The Psychotic

Aspects of the Personality

David Rosenfeld

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367099732
• eBook ISBN: 9780429921964
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The Psychotic: Aspects of the Personality presents the results of the author's many years of experience as an analyst working with deeply disturbed or psychotic patients, and demonstrates how the deeply resulting clinical and theoretical formulations may additionally be applied to less disturbed patients. Dealing with the theory and clinical treatment of the psychotic aspects of the personality, includes a review of the literature and a rich array of clinical material to illustrate the author's technical approach. A chapter devoted to the survivors of concentration camps shows how the concept of encapsulated autistic nuclei leads to new diagnostic and technical procedures, while a further paper discusses the psychotic difficulties attending heart-transplant surgery. Further essays illuminate the importance of the accurate detection and the use of the countertransference and the significance of the supervisor's supportive role in severe cases.

Part One

PSYCHOSIS AND PSYCHOTIC PART

Chapter One

Psychosis and psychotic part: a clinical approach

O, throw away the worser part of it and live the purer with the other half.

[Shakespeare, Hamlet, Act III, Scene 4]

In this chapter I present clinical material corresponding to two patients, Samuel and Pierre, in order to illustrate some views on the psychoses. As defined by Freud, by psychosis we understand the denial of reality and non-adjustment to it. It is a narcissistic disturbance, a damaged psychic apparatus. In addition, I develop some concepts about the psychotic part, psychosis, transference, transference in the psychosis, projected insight—expelled and then attacked outside—and the models and theories that might be used to explain the emergence of violence in the psychoanalytic treatment of the psychotic patient (Samuel). I discuss the usefulness of research into psychosis in order to create new models and hypotheses—for instance, the primitive psychotic body image model. Pierre’s case, likewise, shows the alternation between a psychotic part and a neurotic part, even within the same session.

I also describe the countertransference with these psychotic patients and stress its importance when an adequate technical use is made of it and, particularly, its unique intensity. I feel that the study of countertransference (and of psychotic transference) are the via regia to future investigations and for progress in the treatment of the psychoses, just as dreams were the royal road to the investigation of the neuroses. The patient makes the therapist experience intense and violent emotions, which he cannot express in words. This is the analyst’s paramount task: to be able to tolerate such emotions for days, weeks, months, or years and to decode them and translate them into words, with the appropriate timing.

The psychotic part

It should be noted that Freud did not develop the concept of a psychotic part, even though he suggested it in several works (Freud, 1911c [1910], 1924b, 1926e, 1940e [1938] and, especially, 1940a [1938]).

The definition of psychotic part might be based on the process that Freud referred to as splitting. It should be pointed out that the process of splitting is not a psychosis. Freud (1940e [1938]) regarded splitting as a defensive process, but one that is more precocious than other defenses.

We may then conjecture that the healthy or neurotic part present in every patient may establish, with that part of the ego, some kind of transference relationship. We understand some things about the psychotic patient thanks to the healthier part with which he can verbalize and conceptualize. We do not know the hidden psychotic part directly: it is a model that we must create as we work. Freud (1925d [1924]) suggests that the psychotic patient may be studied with further research and also that the analyst must discover the things that are behind a wall:

... since the analysts have never relaxed their efforts to come to an understanding of the psychosis . . . they have managed now in this phase and now in that, to get a glimpse beyond the wall . . . but the mere theoretical gain is not to be despised, and we may be content to wait for its practical application. In the long run even the psychiatrists cannot resist the convincing force of their own clinical material, [pp. 60-61]

In agreement with what has been previously stated, Freud (1925 [1924]) says, in connection with the parts that make transference possible in psychotic patients, that, in psychosis,

. . . transference is not so completely absent, but that it can be used to a certain extent, and analysis has achieved undoubted success with cyclical depressions, light paranoiac modifications and partial schizophrenias.

In another paper, Freud (1926e) says,

I should have thought that it would be recognizable from the phenomena, the symptoms, of which he complains. This is when a fresh complication arises. It cannot always be recognized, with complete certainty—the patient may exhibit the external picture of a neurosis, and yet it may be something else. The beginning of an incurable mental disease . . . —the differential diagnosis— is not always easy and cannot be made immediately in every phase . . . the illness may have an innocent appearance for a considerable time, till in the end it displays its Evil character ... [p. 202]

Bion (1967a) contributed some interesting ideas about the clinical and technical fields. For example, in clinical practice it is very important to perceive the functioning of the psychotic personality. Interpretations should make reference to the possibility of recovering expelled mental functions. As Elizabeth Tabak de Bianchedi (1989) suggests, this implies laying the stress on the function rather than on the interpretation of conflicts, emotions, or doubts. The psychotic personality lacks the capacity to ask itself questions; it is not aware of the conflict. It expels its ego and its perceptual functions. The analyst must help the patient to recover what he has got rid of (not only objects and emotions, but also ego functions which the patient has got rid of through projective identification).

Bion (1967a) states:

I do not think, at least, as touches those patients likely to be met with in analytic practice, that the ego is ever wholly withdrawn from reality. I would say that its contact with reality is masked by the dominance in the patient’s mind and behaviour of an omnipotent phantasy that is intended to destroy either reality or the awareness of it. Since contact with reality is never entirely lost, the phenomena which we are accustomed to associate with the neuroses are never absent and serve to complicate the analysis, when sufficient progress has been made, by their presence amidst psychotic material. My second modification is that the withdrawal from reality is an illusion, not a fact, and arises from the deployment of projective identification against the mental apparatus listed by Freud . . . the patient acts as if his perceptual apparatus could be split into minute fragments and projected into his objects. ... [p. 46]

Psychosis, psychotic part, and neurotic part

A thought which, quarter’d, hath but one part wisdom.

[Shakespeare, Hamlet, Act IV, Scene 4]

Freud’s (1940a [1938]) description of the splitting of the ego in the psychoses into a normal part and another that ‘detaches the ego from reality’ is of fundamental importance for the understanding of the psychoses.

In the course of treatment, the analyst avails himself of the patient’s neurotic part, with its minimum capacity for verbalization, in order to establish a transference relationship. In other words, if on the basis of some of Freud’s writings we infer that in every psychotic there is a neurotic part, this part could be the basis for the establishment of a transference relationship in accordance with his own definition. As from 1913, Abraham began to suggest, perceive, and state that there is transference in schizophrenia (Abraham, 1908, 1911, 1916). As Freud (1940a [1938]) points out,

even in a state so far removed from the reality as the hallucinatory confusion . . . that at one time in some corner of their mind there was a normal person hidden.

He adds that,

Two psychical attitudes have been formed instead of a single one. One, the normal one, which takes account of reality, and another which under the influence of the instincts detaches the ego from reality. The two exist alongside of each other. The issue depends on the relative strength. If the second is, or becomes, the stronger, the necessary pre-condition for a psychosis is present. If the relation is reversed, then there is an apparent cure of the delusional disorder.

A healthy part is necessary in order to work with a psychotic patient. As Shakespeare puts it: ‘Nothing can be made out of nothing’ (King Lear, Act I, Scene 4).

Transference in Freud: a methodological approach

According to Freud’s definition of transference, it is a process by which the unconscious wishes are displayed upon an object within the framework of a special type of relationship established with them and, above all, in the psychoanalytic relationship (Laplanche & Pontalis, 1973). It is a repetition of infantile prototypes experienced as if they were intensely present.

Freud (1912b) stressed that transference is associated to prototypes or imagos (mainly that of the father, but also the mother, a sibling, etc.). The physician will become a part of one of the psychic series already formed by the patient.

Freud gives a definition of transference that includes a libidinal relationship with the part capable of communicating, and, from the methodological point of view, this also implies a definition. For instance, even though Freud does not specifically speak of an ‘acute psychosis’ but of ‘acute or hysterical psychosis’, we might infer that as regards the treatment of the psychoses they amount to the same thing. Freud (1895d) refers to ‘hysteria’ and then to ‘hysterical psychosis’ and adds that ‘... it can be assisted to an extraordinary degree by our therapeutic intervention’. This shows that our work with a patient with an acute condition can be useful (Avenburg, 1975).

Although Freud investigated cases in which, theoretically, transference was not assumed to be present, in practice the opposite phenomenon could be observed. Let us consider the case of Schreber, a psychotic patient, and his relationship with Flechsig, his doctor (see Freud, 1912b, pp. 47, 50, 55; see also transference with Flechsig, pp. 18, 19, 38, 39, 40, 69, 72). Why did Freud not state that these transferences had to do with the doctor? This is difficult to understand, but perhaps not so much so if we re-define it from the methodological point of view.

To establish whether the psychoanalytic treatment of psychotic patients is useful today, the first point to be mentioned is that every investigation is useful, provided that it is carried out in the transference. It is for this reason that I will now discuss the concept of transference and of transference in the psychoses. As stated before, I shall use a methodological approach to this subject.

A first step would be to ask ourselves whether the current definition of transference is useful. We think it is, since it has made it possible to centre our attention upon a certain type of phenomenon occurring in the course of a session (Brudny, 1980).

When a classificatory term that includes some phenomena while excluding others is introduced, we must make sure that what we are defining is a ‘natural class’.

In the first place, this class should be relevant.

In the second place, it must have typical and constant characteristics and relationships that differentiate it from what has been excluded from the classification.

If we asked ourselves whether Freud’s definition of transference directly involves neurosis and psychosis (Freud, 1912b) or whether it is a definition of a situation of a relational nature, we might answer that this kind of definition does not presuppose that we are speaking of neurosis or of psychosis (Klimovsky, 1980). The definition of transference describes a phenomenon that may or may not occur—that is, it defines a natural class and is useful (Popper, 1965).

It might be asked whether Freud made a methodological mistake in his general definition of transference. We might answer that it is legitimate to define a new concept stipulatively, provided that the stipulations are not arbitrary.

Freud’s definition of transference is not so narrow, since it can be applied to the study both of psychotic and of neurotic patients. An epistemologist would be inclined to think that there are no methodological mistakes in Freud’s general definition of transference, since it makes it possible to study patients as well as the conditions and effects of transference and even the use to which this phenomenon can be put. It may very well be that Freud has given us more than a definition—an empirical statement, an empirical generalization (Klimovsky, 1980).

How and why does Freud come to the conclusion that transference is a phenomenon observed in neurotic but not in psychotic patients? The reason could be:

1. the type and number of patients he saw;
2. the time element.

In my view, this is very important, because, in fact, his definition of transference does not seem to imply that it must necessarily be a transient phenomenon, that is, that it should be detected immediately. It would seem that there is here a kind of methodological mistake, not in the general definition of transference, but in the way in which Freud collected his empirical data. Freud thought that if transference in the psychoses did not appear within a short period of time, then it did not exist. (I must point out, however, that at that time the course of an analysis was usually brief.)

Transference in the psychoses

Somewhat contradictorily, in other writings Freud suggests that the treatment of psychotic patients may be useful for the creation of theories: Therapeutic attempts initiated in such cases have resulted in valuable discoveries . . .’ (1925d), and also that transference is not wholly absent in psychotic patients. For instance, with reference to psychotic patients, he says that: Transference is often not so completely absent but that it can be used to a certain extent’ (1925d).

Freud’s definition is very useful because it provides information, and we may think that the negative, disruptive, or disorganized transference of psychotic patients would also provide us with information. (Even the patient’s indifference is information. Freud describes indifference as the way in which ‘they reject the doctor . . .’ [1916-17].)

This is similar to the study of particles in a cyclotron, where Wilson’s chamber, which photographs atomic particles, provides information. What matters is not whether the pictures are in black on white or white on black, but the information. The same applies to the investigation of transference in psychotic patients: whether positive or negative, it provides us with adequate information, given the adequate elements and time.

After defining transference, Freud seems to have come up against epistemological difficulties as regards the observation of the data.

In his autobiographical study (1925d), Freud says that it is in the extreme forms that the material emerges most clearly. The extreme cases teach us the most. For example, Freud says:

Am meisten kommt aber in Betracht, dass in den Psychosen so vieles für jedermann sichtbar an die Oberfläche gebracht wird, was man bei den Neurosen in mühsamer Arbeit aus der Tiefe heraufholt[Gesammelte Werke, p. 87]

But the chief consideration in this connection is that so many things that in the neuroses have to be laboriously fetched up from the depths are found in the psychosis on the surface, visible to every eye. For that reason the best subjects for the demonstration of many of the assertions of analysis are provided by the psychiatric clinic. [1925d, pp. 60-61]

Perhaps what Freud called transference in the psychoses was a type of transference that did not fit in with his theory of transference and of the neuroses at that moment.

But if we regard as transferences more primitive and undifferentiated ways of communicating and if we place them within the context of other hypotheses or other theoretical conceptions, some events between patient and therapist may be defined as transferences.

The display of the transference in a psychotic patient requires some time and such transference may be abrupt and premature [d’emblée]; at other times, conversely, it takes months to detect transference material with certainty. (Abraham did describe transference in the psychosis, in 1908, 1911, and 1916.)

Psychotic transference may be observed particularly in the treatment of psychotic patients and is usuall...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Foreword
• Preface
• Part One Psychosis and Psychotic Part
• Part Two Psychosis, Technique, and Body Image
• Part Three Drug Addiction, Impulsions, and Linguistics
• References and Bibliography
• Index