became a person who “did not know the difference” any longer.

She came back the next day very hallucinated and persecuted, externally and internally. She was obviously having unpleasant hallucinations, and she also turned away from me in an angry and frightened way. She did a lot of grimacing, muttering, and biting. She again picked up and broke off threads. I reminded her of the previous session and how she was trying to get rid of her painful feelings by putting them into me. I drew her attention to the breaking of the threads and told her that in getting rid of those painful feelings she felt she was trying to break off and get rid of her sanity. At the same time she felt that I had become a persecutor because she put her painful feelings into me and, as a result, she felt that in interpreting I was trying to push those feelings back into her and persecuting her with them.

The next day she came looking sad and quiet. She started again picking threads out of the couch, but instead of breaking them off completely she was intertwining them. When I made some reference to her Ophelia-like feelings, she said, “You know, when Ophelia was picking flowers it was not, as you said, all madness. There was a lot of the other thing as well. What was unbearable was the intertwining.” I said, “The intertwining of madness and sanity?” She said, “Yes, that is what is unbearable.” I then told her that my interpretations about how she tried to put her sanity into me made her feel that she had regained the sane part of herself, but she felt it was unbearable because now that sane part of herself could appreciate and feel distress about the disintegration of the rest of herself. In the previous session, she had tried to make me into the sane part of herself who knew about and so was distressed by her, the patient’s, insanity. I pointed out to her how she was intertwining the threads that she was picking up and contrasted this with the earlier session in which she was breaking the threads. I interpreted to her that the breaking of the threads represented her breaking her sanity because she could not bear the distress, sadness, and guilt that sanity seemed to bring into her mind.

In the next session she looked at me very carefully and said: “Do you ever smile or laugh? My Mummy says that she cannot imagine you doing either.” I pointed out to her how much laughing and giggling she had done during the last weeks and said that she felt that she had stolen all my smiles and laughter and put into me all her depression and guilt, thereby making me into the sad part of herself, but in doing that she made me into a persecutor because she felt I was trying to push this unwanted sadness back into her; then she could not experience her guilt or her sadness as her own but instead felt it as something pushed into her by me in revenge and punishment. She felt that I had lost my laughter but she herself had lost the meaning and understanding of sadness.

Whenever the patient could be put in touch with her emerging depression she became communicative in a sane manner, sanity and depressive feelings returning together to her ego. Whenever the depressive feelings became intolerable, re-projection occurred with the corresponding loss of reality sense, the return of mad behaviour, and an increase of persecutory feelings.

For the schizophrenic mind, the guilt and distress are intolerable, and so the steps that the patient has taken towards sanity have to be reversed. The patient immediately projects the depressed part of the ego into the analyst. This constitutes a negative therapeutic reaction. The saner part of the ego is lost and the analyst becomes again the persecutor, since he is felt to contain the depressed part of the patient’s ego and is experienced as forcing this unwanted depression back into the patient. In order to control this negative therapeutic reaction and to enable the patient to regain, retain, and strengthen the sane part of the personality, the whole process of the emergence of the depression and the projection of it has to be followed closely in the transference.

This is, I think, as much as I can say in the context of this chapter to try and indicate what I as a psychoanalyst see myself as doing when confronted by a psychotic patient. The question arises—of what value is this procedure? Quite clearly, psychoanalytic treatment, so very time-consuming and lengthy, does not give the answer to the social problem posed by schizophrenia. If all the psychoanalysts in the world were expert in the analysis of schizophrenic patients and devoted themselves solely to this task, it would statistically do very little for the world problem of the treatment of psychosis. What, then, is the value of psychoanalytic treatment? I think we have to differentiate here between the value to the patient and the value to the community. To take the patient first. It is my conviction that in the rare cases where all the conditions are right, psychoanalytic treatment is the treatment that gives the most hopeful therapeutic prognosis for the individual patient, and that when successful, it is the treatment that deals with the very root of the disturbance of this personality. I would not refrain from recommending it to an individual patient on the grounds that it is not a social solution, any more than I would withhold kidney machines or grafts from patients to whom they may be available just because they are not universally available. From t...

Table of contents

• Cover
• Half Title
• Series Page
• Title
• Copyright
• CONTENTS
• SERIES EDITOR’S PREFACE
• ACKNOWLEDGEMENTS
• ABOUT THE EDITORS AND CONTRIBUTORS
• INTRODUCTION
• FOREWORD
• 1 The psychoanalytic approach to the treatment of psychotic patients
• 2 Reflections on “meaning” and “meaninglessness” in post-Kleinian thought
• 3 Rigidity and stability in a psychotic patient: some thoughts about obstacles to facing reality in psychotherapy
• 4 Forms of “folie-à-deux” in the couple relationship
• 5 Psychotic and depressive processes in couple functioning
• 6 The Frozen Man: further reflections on glacial times
• 7 Psychotic processes: a group perspective
• 8 Psychotic processes in large groups
• 9 A community meeting on an acute psychiatric ward: observation and commentaries
• 10 Asylum and society
• 11 Schizophrenia, meaninglessness, and professional stress
• 12 Brilliant stupidity: madness in organizational life—a perspective from organizational consultancy
• 13 The dynamics of containment
• REFERENCES
• INDEX