Psychotic Organisation of the Personality

Psychoanalytic Keys

Antonio Perez-Sanchez

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429882241
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The book is a psychoanalytic understanding of psychosis as a particular organisation of the personality, based on 'psychotic personality' (Bion) and 'pathological organisations' (Steiner). The theoretical development is traced through Freud, Klein and Bion, along with contemporary Kleinian authors. An important role is granted to psychic pain as the cornerstone of psychopathology, and particularly to the psychotic patient's difficulties in dealing with it. Bion's distinction between "feeling psychic pain and suffering it" is considered an indicator when evaluating the patient's ability to cope with psychoanalytic treatment. The author's experience with a schizophrenic patient is related in detail, offering a view of the patient and her relationship with the analyst from various different angles, and showing how the psychoanalytic method can be used to treat psychosis.

PART I

THEORETICAL (AND CLINICAL) ASPECTS

CHAPTER ONE

Psychic pain, the psychotic part of the personality, and pathological organisation

“Grief bunches up between my ribs,
each breath I take is painful”

(Miguel Hernández, quoted by Ms B (translated by Ted Genoways))

Theoretical considerations on psychic pain and psychotic pain

My analytic experience with a schizophrenic patient, which, as I mentioned earlier, will constitute the central clinical reference material in this book, made me see both the significance of psychic pain in mental life and the level of intensity that it can reach in these patients, making it easier to understand the enormity of the defences raised against it. Hence, my wider interest in the study of psychic pain, notably psychotic pain, as well as the resulting defensive organisation that acts as a pseudo-container for it.

The pain described by the patient is of intolerable dimensions, and tends to be expressed in terms of somatic pain. This does not refer to a metaphor, such as neurotic patients, at times, describe mental pain. The impression one has is that the patient is experiencing a painful sensation as if he had received a tremendous impact, a body blow, with the additional problem that it cannot be localised to any particular organ or body part. Thus, my patient speaks of a profound pain suffusing her entire body, which may be likened to the words of the poet, whom she quoted on one occasion, “each breath I take is painful”, or when she says: “It hurts me deeply”, or “It is so painful I can’t take it any more.” It is almost as though she were referring to the pain of a wound or lesion that occupies her entire being, which never fully subsides and which almost nothing can alleviate. Incidentally, the very fact that the patient quotes the poet indicates that her mental state, at that moment, was such that it allowed her to give (poetic) form to the pain, and, as such, it would have ceased to be the unspeakable pain that Bion describes. I would then anticipate that the fact that the patient is able to speak about the pain is an indication to me that she has a minimal capacity for psychoanalytic work.

From the perspective of psychic pain, and borrowing the two parameters used by Bion (1991[1962]), psychopathology can be seen as a way of organising the individual’s personality in order to modify or evade the reality that generates that pain. To some extent, the tendency towards both the modification and the evasion of reality are present in every person, as it is not always possible for us to modify it, or we would be omnipotent, and neither can we avoid it absolutely, since this would signify death. That being the case, the degree of psychopathology in one’s personality organisation will be all the greater the more one channels psychic activity in favour of the second term, in other words, the avoidance of reality. In more severe cases, the psychopathology entails deploying a wide range of strategies and defences that, while they achieve the avoidance of pain resulting from contact with reality, they generate another type of pain that, in turn, requires new strategies and defences, in a never-ending spiral, in order to not only suffer increasingly less pain, but also to feel less of any emotion. This leads to a certain depletion, distortion, or fragmentation of psychic life (both affective and cognitive). Within the affective sphere, the devitalisation can be so pronounced that it leads the patient to what Resnik has termed a “time of glaciation” (Resnik, 2005). This is the mental impairment we find in long-term psychotic and schizophrenic patients.

Before examining the nature of this type of pain, certain clarifications should be made regarding the expression “psychic pain”. I think that it can be understood by considering two levels of categorisation. On one level, pain is a generic concept comprising any sensation that is unpleasurable to mental life. Freud was the first to use it in this wide sense (1911b), by using the term “unpleasure” in relation to contact with reality. Bion also tends to prefer using the term in this broad sense. (His English translation for “pain” appears to have been taken from Freud’s “unpleasure”.) In his case this includes any sensation of discomfort or malaise for the mind: mourning, grief, anxiety, guilt, and so on.

There is a second, more limited, level, essentially referring to situations of object-loss. Freud also uses the term in this sense, bound up with mourning, to the emotional impact (which would equate to physical pain) originated by the loss of the object (Freud, 1925d). Indeed, Bion also refers to pain in similar terms when he says that the absence of the object results in the presence of the no-object, which is accompanied by discomfort, and as such an experience of having bad objects, which incidentally, is necessary for the structuring of primitive thought. In this book, I will use the expression “pain” in the wide sense, because it is the use that I have encountered in clinical practice. When the patient speaks about pain this refers to a whole range of unpleasurable emotional phenomena that go beyond the loss of the (loved and needed) object, which might be considered as the prototype of painful psychic experience.

Another matter that requires clarification is the quality and the quantity (intensity) of the pain. As for the first, this is not always discernible. Ultimately, we could say, in a very general way, that pain arises as a manifestation of life forces in conflict with death forces (annihilation anxieties) that threaten to exert absolute dominance. However, this threat might be temporary, as is the case with the pain associated with growth, that is to say, with any mourning process. Equally, it might be instated as something perpetual, when it is the outcome of a certain type of object relation based on a pathological state of mind (a paranoid–schizoid state, for example, as we shall see later). The only aspect distinguishing “healthy” pain from “pathological” pain is arguably the sense of its duration, but in order to find out if it is temporary or not, we first of all need to tolerate it. The individual with very little capacity for tolerating pain will act quickly to get rid of it. By acting in this way, he will cut short the experience evolving with that pain, impeding the consequent strengthening of the personality.

In terms of the intensity of the pain, we might consider what quantity of psychic pain a person is able to tolerate. Let us say, for example, that the spectrum of tolerability for every person runs from just above zero (absolute zero would be incompatible with life) to n. The pain that any given person will be able to tolerate will depend upon the specific threshold he has reached (through his constitutional resources and the development of his personality in interaction with his environment). However, if this person is subjected to an intensity greater than n, in other words, which exceeds the threshold of what is humanly acceptable to him specifically, despite him being otherwise sane and well-balanced, this will bring about an inevitable distortion, reversion, or disavowal of reality. The psychotic patient will act likewise, albeit faced with levels of pain well below those acceptable to others, but always above his own personal threshold.

According to Freud, contact with reality entails pain because it denies access to pleasure. To which Bion adds that, in so far as this pain is felt as a threat to mental integration, the individual will try to evade it, thus jeopardising the necessary establishment of a good relation to reality and, along with it, the constitution of the personality. Thus, Bion continues, “pain cannot be absent from the personality” and, “I shall therefore consider pain as one of the elements of psychoanalysis” (Bion, 1989[1963], p. 61).

Klein also explored the idea of pain in relation to mourning, but gave it a broader definition, as she considers that all pain coming from any unhappy experience has something in common with mourning: it reactivates the depressive infantile position.

All pain, says Segal (1997[1993]), comes from the life aspects. The conflict between life and death can be stated in psychological terms. Faced with the experience of need, the drive might seek the object that satisfies it or, conversely, the impulse to negate the need itself, as well as the perception of the object, might predominate. Both tendencies can be merged. Freud points to the fact that although the death drive works in silence, in patients with severe disorders, such as psychotics (but not only in these patients), we might detect the working of the death drive in battle with the life drive (Segal, 1997[1993], p. 17). Later on, Segal tells us:

The question arises: if the death instinct aims at not perceiving, not feeling, refusing the joys and the pain of living, why is the operation of the death instinct associated with so much pain? I think the pain is experienced by the libidinal ego originally threatened by the death instinct. The primary source of pain is the stirring of the death instinct within, a dread of annihilation. (Segal, 1997[1993], p. 22, my italics)

Joseph talks of a specific psychic pain in patients with significant psychotic anxieties and a heavy use of projective identification. The pain arises, she says, in the periods of transition when the patient is emerging from a state of quasi-delusional withdrawal in which he experienced a fusion with the analyst through the use of projective identification. In her description, Joseph also notes the almost physical nature of this pain, although it is not psychosomatic, she specifies. The author also refers to the pain that brought the patient to analysis, but she only explores that which arises in the analytic process. This is a pain that is at a halfway point, it is borderline—she concludes— between the pain of fragmentation anxieties and the pain of integration or depressive pain (Joseph, 1989[1976]). We will have the opportunity to determine the legitimacy of these descriptions by Joseph in my patient’s case material (for example, in Theme 3 of Chapter Ten).

Steiner remarks that the psychotic patient experiences intense anxieties of a catastrophic nature, requiring drastic and omnipotent defensive measures and that the loss of the pathological organisation entails the return of the uncontrolled panic with experiences of fragmentation and disintegration of the self and its world (Steiner, 1993, p. 64). Bott Spillius also talks about the existence of an intense component of the death instinct in these pathological organisations (1988, p. 6).

We can describe three types of psychic pain. One, related to the loss of the object (I will include pain owing to frustration here), another, owing to the integration of the mind (this would be the pain of the depressive position), and a third, relating to the predominance of catastrophic anxieties and the threat of annihilation (pain specific to the pathological organisations), to which, in particular, I shall turn now, without, however, disregarding the other forms of pain.

I shall return to Bion to refer to various stages of his work where he discusses pain and the organisation of the mind produced to manage it. According to his theory of schizophrenia, the patient experiences a conflict that is never finally resolved between life and death drives, with a preponderance of destructive impulses. Hence, the unremitting dread of imminent annihilation. Consequently, the patient is forced to attack the ego apparatus, in its function of internal and external reality perception, which he isolates and divides into multiple fragments to then expel them (by projective identification) into the object. These are some of the characteristics of the psychotic part of the personality, which, if predominant, cause an increasing divergence with the non-psychotic part, until a gulf is created between the two that proves to be insuperable. From that moment on, maintaining the splitting that deepens that divide between the two parts is an important condition of the perpetuation of the schizophrenic equilibrium or the psychotic organisation. At the same time, the minute and violent fragmentations of the self, and the corresponding projection of them, continues unabated (Bion, 1993[1957], p. 51).

I think that any approach between these two parts of the patient (the psychotic and non-psychotic parts) constitutes another of the most fundamental causes of mental pain experienced by the psychotic. The non-psychotic part of the personality is the fundamental marker of the predominance of the life drive. The psychotic part, as we have seen, is a marker for the destructive drives. Consequently, when there is insufficient consistency in the life aspects, the conjunction of the two can lead to total catastrophe, with a form of mental annihilation that would be completely dominated by the destructive impulses. Segal describes a patient who expresses very well the nature of the interconnection between madness and health, which became truly unbearable to her (Segal, 1981), which I have also seen for myself in my patient.

The most critical stages of my patient’s analysis have taken place precisely when there has been a true recognition of the psychotic part. In other words, when she identifies it as an active part of her mind, although not a dominant one, and not just as something that is past. In these moments, in which the splitting decreases, the resulting experience becomes unbearable to the patient, and the way she defends herself against it is by attempting to translate the split to the analyst’s function. Thus, she may value him, and even retain his help and affection for him, and so on, but all of this is detached from his therapeutic function. Although envy can also be operating in that defence, it is important to highlight the splitting fantasy of the analyst, in which he seeks to avoid the therapeutic relation with her, as a “person able to see herself as psychotically ill”, as unbearable as this might prove to be for her.

I would like to emphasise the presence of the death tendencies as the basic problem, owing to the profound difficulties in containing them. In several passages of his work, Bion turns to the example of the baby or the psychotic patient who experiences the fear of dying and his need of an object to contain such anxieties. We find in “A theory of thinking”:

Normal development follows if the relationship between infant and breast permits the infant to project a feeling, say, that it is dying, into the mother and to reintroject it after its sojourn in the breast has made it tolerable to the infant psyche. If the projection is not accepted by the mother the infant feels that its feeling that it is dying is stripped of such meaning as it has. It therefore reintrojects, not a fear of dying made tolerable, but a nameless dread. (1993[1962], p. 116, my italics)

That means that the bases of the individual’s first relationships is the need for an object to deal with the imminent “feeling of dying”, which the baby’s fragile mental structure cannot yet contain, and constitutes a fundamental element of the individual’s early relations. Furthermore, by elaborating his “container–contained” model in Elements of Psychoanalysis (1989[1963]), Bion moves forward in the representation of this process with his simple but masterful description:

The infant, suffering pangs of hunger and fear that it is dying, wracked by guilt and anxiety, and impelled by greed, messes itself and cries. The mother picks it up, feeds it and comforts it, and eventually the infant sleeps. (1989[1963], p. 31, my italics)

Here, the account he offers us presents bodily sensations (hunger) together with feelings (fear of dying, guilt, greed, and anxiety, bodily and emotional) which form a complex mesh that is impossible for the baby to differentiate and which must be taken in by the mother. In addition, I must reproduce the full text of the following paragraph in its entirety, where he gives us a more complete version of the process, clearly illustrating the transformation of the bad experience and bad feelings of the baby into another, more tolerable one, through the intermediary of the object. So we see

The infant, filled with painful lumps of faeces, guilt, fears of impending death, chunks of greed, meanness and urine, evacuates these bad objects into the breast that is not there. As it does so the good object turns the no-breast (mouth) into a breast, the faeces and urine into milk, the fears of impending death and anxiety into vitality and confidence, the greed and meanness into feelings of love and generosity and the infant sucks its bad property, now translated into goodness, back again. (1989[1963], p. 30, my italics)

Noteworthy is the clear description Bion gives of the primitive level of the mind, where soma and psyche are so closely intermingled. Thus, he groups physical elements (faeces, urine) together with emotional elements (feelings of guilt or fear of dying), indicating that the former are translated, by the adequate return of the object, into other elements that are also material (milk) but have the opposite physical effects (satisfying hunger), so that they bring about the transformation of those feelings of greed and meanness into other, benevolent ones: love and generosity. Once more, the fears of impending death, thanks to object intervention, can be turned into vitality and confidence.

In “Attention and interpretation” (Bion, 1993[1970]), Bion returns to the idea of the patient who is unable to suffer pain, either because there is a pathological projective identification, or because the normal projective identification has not been received by the object, and he describes with uncanny accuracy the intensely painful emotions that he needs to project “explosively”. However, given the restrictive character of his reality and the dependence on projective identification, there is no adequate conception of containers into which the projection could take place. Consequently, this leads to the following dramatic situation:

The explosive projection is therefore felt to take place in what is, to the analyst, the realization of mental space: a mental space that has no visual images to fulfil the functions of a co-ordinate system, either the “faceted solid” or the multi-dimensional, multi-linear figure of lines intersecting at a point. The mental realization of space is therefore felt as an immensity so great that it cannot be r...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHOR
• SERIES EDITOR’S FOREWORD
• PREFACE
• INTRODUCTION
• PART I THEORETICAL (AND CLINICAL) ASPECTS
• PART II CLINICAL (AND THEORY)
• REFERENCES
• INDEX