Making Room for Madness in Mental Health

The Psychoanalytic Understanding of Psychotic Communication

Marcus Evans

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781782203292
• eBook ISBN: 9780429915994
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In this book, Marcus Evans makes a strong case for the importance of psychoanalytic supervision in mental health practice and its role in helping frontline staff to "tune in" to their patients' unconscious communications or the "psychotic wavelength".

Chapter One
Theory in practice

In this chapter, I outline some of the Freudian and Kleinian theories that I have found useful when thinking about clinical care in mental health settings, whether in direct work with patients or in teaching and supervising frontline staff. I also provide vignettes to illustrate the theory in clinical practice. In consultation and supervision, the skill is to introduce theory in a way that is relevant to mental health professionals’ work. I have found that live super vision of a clinical case is the most effective way of bringing the concepts to life. It is important to stress that we all employ psychic defences in order to protect ourselves from overwhelming psychological pain and anxiety. Indeed, these psychic defences are essential for healthy functioning. However, there are problems when overwhelming psychological turmoil or conflict drives the individual to employ primitive defences in a rigid way.

Freudian and Kleinian theories

The transference and the countertransference

Freud (1895d, p. 253) discovered the transference phenomenon early in his work. He described the way the patient transfers repressed feelings and desires from childhood onto the therapist in the here and now. Initially Freud thought that the transference was an obstacle to therapy; however, he later discovered that the transference could throw light on deep-seated and repressed childhood conflicts. Patients develop powerful transferential feelings towards the professionals and carers responsible for their treatment. Professionals need to be sensitive to the meaning these roles carry for patients. It is important for them to try to tune in to the patients’ transference towards them, because this can convey meaningful insight into the nature of early relationships and underlying difficulties.

At short notice I had to cancel the appointment of Ms B, a 30-year-old patient who always felt she had been a disappointment to her parents. She was born after her mother miscarried a boy, and she believed her mother would have preferred the miscarried baby to her. Ms B arrived at the next session saying that she nearly had not come, as she had assumed the cancellation meant that I no longer wished to see her, and she believed that I would feel that the therapy was a waste of my time. In her phantasy, she thought I would have preferred to see a more satisfying male patient.

Freud first described the term “countertransference” to denote the patient’s impact upon the therapist’s unconscious mind (Freud, 1912b). This idea was developed by Heimann (1950) to explain and make use of the therapist’s feelings towards the patient. Her idea was that the patient generated feelings in the therapist that were responses to the patient’s transference feelings. Money-Kyrle (1956) also developed this theory by differentiating between normal and abnormal countertransference. In normal countertransference, therapists take in the patient’s experience and identify with it in a subjective way. Therapists then separate from the patient’s subjective experience and objectively examine the interaction before deciding on an interpretation. In many ways, it is true to say that therapists are having a conversation with themselves before talking to the patient. In abnormal scenarios, therapists may have difficulty separating themselves from identification with their patients and react by treating the patients as if they were a damaged aspect of themselves.

Klein worried that this development could lead to wild analysis as analysts might attribute ideas and feelings to the patient for neurotic reasons of their own. Hanna Segal (1977) wrote that the countertransference was the best of servants and the worst of masters. She, too, emphasized the need for therapists to be cautious in attributing feelings in themselves to the patient. One of the functions of psychoanalytic supervision is to provide the space to explore therapists’ or mental health professionals’ emotional responses, to see how much light they shed on projective processes going on between them and the patient.

Mr C, who was in his late thirties, was plagued by a feeling that he was not working hard enough. He was determined to gain promotion at work because he saw this as a way of triumphing over his sister. Mr C had always felt that his sister was the favourite and got the support of their parents at his expense. He came into the session, sat down in the chair, and after a few minutes’ silence said: “Look, I can’t afford to sit here wasting my time. If you haven’t got anything helpful to say, I’m going to leave.” My immediate response was to feel guilty, as if I had not been working hard enough or fast enough, leaving the poor patient suffering with anxiety about the threat of failure. After a pause, I began to find the space to separate myself from the effect of the patient’s communication and think that this must be what it was like to be the patient: constantly feeling that he was never doing enough and that if he didn’t keep himself under considerable pressure to work and progress then he would fail, his sister would triumph, and he would be unloved and unlovable.

The paranoid-schizoid and depressive positions

Klein described the healthy infant’s dependence upon the mother for sustenance, care, and love in order to support the development of a strong ego and sense of self. When the infant feels safe, it feels that it is in the presence of an “ideal” loving mother and has loving feelings towards her. The “ideal” mother is internalized by the infant in a loving way and forms the basis of the infant’s ego. However, when the infant feels anxious, in pain, or neglected, it feels that it is in the presence of a “bad” threatening mother who fails to provide protection and care. Aggressive feelings towards this uncaring “bad” figure then further threaten the infant’s ego and sense of security. In order to protect the ego and any residual good feeling, the infant projects these aggressive feelings towards the “bad” mother out into the external world. These aggressive feelings are then felt to reside outside the object in the external world and are always threatening to return. Klein described the way the infant internalizes the good object it depends upon for life, in order to protect it, while projecting the bad threatening object into an object in the external world. The bad object is then attacked and treated as a threat that needs to be kept outside; this is known as the paranoid-schizoid position (Klein, 1935). The psychic defences used in the paranoid-schizoid position include splitting, projective identification, denial, and idealization.

Early in the morning I sat down on the train opposite a man holding a can of strong lager, and he looked drunk. I glanced at him in passing. He seemed to be waiting for me to look at him. He became aggressive—“What the f*** are you looking at you c***?”

In this instance, the man has split off and projected his conscience into me, so that he is free to enjoy his inebriated state, free of conflict and questions. I then become his conscience, looking at him in a moralistic and judgemental way and asking him questions like “What are you doing, drinking at this time in the morning while everyone else is going to work?” He then attacks me in a paranoid way, in order to get rid of the questions and the critical thoughts. So here we have the man splitting off part of his mind and then projecting this elsewhere, out of his mind, hence “paranoid-schizoid”.

Over time, as ego strength develops, the infant begins to lessen the split between the loved “ideal” mother and the hated “bad” mother. Indeed, the infant starts to recognize that the aggressive and loving feelings are both directed towards the same mother. The ideal object/mother is given up and replaced by the “good” mother. At the same time, the infant begins to realize that it is dependent on the good mother for sustenance and life. Faced with the guilt and subsequent realization of its dependency upon the “good” mother, it internalizes the “good” mother object in order to protect her from aggressive attacks. The infant mourns the loss of the ideal object mother; Klein called this state of mind the “depressive position”.

In a psychotherapy session, a young woman who persistently harmed herself was suddenly aware of the fact that she had done tremendous damage to her body and her mind. During this session, she bent forward in pain and, in a way that conveyed her pain and anguish, said, “I can never repair the damage I have done to my body.” She went on to say that she hoped she could stop self-harming because she still had a mind that had things to offer, and she would like to get on with her work.

In this instance, we can see how the young woman becomes aware of the damage she has done, which is irreparable, and this leads to sadness about the loss. At the same time, she is able to stay with the sense of loss, resist the temptation to get back into further acting out, and express a wish to protect the functioning part of her that is not damaged.

Manic defences against persecution and guilt

Klein also recognized that guilt and depression can lead to a regression into a manic state of mind, in which the infant tries to deny its dependence upon the object by denigrating the object and employing mechanisms of triumph.

Ms D, a 25-year-old patient with manic-depressive psychosis and a previous history of psychiatric admissions, was being seen in once-weekly psychotherapy. She had been stable for a number of years and was due to get married to the supportive man she had been living with. Her breakdowns had been precipitated in the past by casual affairs with men. These men had several characteristics in common: they were macho, good-looking, and sexually interested in her but not interested in other ways. Historically these affairs were often the precursors to manic breakdowns, during which Ms D would damage her relationships, self-esteem, and bank balance. Several weeks before a break in the therapy, Ms D told the therapist that she was sexually frustrated with her fiancé and had become attracted to a man who said he had been a member of a local gang and talked about killing men, which she found exciting. As the therapy break drew closer, she said that she was increasingly fantasizing about the violent man and planned to see him the following week. At the same time, Ms D also said she was worried about the forthcoming break in the therapy, which made her feel her therapist was worn out by her and needed a long rest to recover his strength. She had a similar worry about her fiancé, who, she complained, did not like sex as much as she did.

Ms D felt threatened by feelings of vulnerability and would turn to manic aspects of her own mind in order to triumph over underlying feelings of sadness and loss. As the marriage and the break approached, she worried that these ordinary, supportive men were not going to be able to provide the manic excitement she relied upon in order to triumph over her underlying feelings. Ms D was driven to distance herself from her underlying difficulties by starting an affair with an omnipotent, phallic man. The violent macho man represented Ms D’s shift into a manic state of mind, in which excitement and violent psychic states triumphed over feelings of weakness, vulnerability, anxiety, sadness, and loss.

Reparation and manic reparation

Klein (1929) described reparation as the impulse to repair phantasied attacks on the object. Klein believed that reparation was central to all creativity, as individuals want to make amends for their attacks on the object through a creative act. Some reparative acts may take place in concrete external reality, while others are related to internal changes. As the object is symbolically repaired by the creative act, the ego is strengthened.

A 28-year-old woman with a long-standing grievance towards her single mother for being overbearing came into therapy complaining that she could not establish a life of her own, as she felt this would be at her mother’s expense. After some time in psychotherapy, she began to develop a capacity to put herself first and bear the guilt involved in developing a life of her own. Just before one Christmas break, she told me she felt guilty, because she had told her mother that she had decided to go to her new boyfriend’s parents for Christmas rather than spending it with her. She said that she felt her mother was really hurt, but she was determined to put her wishes first and bear the feeling of guilt. A few months later, she told me that she and her boyfriend had decided to move in together, and she went through a similar feeling of guilt. She went on to say that she had just started playing the violin again, having not played since the age of 14. She started to cry as she remembered the pleasure that her violin playing as a child had given both her and her mother. Her mother had encouraged her to play the violin when she was younger, but she had given it up in her teens in a rebellious tantrum.

We can see in this example the way the psychotherapy helps the patient separate from her mother and bear the guilt of putting herself first. This allows the patient to give up her stance of masochistic but resentful compliance. She is subsequently able to rediscover a pastime that gave them both pleasure when she was younger. In this way she is able to bear the guilt of separating from her mother while rediscovering a warm and passionate relationship between herself and her mother, represented by the violin playing.

In contrast to reparation, which involves the experience of guilt, manic reparation employs omnipotent and manic defences in an attempt to repair the damaged object. The attitude towards the object often involves control and triumph rather than genuine remorse.

A patient in the early stage of therapy had a habit of going into loud and violent verbal outbursts when she was upset. As we came to the end of the therapy, she worried that she had damaged me through her verbal attacks and that I would be very keen to see the back of her.

Several weeks before the end of the therapy, she told me a dream. In the dream, I was speaking at a prestigious conference, and she was in the audience with a friend. At the conclusion of my paper there was a long ovation, and the patient remembers feeling superior to her friend. I said I thought she wanted to end her treatment with a long applause, admiring me as a figure of eminence, as this allowed her to feel that she had received a superior therapy and therapist, which would help to keep her above more ordinary feelings of anger and disappointment as well as gratitude and feelings of loss about me as her therapist. However, she worried that she could not protect anything ordinary from her criticism and contempt. She then said she remembered at the end of her dream seeing a beggar on the steps of the university. He was dishevelled and unkempt but also bald, and he reminded her of me.

In the example above, we can see the way the patient wishes to deal with her anxieties about the damage she may have done to me during the therapy by flattering me. However, the dream also reveals her triumphant feelings in relation to her friend. In this way, she tries to triumph over ordinary feelings of anger, disappointment, as well as gratitude about the end of the therapy. The association to the beggar on the steps of the university reveals the underlying anxieties about the damage she fears she may have caused me by her verbal attacks.

Projective identification

Klein used the term “projective identification” to describe a mental process in which the person gets rid of unwanted psychological knowledge or perceptions, while putting pressure on objects to conform to his omnipotent view of the world (Klein, 1946). Klein also outlined the infant’s fluctuations between the disintegrated states of mind—the “paranoid-schizoid position”—and the integrated states of mind—the “depressive position” (Klein, 1935). In the paranoid-schizoid position, the infant’s loving feelings for the mother are kept separate from its hateful feelings; thus, the ego and the object are split between an idealized, loved object and a denigrated, hated object. The infant then acts towards the external object as if it were identified with the element projected from the infant’s mind.

Mr E, a patient I saw in psychotherapy, had very little tolerance of his emotional difficulties and usually wanted to get away from the problem once he had told me the facts. Indeed, when I tried to think with him about the difficulty he had raised, he frequently said that he was bored with the subject and wanted to move on.

Mr E started one session by telling me about an upsetting argument he had had with his girlfriend over the weekend. I paused for a minute, thinking about his communication, and within a few seconds he asked me if I was bored. In a split-second, the intolerance of his difficulties had been projected into me, and in his mind I had become the one who can’t stay with an emotionally upsetting problem.

The depressive position comes about when the infant is able to reduce the split between the good mother and the bad mother and begins to realize that the mother he hates is the same as the mother he loves. This process of integration demands that the infant has internalized a good object capable of bearing painful emotions as well as being able to reflect upon the meaning of those emotions.

The depressive position and loss of the ideal mother coincides with the emergence of the oedipal situation as the infant becomes aware of a third object—often the father. Knowledge of the parents’ sexual relationship creates feelings of curiosity as well as jealousy and loss. The triangular relationship between the parents and the child closes a psychic space and provides boundaries around the child’s experience of itself. On the one hand, patients have an experience of their mother taking in their subjective experience, while, on the other hand, they are aware of a third object—the father—who is looking at the child’s relationship with the mother from a different point of view. This model allows the integration of the infant’s subjective experience of being understood emotionally by the mother with the objective experience of being thought about by the father from a separate point of view. This form of triangulation is necessary as it provides a space in which the object can be thought about in its absence, and it paves the way for symbolic thought (Britton, 1989).

Symbolization and concrete thinking

Segal (1957) bu...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• SERIES EDITORS' PREFACE
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHOR
• PREFACE
• FOREWORD
• Introduction
• 1 Theory in practice
• 2 Psychoanalytic supervision in mental health settings
• 3 Being driven mad: towards understanding borderline states
• 4 Pinned against the ropes: psychoanalytic understanding of patients with antisocial personality disorder
• 5 Tuning in to the psychotic wavelength
• 6 The role of psychoanalytic assessment in the management and care of a psychotic patient
• 7 Deliberate self-harm: "I don't have a problem dying, it's living I can't stand"
• 8 Anorexia: the silent assassin within
• 9 Hysteria: the erotic solution to psychological problems
• Conclusion
• REFERENCES
• INDEX