Impasse and Interpretation

Therapeutic and Anti-Therapeutic Factors in the Psychoanalytic Treatment of Psychotic, Borderline, and Neurotic Patients

Herbert Rosenfeld

• Publisher: Routledge
• Year: 2003
• Topic: Psychology
• eBook ISBN:
  9781134983889
• Subtopic: Abnormal Psychology
• Index: Psychology

Herbert Rosenfeld makes a powerful case both for the intelligibility of psychotic symptoms and the potential benefits of their treatment by psychoanalytic means.

PART ONE

Introduction

1

A psychoanalytic approach to the treatment of psychosis

Patients who suffer from severe psychotic illness, those who are severely narcissistic, and those who do not get better or even get worse as psychotherapeutic treatment progresses have always been a special focus of my interest. In this book, drawing on material from my own practice and from those of psychoanalysts and psychotherapists whom I have supervised over the last twenty years, I want to give an outline of the ideas I have developed about such patients. In Part Two of the book, I shall present my ideas about the specific contribution the analyst or therapist can make towards influencing the patient for better or worse. In Part Three, I will outline how I think a correct understanding and approach to the problems created by what we have come to term ‘narcissism' are essential if the analyst is to function therapeutically. In Part Four, I shall discuss the complex ways in which aspects of projective identification can both assist and undermine the therapeutic relationship.

It is central to my thinking that analytic psychotherapy can be an enormous influence on very disturbed patients, but this influence can be for both good and ill. Some of the treatments I shall discuss did not end well, although not, I think, because the patients were beyond help. What happened was that an impasse developed in the relationship between patient and analyst, something which can happen very easily with a psychotic patient, and this could not be overcome. I believe that such impasses are often created by the therapist's response to the patient's communications and can be avoided by paying careful attention to what the patient is saying. It is my conviction that the psychotic patient's speech and behaviour (particularly in sessions) invariably make a statement about his relationships to the therapist. In this context it is important for the therapist to pay minute attention to the patient's communications and to seek to conceptualize and understand what these communications mean in the transference relationship. However, to provide some background for these views, I want to use this first chapter to say something about the development of my own thinking and therapeutic technique and the clinical experiences that prompted it.

Beginnings

My interest in psychological medicine began during my medical training in Germany, and my MD thesis dealt with the influence of ‘Multiple Absences in Childhood'. However, I had no chance to pursue the study of disturbed children or adults in the Germany of 1933 and 34. The Hitler regime forbade non-Aryan doctors to have personal contact with their patients. On coming to England I had intended to practise general medicine for several years before following my psychological interest. But I was catapulted into becoming a psychotherapist after passing my qualifying examination to practise medicine in Britain in the autumn of 1936. At that time the Home Office was prepared to allow only experienced foreign doctors, generally specialists, to stay in Britain to practise, and so I was among those who were asked to leave once I was qualified. However, on closer investigation into the possibility of becoming a psychotherapist, for whom there were openings in Britain, I found that the Tavistock Clinic had a two-year course for training psychotherapists and I immediately applied and was accepted for it.

In the waiting period of nine months before I began at the Tavistock I succeeded in getting first a locum job in a mental hospital near Oxford and later one at the Maudsley Hospital, London. At the mental hospital near Oxford I had to look after 350 patients, half the patient population. There were only three doctors to look after about seven hundred patients: the Superintendent in charge of the hospital and its administration, a senior colleague, and myself. My senior colleague, who had been working in the psychiatric hospital service for many years, introduced me to my job by explaining that there was very little work to do. After occasionally seeing a new admission, my task was to do rounds of the wards. Altogether I would work no more than one and a half hours in the morning and I would then generally be free for the rest of the morning and the afternoon. In fact, apart from their being looked after in the hospital physically, no treatment was given to the patients.

I decided to look among the new admissions for patients who might be suitable for psychotherapy. I selected a patient diagnosed as having catatonic schizophrenia. He had severe attacks of catatonic excitement every four weeks which always lasted one week. The patient, Edgar, had been in the hospital for more than a year, and the staff complained that he was uncooperative, would not do any work in the wards, and was at times violent. However, he seemed to be quite friendly to me. I asked the Superintendent whether he would agree that I could practise some simple psychotherapy with Edgar. At the same time I inquired whether he would agree, if an improvement was to take place, that such an outcome had been achieved by psychotherapy. Few in England believed that psychotherapy could have an appreciable effect, and so any improvement was called a ‘remission'. Although I did not doubt that remissions were common, there was obviously a difference between a spontaneous remission and one which was due to some external positive influence, such as a psychotherapeutic approach. Such a hypothesis would imply that schizophrenia might have a psychogenic basis, which at that time was not acceptable to psychiatrists in Britain-apart perhaps from R.D.Gillespie and one or two others, such as Clifford Scott, whom I had not then met. In any case the Superintendent agreed with me that Edgar appeared chronic, and therefore that any improvement would have to be attributed to my work with the patient.

When I talked to Edgar, he explained to me that he had to endure electric shocks every night when he was going to bed. This occurred about every few weeks and made him feel very disturbed. I realized that what he was describing was a delusion of being influenced by a machine, a condition Tausk described in 1919 (Tausk 1919). Edgar asked me many questions and was friendly. He readily listened to my explanations about the physical sensations that were troubling him, which I thought were mainly sexual feelings. He seemed to be completely ignorant about sex. When I informed him about it, it seemed to enable him to become less frightened of his sexual feelings and more accepting of them. He was very appreciative and asked me what he could do for me. I told him that it would be useful if he could show his appreciation by co-operating in the ward and so make it easier for everybody. He proceeded to do so. From this time onwards Edgar's periodic excitement ceased, and I saw him only occasionally. When I left the mental hospital a month or two later he had not been discharged. However, when I returned six months later I asked the Superintendent about him and what the Superintendent now thought of psychological treatment. He was surprised by my question. He said the patient had been discharged. It had been an unexpected remission!

This kind of response to psychological treatment was something I had to get used to when later that year I worked at the Maudsley

for a few months. There, I had the

While I was working at the Maudsley I kept an open mind. Eliza, one patient I observed, was a schizophrenic girl of sixteen who was severely withdrawn and refused to talk to anybody or to take part in any occupation. She explained to me that it was impossible for her to be part of a world where horrible things were going on. She said that she had been born through a hole in her mother's body which disgusted her to the extent that she felt life was unacceptable. Eliza said that she had discovered this fact just a short time before her illness began and that the knowledge had turned her violently against her mother. Eliza seemed to me a similar case to Edgar, the young catatonic who had responded to the very simple psychological approach to discussing his sexuality, which I had attempted in the hospital near Oxford; but unfortunately I was not allowed to treat her. Hospital for a few months. There, I had the opportunity to have talks with Doctors Slater and Gutman, two well known psychiatrists of the day. I explained to Dr Gutman that I was interested not only in taking detailed case histories but also in following up the patients for a while and in talking to them regularly. He did not object to what I wanted but considered that talking to patients for any purpose other than to make a diagnosis was a complete waste of time. I had to realize that schizophrenia was an organic illness, and talking could have no causal effect on its appearance and disappearance.

In fact, I saw only a few patients regularly at the Maudsley. One of them, whom I shall call Edward, was highly intelligent, suffered from paranoid delusions, and was very withdrawn. He had had two or three schizophrenic attacks which lasted a few months and from which there had always been a spontaneous remission. He seemed to take very little notice of me when I spoke to him, and when I left the Maudsley he did not seem to have improved. However, two years later when I was working privately, I was contacted by the patient's father. Edward had apparently been talking to his father about my visits to him in the hospital and during the intervening years he had asked the father again and again to try to find out whether he could come to see me. Since my leaving the Maudsley, Edward had had several more quite severe schizophrenic attacks of a paranoid kind. I saw him for a consultation, and he was very pleased to see me. He asked to come regularly, and I arranged to see him twice a week.

Edward was generally very carelessly dressed and unshaven but he would always come on time and report some problems relating to himself. I do not now remember the details of my talks with him but I recognized at the time that many of the stories he told me had some symbolic meaning, and this I would explain to him. At that time I did not know anything about transference analysis, and very little of that would have entered into this treatment. However, after about six months Edward started to dress very much better and appeared in the consulting room cleanly shaven. He had not been able to work for many years and was now keen to do some. Therefore, when his boarding-school, which he had left about seven years before, asked to have him as a teacher, he felt eager to accept. This seemed rather risky, but in fact he decided without any hesitation to do so, and the job was a great success. However, from this time onwards he was reluctant to see me, saying he was afraid that returning to me would remind him of his previous illness. His father reported to me from time to time that he was getting on well, but I had to accept Edward's need to keep his split-off schizophrenic state in control by avoiding me. I later came to realize that this is a typical response of patients who achieve an improvement in psychotherapy but who do not sufficiently work through the process in a transference analysis. My view now is that it is only when the psychotic process, particularly the splitting mechanisms, is thoroughly worked through in psychoanalytic treatment that returning to visit the therapist reminds the patient not only of the previous illness but also of the help he has been able to get.

My experiences with Edgar, Eliza, and Edward all made me optimistic about treating schizophrenic patients—or at the very least about communicating with them—and this was a considerable influence on my career.¹ My approach in those days was very simple as I had little knowledge of psychotherapy or psychoanalysis nor of analysing the transference relationship between patient and therapist. However, some features of what I did then remain a central part of my approach. I always felt at ease with the idea that the patient was trying to communicate something and so I tried to adopt a very open attitude with the hope that this would help him to do so. In this I was almost always successful, and even persistently mute patients often talked to me. I also tried to adopt an empathic attitude, attempting to put myself as much as possible into the patient's state of mind. Looking back, I think the few patients who responded well to this simple treatment probably felt helped by their experience of me as close to them and as able to hold them together. Of course, the improvements that took place were superficial. Moreover, the ‘mechanics' of the ‘cure' were based most likely on the idealization of the therapist and the idealization of the patient-therapist relationship.² At this early time I was unaware of the dangers of an unskilled therapeutic approach to the psychosis, as the importance of analysing the transference and the detailed psychotic mechanisms I and others came to formulate were a closed book to me. However, the experiences themselves were very powerful ones that I remember and which helped me to formulate my views later. As I hope to show in later chapters, unskilled psychotherapy of the psychosis is a danger to the therapist's personality because it inevitably stimulates his feelings of omnipotence and helplessness. Fortunately, it was obvious to me in those days that there were only very few schizophrenic patients who were able to respond to the simple empathic understanding I was offering with temporary, even less so with lasting, improvement.

After working at the Maudsley Hospital I began my psychotherapeutic course at the Tavistock Clinic. Training at the Tavistock in psychotherapy then consisted of some form of analysis by somebody on the staff or outside the Clinic, treatment of several patients, who were seen three times a week, and supervision once a week by a member of the staff. In those days one could not choose who supervised one's work, and this, together with the fact that my analyst at that time gave me very little understanding, was frustrating. Nevertheless I went on for some time, and several further experiences were, I think, formative to my later thinking.

One of my patients at the Tavistock Clinic, Thomas, had been diagnosed as suffering from obsessions. Most patients were treated on the couch, but Thomas refused to lie down. However, he formed a strong positive transference and had little difficulty in talking. He was fascinated by cancer and cancer research and he was also very interested in experimenting with death. For example, he would describe how he would turn on the gas at his home and estimate the time it would take before he might be overcome by the fumes and lose consciousness. He would try to turn off the gas just before this event occurred. Obviously this was a very dangerous way of behaving, and it also became apparent that he was not suffering simply from obsessional thoughts and behaviour. Behind this was a real psychotic thought disorder. My senior colleagues at the Tavistock Clinic were convinced that the patient was schizophrenic and they were probably right. As a result they asked me to discontinue the treatment.

Stopping Thomas's treatment was painful for both the patient and myself. At that time I was not very clear whether I could help him or how I could prevent one of his experiments from going wrong, so I reluctantly persuaded him to go to a mental hospital for treatment. He eventually agreed but wrote me pathetic letters from the hospital telling me that he was not better and that he felt deserted by me. He did not return to me for treatment after leaving the hospital—something for which I do not blame him. I clearly had a very meagre knowledge of psychopathology and offered a rather primitive form of treatment. Moreover, I had let him down.

My feeling that I had let Thomas down decided me that whenever possible in future I would try to treat any schizophrenic patient who was offered to me for treatment, and would continue with them whenever possible. In the event, when I qualified to do private work with patients in autumn 1938, a senior colleague, Dr B.B. of the Tavistock Clinic, sent me a schizophrenic patient whom he had treated for many years. The patient came from a Quaker family and as a young man had been very ignorant and frightened about sex. When he was about twenty-five he had developed a delusion that to teach him sex his mother wanted him to have sexual intercourse with her. When he had proceeded to creep into bed with her one night she had abruptly rejected him, and soon afterwards he had attempted suicide and had to be hospitalized. He was sent to Bowden House, a private hospital near London, where Dr B.B. had worked as an assistant to the Director, Dr Crighton-Miller. The patient had paranoid delusions of reference for many years after the acute schizophrenic episode had passed, and Dr B.B. attempted to treat the patient mainly by re-education, encouragement, and friendly social relations. Dr B.B. had recognized that the schizophrenic breakdown had a psychogenic origin, but his own approach was purely intuitive. Over a period of more than ten years there had been some improvement, but when Dr B.B. referred him to me the treatment had got stuck. I treated this patient from 1938 onwards, when he discussed in great detail the ambivalent relationship existing with Dr B.B. Fundamentally the patient felt not understood and rejected by his too active treatment, which he experienced as intrusive and seductive. My non-intrusive approach, with which he felt more comfortable, was also idealized. During the first years of the Second World War the patient attended only occasionally but then he came regularly for more than ten years and occasionally thereafter. Over the course of treatment he gradually became more able to work as a caretaker in a psychiatric nursing home, and his relationships with other people improved. He even had a woman friend for many years although he never achieved a really close relationship with her.

My experience with Dr B.B.'s patient directed my attention to the dangers if the therapist becomes idealized or appears to be seductive or intrusive. A second patient, seen for a short period during 1939, emphasized the problem. She was a young girl who had sexual delusions of people wanting to marry her. During the treatment the delusions could be seen very clearly within an Oedipal framework, and I interpreted her only too obvious incestuous sexual wishes in relation to myself. For example, after she had told me that a voice had just told her that she was going to get married in a month's time I pointed out to her that she had begun to care for me and hoped that I would marry her. To my surprise these transference interpretations unfortunately made her very much worse; her delusions increased, and she had to go into a mental hospital for a long time. I felt very bad about this result, but it eventually helped me to realize that interpretations of openly Oedipal material were very dangerous in schizophrenia. This was an important discovery which eventually enabled me to formulate ideas about the concrete nature of psychotic thinking and feeling and its influence on the way the analyst's interpretations can be distorted so that they are misheard as actual suggestions. For this reason interpretation of sexual material in the transference was experienced by the patient as seduction. However disturbing this worsening of the patient's condition had been, it also convinced me that the psychological approach was very powerful; if psychotherapy was able to make a patient so much worse it should also be able to make him or her better. This was probably the first time that I attempted to analyse sexual delusions in a woman patient by interpreting the delusions both in relationship to her father and in the transference. In other words, I treated her as if she were one of the neurotic patients about whom I had supervisions at the Tavistock Clinic. My earlier treatments of schizophrenic patients had been much simpler, and in one way this had been an advantage, because I did not stir up problems which I could not deal with at the time.

The Influence of Melanie Klein

At the beginning of the war I was working at the Tavistock Clinic as a psychotherapist, and in my discussions with colleagues there the name of Melanie Klein and her way of thinking and interpreting were generally admiringly discussed. It seemed accepted that she had made very important contributions to psychoanalysis and psychopathology, but in spite of using her terminology none of the therapists at the Tavistock Clinic had yet had an analysis from her or from her closest colleagues. In those days I felt very dissatisfied with my work, particularly with my very difficult patients. My wife needed treatment at that time, and one of the doctors at the Tavistock Clinic recommended Dr Paula Heimann, who was a coworker of Melanie Klein's. My wife frequently discussed her analysis with me, and I was astonished by the understanding and insight which she gained very quickly. I also found that I could apply much of what she told me to my difficult patients and I realized even more forcefully how limited my own knowledge was. During this period I heard that Melanie Klein was returning to London from Pitlochry, Scotland, where she had been evacuated for a while. As it was not likely that I would be called up to the Forces as an enemy alien, even if I was a friendly alien, I decided to apply for training at the Institute of Psychoanalysis. I then saw Melanie Klein, who accepted me for analysis, and members of the Training Committee of the British Psycho-Analytic Society, who accepted me for training. The analysis with Melanie Klein was a revelation to me from the beginning. I felt particularly receptive to analysis, and Melanie Klein had the capacity to understand immediately the anxieties and problems which were preoccupying me and to interpret them to me in a very direct way. However, I experienced the benefits of the analysis not only in myself. Many of my patients improved with the widening of my personal psychoanalytic experience. My contact with Melanie Klein as a therapist and thinker inaugurated a new phase of work.

My second training case at the Institute turned out to be a patient suffering from a schizophrenic state with depersonalization. I have published my experience with this patient in the first chapter of my book on Psychotic States (Rosenfeld 1965). When I first saw her, Mildred had been suffering from what she called influenze for four to five months. She said she felt tired and ill and could not get up in the morning. She also had difficulty in feeling and thinking because her head felt so heavy. During the early stages of the analysis she described her sensations and feelings in great detail. She said she felt dim and sleepy, half unconscious, and could hardly keep awake. A...

Table of contents

• Cover Page
• Half Title Page
• Frontmatter Page
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• Part One: Introduction
• Part Two: The analyst's contribution to successful and unsuccessful treatment
• Part Three: The influence of narcissism on the analyst's task
• Part Four: The influence of projective identification on the analyst's task
• Part Five: Conclusion
• Appendix: on the treatment of psychotic states by psychoanalysis–an historical approach
• References
• Indexes