Progress in Self Psychology, V. 3

Frontiers in Self Psychology

Arnold I. Goldberg

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781134878291
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

The third volume in the distinguished Progress in Self Psychology series brings together the most exciting issues in a rapidly expanding field. Frontiers inSelf Psychology is highlighted by sections dealing with self psychology and infancy and self psychology and the psychoses. Clinical contributions include several case studies along with a reconsideration of dream interpretation. Theoretical contributions span issues of gender identity, boundary formation, and the biological foundation of self psychology.

II
		Self Psychology and the Psychoses

Chapter 4
		A Short History of the Psychoanalytic Approach to the Treatment of Psychotic Disorders
		Arthur Malin

A psychoanalytic approach to the theory and treatment of psychosis has been discussed in the literature since Freud's early writings. In “Further Remarks on the Neuro-Psychosis of Defence” (1896) Freud reported a case of chronic paranoia. At that time, before the development of an instinct theory, he described paranoia as proceeding from the repression of distressing memories, and the symptoms were determined in their form by the content of what had been repressed. These ideas were later modified by Freud especially with the introduction of instinct theory.

Freud was basically pessimistic about the treatment of psychosis. He wrote in 1905: “Psychosis, states of confusion and deeply rooted depression therefore are not suited for psychoanalysis; at least not for the method as it has been practiced up to the present” (p. 264).

In 1916–17, he also advised against treatment of the psychosis. “The narcissistic neuroses can scarcely be attacked with a technique that has served us with the transference neurosis. … What always happens with them is that, after proceeding for a short distance, we come up against a wall which brings us to a stop. … In the narcissistic neuroses the resistance is unconquerable” (p. 423).

Later (1933, 1937, 1940), Freud continued to advise against psychoanalytic treatment in the narcissistic neuroses. He believed that with the decathexis of internal and external objects, a narcissistic neurosis would result with the inability to form a transference. The term “narcissistic neurosis” as used by Freud refers to psychosis, and since these patients cannot form transferences they cannot be treated by psychoanalysis.

The 1911 paper “Psycho-Analytic Notes on an Autobiographical Account of a Case of Paranoia” (The Schreber Case) was a discussion of a book published by a German judge that described in some detail a psychotic breakdown. Schreber's psychosis was that of paranoia, and it is in this paper that Freud made the connection between homosexuality and paranoia. Niederland (1974) described Freud's explanation of the mechanism of paranoia in this way:

The exciting cause of the illness was the appearance of a feminine (that is, a passive homosexual) wishful fantasy, which took as its object the figure of his doctor. An intense resistance to this fantasy arose on the part of Schreber's personality, and the ensuing defensive struggle, took on that of a delusion of persecution. The person he longed for now became his persecutor, and the content of his wishful fantasy became the content of his persecution. The patient's struggle with Flechsig became revealed to him as a conflict with God. This is construed as an infantile conflict with a father whom he loved; the details of that conflict were what determined the content of his delusions. In the final stage of Schreber's delusion a magnificent victory was scored by the infantile sexual urge; for voluptuousness became God-fearing, and God himself (his father) never tired of demanding it of him. His father's most dreaded threat, castration, actually provided the material for his wishful fantasy of being transformed into a woman [pp. 24, 25].

Freud explained that during the first stage of psychotic illness, the process of repression decathects the repressed mental representations of objects which, as a result, cease to exist. Hence, the psychotic patient's break with reality. The delusions and hallucinations which, in Freud's view, characterize the second or restitutive phase of the illness are attempts to recathect object representations [pp. 25–26].

This theory of paranoia requires instinct theory and the concepts of cathexis and decathexis of mental representation of objects (internal objects), as well as the cathexis and decathexis of real, external objects.

Abraham also discussed the treatment of psychosis by psychoanalysis. In contrast to Freud, Abraham (1911, 1916, 1924) reported the development of transference and successful psychoanalytic treatment of psychotic patients, including manic-depressives, through interpretation.

Starting in the 1930s, Melanie Klein (1935, 1946) and those influenced by her ideas, developed an approach to psychoanalysis that included working with psychotic patients. The developmental phases which they called the depressive position and the paranoid schizoid position were described as occurring in the first months of life. Rosenfeld (1965) has written extensively on psychosis and schizophrenic states. He has discussed the concepts of transference psychosis and of projective identification in the psychoses. Instinct theory, especially the death instinct, and internal object relations are very significant in his work. Bion (1959) was also influenced by Klein in the early part of his career and did make contributions to the treatment of schizophrenia, particularly with his concept of the attacks on linking.

Bullard, in the early 1940s, began a tradition of psychoanalytic dynamic psychotherapy of psychotic patients at Chesnut Lodge. Bullard was able to work with his very severely ill patients who manifested intense swings of transference, both positive and negative.

Sullivan (1947) made contributions to the dynamic therapy of severely ill psychotic patients. Freida Fromm-Reichmann (1939) worked under Sullivan and then continued treating schizophrenic patients at Chesnut Lodge. She was very sensitive to the severe problems of trust in psychotic patients. Therefore, she advocated an atmosphere of relatively complete acceptance toward the patient since any aggressive approach by the therapist would reactivate a very early traumatic situation in the patient's childhood. In her later papers (1948, 1952), Fromm-Reichmann revised her views and advocated less caution and a more vigorous analysis of the transference relationship. The doctor-patient relationship and its distortions should be a part of the psychodynamic treatment.

In 1951, Wexler, working at the Meninger Clinic, described his work with a psychotic patient in which he felt he could observe the effects of the decathexis of internal and external objects. For that reason he felt that he had to find a technique which would force the patient to take the therapist into account. Wexler took on a superego role with the patient and would actually agree with the patient's condemnation of herself for sexual interest and activity, and so on. His theoretical idea was that the severe ego defect would be filled in by the superego injunctions of the therapist, and when sufficient internal structure was built up through this means then further therapy could go on in a more traditional way. Wexler struggled with his patients to overcome the severity of the decathexis of objects. In later writings (1971), he emphasized both conflict and deficiency in schizophrenia.

Edith Jacobson (1967) described working with manic-depressive states and the analysis of the developing intense transference reactions. With ambulatory schizophrenic patients she would let the patient “borrow” the analyst's superego and ego and to “project his guilt, his faults, and weaknesses onto me; or turn me into the ideal of saintliness he needed.” (p. 57).

Searles (1965) made a number of contributions to the understanding of psychodynamic psychotherapy of schizophrenia. He took up the term “transference psychosis,” which had been introduced by Rosenfeld (1965) and discussed an approach to the patient that included what he called symbiotic relatedness. He stated that “the therapist must become able to function as a part of the patient” (p. 661). The therapist has to interpret the patient's transference psychosis that was dominated by projective identification and, finally, to interpret the patient's whole object relations. The idea was to develop a transference neurosis from the transference psychosis. Searles made a number of contributions concerning countertransference. He suggested that the analyst had to be aware of countertransference and make it a part of the therapeutic relationship.

It appears that a number of contributors were describing transference relationships that could now be called selfobject transferences.

Arlow and Brenner (1969) pointed out that the psychoses were never described by Freud from the structural point of view, only the topographic. They stated that, therefore, the concepts which Freud applied so fruitfully to the neuroses can be applied with great advantage to the psychoses and will prove a more useful frame of reference than the earlier concepts of decathexis, hypercathexis and recathexis (p. 12). They therefore advocated that “Interpretations of conflict, motivation, danger and defense can be given to patients in a manner which, if not identical, is at least analogous to the approach used in the treatment of the neurotic” (p. 12). They went on to state that as compared to the neuroses, “In the psychoses, instinctual regression tends to be more severe … , conflicts over aggressive impulses are more intense and more frequent … , [and] disturbances of ego and superego functioning are much more severe …” (p. 10). Arlow and Brenner used the structural point of view and ego psychology as a way of revising earlier concepts of psychopathology in the psychoses, and they advocated a new approach to therapy that was similar to working with the neuroses.

Boyer and Giovacchini (1967) have advocated a basically classical psychoanalytic approach to working with psychotics with very little use of parameters.

Over the years many psychoanalysts have been concerned with the treatment of the psychotic patient. But the injunction of Freud that psychoanalysis would not be applicable in psychotic states has always remained in the background. In recent years the advent of psychotropic medication has offered a promise of a new, more effective, and very medical approach to the treatment of the psychotic. The psychopharmacological approach has been around long enough for studies that might put that approach in perspective. In a recent book by Karon and Vandenbos (1981), there is a well-designed study demonstrating that over both a twenty-month period, and a four-year period psychotherapy without use of medication was more effective in the treatment of schizophrenia than medication alone or medication and psychotherapy. The patients were all from the black innercity subculture. The evaluation of results included cost effectiveness, which turned out to be very much in favor of the psychotherapy approach. Has the psychopharmacological approach been available long enough for disappointment in the promise of a fast cure? Have we come around again, or perhaps even increased our awareness, to the possibility of psychoanalytic, psychodynamic psychotherapy of schizophrenia?

REFERENCES

Abraham, K. (1911). Notes on the psycho-analytic investigation and treatment of manic-depressive insanity and allied conditions. In Selected Papers. New York: Basic Books. 1953.

—— (1916). The first pregenital stage of the libido. In Selected Papers. New York: Basic Books. 1953.

—— (1924). A Short Study of the Development of the Libido. In Selected Papers. New York: Basic Books. 1953.

Arlow, J., & Brenner, C. (1969). The psychopathology of the psychosis: A proposed revision. International Journal of Psychoanalysis, 50:5–15.

Bion, W. (1959). Attacks on linking. International Journal of Psychoanalysis, 40:308–315.

Boyer, B., & Giovacchini, P. (1967). Psychoanalytic Treatment of Schizophrenia and Charac- terological Disorders. New York: Science House.

Bullard, D. (1940). Experiences in the psycho-analytic treatment of psychotics. Psychoanalytic Quarterly. 9:493–504.

Freud, S. (1896). Further remarks on the neuro-psychosis of defence. Standard Edition, 3:162–185. London: Hogarth Press. 1962.

—— (1905). On psychotherapy. Standard Edition. 7:257–268. London: Hogarth Press. 1953.

—— (1911). Psycho-analytic notes on an autobiographical account of a case of paranoia. Standard Edition, 12:9–82. London: Hogarth Press. 1958.

—— (1916–17). Introductory lectures on psycho-analysis. Standard Edition, 15–16. London: Hogarth Press. 1963.

—— (1933). New introductory lectures on psycho-analysis. Standard Edition, 22:5–182. London: Hogarth Press. 1964.

—— (1937). Analysis terminable and interminable. Standard Edition, 23:216–253. London: Hogarth Press. 1964.

—— (1940). An outline of psycho-analysis. Standard Edition. 23:144–207. London: Hogarth Press. 1964.

Fromm-Reichmann, F. (1939). Transference problems in schizophrenics. Psychoanalytic Quarterly. 8:412–426.

—— (1948). Notes on the development of treatment of schizophrenics by psychoanalytic therapy In D. M. Bullard, ed., Psychoanalysis and Psychotherapy. Chicago: University of Chicago Press. 1959.

—— (1952). Some aspects of psychoanalytic psychotherapy with schizophrenics. In D. M. Bullard, ed., Psychoanalysis and Psychotherapy. Chicago: University of Chicago Press. 1959.

Jacobson, E. (1967). Psychotic Conflict and Reality. New York: International Universities Press.

Karon, B., & Vandenbos, G. (1981). Psychotherapy of Schizophrenia. The Treatment of Choice. New York: Aronson.

Klein, M. (1935). A contribution to the psychogenesis of manic-depressive states. International Journal of Psycho-Analysis. 16:145–174.

—— (1946). Notes on some schizoid mechanisms. International Journal of Psycho- Analysis, 27:99–110.

Niederland, W. (1974). The Schreber Case. New York: Quadrangle.

Rosenfeld, H. (1965). Psychotic States. New York: International Universities Press.

Searles, H. (1965). Collected Papers on Schizophrenia and Related Subjects. New York: International Universities Press.

Sullivan, H. S. (1947). Therapeutic investigations in schizophrenia. Psychiatry. 10:121–125.

Wexler, M. (1951). The structural problem in schizophrenia: Therapeutic implications. International journal of Psychoanalysis. 32:157–167.

—— (1971). Schizophrenia: Conflict and deficiency. Psychoanalytic Quarterly. 40:83–100.

Chapter 5
		Manic–Depressive Illness: Analytic Experience and a Hypothesis*
		Robert M. Galatzer-Levy

The fascinating phenomena of manic-depressive illness are not well understood psychoanalytically for two reasons. First, conflict psychology and libido theory seem particularly forced when applied to this illness. Freud's few pages on mania are perhaps the most obscure of his writings. Later analytic contributions, though evocative, have not led to the development of theories accepted widely even within the analytic community. More important, analytic experience with manic-depressives is very limited. Analysts have rarely used their most powerful research tool, the psychoanalytic setup, to explore bipolar affective disorders. This lack of experience reflects not only the analyst's appropriate caution but also character defenses common in this disorder that make the patient particularly reluctant to enter analysis. Deprived of systematic exploration of transference configurations, sustained empathic immersion in a patient's psychological life, and the opportunity to study in depth the operations and genetics of character structures, analysts have made little headway in understanding this illness. In the presence of extensive evidence for biological determinants of manic-depressive illness, the false dichotomy between organic and psychological pathology has further discouraged analytic exploration.

Lithium makes management of the illness easier and so increases patients' capacity for analytic work by reducing the likelihood of catastrophic reactions that require nonanalytic interventions and that disrupt the analysis. Of course, pharmacological interventions complicate psychological investigation, modifying the illness itself and, like all parameters that have psychological significance to the patient, they may be inadequately explored and resolved. Even so, manic-depressive patients on lithium provide the best opportunity we have for analytic exploration of this condition.

I have worked analytically with three such patients. At the outset the patients were told that psychoanalysis was not a standard treatment for their condition—that our work was research. The first patient terminated a seven-year analysis two years ago; the other two are in analysis at present, one for five years, the other for three and a half years.

All three patients were on lithium, which I managed. The first patient discontinued the lithium during the fifth year of analysis. I anticipated that the medication would be an important issue in these analyses and carefully watched for this possibility. Although the medication served several functions, including as a defense against psychological insight (“If you believe that my condition is treatable with lithium, a chemical, how can it be psychologically meaningful?”), transitional object, an indicator of failures of empathy, and a symbol of the patients' enslavement to the analysis, it never emerged in any of the analyses as a sustained central issu...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• Contents
• Contributors
• Preface
• Introduction
• I Self Psychology and Infancy
• II Self Psychology and the Psychoses
• III Clinical Contributions
• IV Theoretical Contributions
• Author Index
• Subject Index