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Non systematic models

Analytic therapy for psychosis was first used systematically at the Burgholzli Psychiatric Clinic in Zurich on the initiative of its then director Eugen Bleuler. This saw the arrival at the Burgholzli of many psychiatrists. Some of them went on to become future analysts, eager to treat patients with the analytic method; among them were Carl Gustav Jung, Karl Abraham, Arden Brill, Max Eitingon and Ludwig Binswanger. Jung was the most ardent exponent of the free association method, which he believed could beneficially be applied to psychotic patients in order to discover their emotionally charged pathogenic complexes; it was his conviction that the psychotic patient’s thoughts were not absurd but contained a message that needed deciphering. And in fact, through the use of psychoanalytic tools, modifying one’s listening and opening up new therapeutic paths, the symptomatology of people who were otherwise destined to an irreversible regression could be understood.

After this, various therapeutic institutions that offered psychotherapeutic treatment for schizophrenic and psychotic patients were created. One of these was the Bellevue Sanatorium in Kreuzlingen, Switzerland, under the direction of Ludwig Binswanger. Meticulous psychological care was provided there; also, during psychotic breakdowns and while in hospital, patients could carry out work and study activities and attend lessons and workshops to aid their mental recovery.

In the United States too the dissemination of psychoanalysis had raised hopes of recovery with the founding/the foundation of clinics such as the Chestnut Lodge Sanitarium, where patients were treated with analytic therapies proper. Several important analysts worked here, their documented work being an integral part of the history of psychosis therapy. Among these were Frieda Fromm-Reichmann and Harold Searles. Both were influenced by the great American psychiatrist Harry Stack Sullivan, who had created a psychotherapeutic unit at the Sheppard and Enoch Pratt Hospital in Baltimore. Here, a group of doctors, nurses and assistants helped patients find their feet again in interpersonal relations. Sullivan had observed that even severely regressed schizophrenic patients responded positively to the therapeutic group work. In fact, most patients seemed to improve, if not frilly recover, with this method centred around the interpersonal relation.

Sullivan believed in the psychogenesis of schizophrenia as well as in working with transference with these patients, who. in his opinion, preserved the ability to enter a relationship, even in cases of severe pathological splitting.

Many are the analytic contributions on psychosis therapy. Of these, I have listed here the most representative: Freud (1894, 1910, 1915b, 1922, 1924a, 1924b, 1932), Abraham (1924), Federn (1952), Arieti (1955), Rosen (1962), Fromm-Reichmann (1959), Allow and Brenner (1969), Hartmann (1953), Pao (1979), Fairbairn (1952), Winnicott (1954, 1971), Bion (1957, 1958, 1965, 1967), Rey (1994), Lacan (1955-56), Aulagnier (1985), Searles (1965), Segal (1956, 1991), Rosenfeld (1965, 1969, 1978), Katan (1954), Meltzer (1983a), Meltzer et al. (1975), Ogden (1982, 1989), Resnik (1972) Benedetti (1980), Rosenfeld (1992), Volkan (1997), Racamier (2000), Freeman (2001), Symington (2002), Jackson (2001), Williams (2004), Lombardi (2005), De Masi (2000, 2006), Lucas (2009).

I have sought to divide the various analytic models of psychosis into two groups: intuitive-non systematic, or eclectic, and theoretical-systematic post-Kleinian. This division may not seem ideal, considering the complexity and wealth of analytic work on psychosis, but I feel it is useful in order to establish an initial distinction between the various positions.

Whereas the non systematic or eclectic models mainly make reference to intuitions and experiences derived from clinical work, the post-Kleinian systematic models refer to complex, well-organised theories that often preceded the study of psychosis (as in the case of Melanie Klein).

The non systematic models highlight the patient’s alienated condition and his imprisonment in a state of regression; the therapist must therefore enter into contact with him and lead him towards the world of relations. According to the non systematic authors, interpretations are not about what is communicated but are a possible means to take the patient towards recovering the self and symbolic thought. Madame Sechehaye (1951), with her patient Renée, is an extraordinary example of this course.

For the sake of brevity, from the many interesting non systematic authors I have chosen just a few: Fromm-Reichmann. Searles, Sechehaye, Rosen, Federn. Benedetti and separately Lacan.

Non systematic or eclectic models

In that same period when clinics were being prepared for psychotic patients, individual therapies were also beginning to take root. Taken into consideration was how the patient was to be seen and communicated with, which analysts solved by letting themselves be guided by their own intuition and spontaneity; the style of therapy therefore largely depended on each analyst’s personality. At that time, of course, there were no pharmacological therapies to contain the psychotic process.

Several analysts were convinced that patients they had treated had made a recovery, even though it is difficult to establish whether recovery was permanent or only a temporary remission of psychotic manifestations. In any case, their work is testimony to effectively communicating with the psychotic patient as well as receiving responses from him.

Frieda Fromm-Reichmann

Frieda Froimn-Reichmann was born in Karlsruhe, Germany, in 1889 and died in Rockville in the United States in 1957. She was forced to flee to Palestine, France and then to the United States because of Nazism. For twenty-two years she worked as a psychiatrist at Chestnut Lodge alongside other psychiatrists and psychotherapists, such as Harold Searles, with whom she developed a good working relationship.

She was a psychoanalyst who had little love for convention, not only generally speaking, but in her work too; despite believing in the fundamental concepts of psychoanalysis, such as the defences, transference, the unconscious and the importance of childhood for personality development, she above all focused her attention on the analyst-patient relation.

Frieda Fromm-Reichmann believed that the analyst’s participation in the therapy of the psychotic patient needed to be very active and not confined to impersonal interpretations of his communications; she herself did not define her way of working as psychoanalytic but viewed treatment as intensive psychotherapy. In the case of psychosis, she thought that the classical attitude of neutrality, the analyst as a blank screen or mirror, was unsuitable; instead, she was convinced that the therapist needed to transmit interest in the patient in order to reawaken his spontaneity. She did not ask the patient to lie on the couch, nor did she intend to get closer to the patient by breaking down his defences with transference interpretations.

In the beginning, Frieda Fromm-Reichmann had adopted a rather optimistic vision of the illness, giving much value to the analyst’s reparative potential. She believed that psychotic patients had suffered significant childhood traumas during the stage in which they lived in a narcissistic and grandiose world. This kind of traumatic suffering, caused above all by a mother lacking in empathy, made them particularly sensitive to life's difficulties and driven towards illness, where they recreated the autistic and omnipotent world of early childhood.

She had observed that the psychotic patient became suspicious and disheartened when the therapist tried to enter his secret world, and for this reason, she recommended beginning therapy only after a sufficiently long period of interviews. In her opinion, the patient needed to explore the figure of the analyst for an adequately long period before accepting him. Each mistake or shortcoming by the therapist could provoke a serious disappointment that repeated the childhood trauma, whereas his strength and solidity recreated a good maternal-like relationship in which the patient could gradually develop better contact with reality.

Frieda Fromm-Reichmann thought that the analyst had to adopt an attitude of total acceptance with regard to the patient’s behaviour, even when it was bizarre. This tendency, a little naive and excessively reparative, was gradually abandoned when she took into consideration the patient’s aggressive aspects, too, such as hatred, violence and pathological splitting. To avoid adverse regressions, she then began to analyse more thoroughly the negative transference. Here, it was not about injuring the child present in the adult schizophrenic, but rather addressing the adult that existed before the psychotic illness. In this sense, she abandoned the idea of being an ideal mother and developed instead an interest in the internal dynamics and the conflict between the patient’s regressed part and his adult part.

Only later did she speak about how important it was to identify and clarify the distortions the patient made regarding the figure of the therapist and to understand in what way the therapist’s words were understood by the patient. She also underlined the fact that the psychotic patient was stirred by extremely ambivalent impulses; on the one hand, he wished for contact with the therapist, but on the other, he feared losing himself in him.

Something important that Frieda Fromm-Reichmann suggested was that the content of psychotic communications should not be interpreted as the objective is not to make the unconscious conscious, given that the psychotic patient is invaded by unconscious material that bursts into consciousness. In order to respond to hallucinatory and delusional manifestations, she adopted a respectful manner without interpreting by using this sort of sentence: ‘I do not see and do not hear what you see and hear. Let us try to understand the difference between our experiences'.

In the last part of her work, Fromm-Reichmann underlined the importance of working with the non-psychotic part of the personality, and she was convinced that in order to reach the patient's regressed part, it was necessary to be in contact with the healthy or adult part, however modest it might be.

Over the years, she moved away from the hypothesis of trauma and abandoned the idea of needing to be a reparative maternal figure; great effort was made on her part to enter into contact with the intrapsychic pathology that underlay the psychotic disorder.

At a certain point she decided to write a book in collaboration with a patient who was considered to be recovered after three years of therapy. The agreement was that each of them would write one part of the book, but Frieda, elderly and extremely busy, was unable to complete her part; it was her patient Joanne Greenberg who published the book entitled I Never Promised You a Rose Garden (1964), which met with much success and on which a film was then based. The book is really very stimulating, also from a psychopathological point of view, in that it describes in detail the thoughts and actions of this ill young woman and her progressive submission to the psychotic organisation that dominated and terrorised her. The psychotic part conquered and intimidated her, as would an evil prompter that distorts reality. Since childhood, this young woman had created a psychic withdrawal where she believed she lived, an alternative world to the real one; she had distanced herself from her family reality, which in many ways had been traumatic, creating this ideal world, the Kingdom of Yr, which was a sort of paradise. This ideal world progressively transformed into a tyrannical structure that controlled her every action, threatening and intimidating her. For a long time, the gods of Yr had been agreeable companions who shared in her solitude. When camping, where she was hated, and at school, where her oddness increasingly distanced her from the others, the Kingdom of Yr and her isolation expanded hand in hand; her gods were cheerful, amusing characters whose only expectation was her wish to meet them. But then the Kingdom of Yr changed from a world of beauty

Non systematic models 19 and solidarity into one of fear and pain, which the patient became accustomed to subjecting herself to without rebelling; she thus plunged from the rank of queen in a comfortable, glittering world to being a cruelly treated prisoner.

I have summarised the plot of the book because it highlights a typical transformation in the psychotic process. Early on in the illness, the psychotic organisation does not present itself as a pathological entity but as a structure that takes care of the patient, removing him from depending on others and letting him experience a mental state of euphoria. Then, when the patient tries to break away from its power, it turns into a criminal gang that imprisons and threatens to kill him. During therapy, the pathological organisation intimidates him and turns him against both therapy and analyst. Among other things, the therapeutic task is to remove the patient from the domination of the psychopathological structure.

Fromm-Reichmann herself described the case of a patient who revealed her secret during a session, and then in the following session, the patient was terror stricken; in a state of distress, she explained to the therapist that a voice had threatened her to death because she had told her of ‘their' secret.

Harold Searles

Searles started working at Chestnut Lodge in 1949, and he remained there for fifteen years. He had many resident patients and collaborated with Frieda Fromm-Reichmann, whom he expressed his debt of gratitude to on many occasions. Numerous are his publications on psychotic patients and their therapy. Searles underlined the psychotic patient's difficulty in forming a dependence relationship with the therapist or, rather, in his giving up his omnipotent fantasies. In his opinion, the patient defends himself by projecting his needs onto the analyst, which explains why the analyst becomes despised and belittled; therefore, one may say that the schizophrenic patient does not have the problem of how to relate with others, but whether to relate with others. In particular, Searles sustained that schizophrenics, whose sense of cohesion is weak, are ambivalently persecuted by distress and by their wish to become non-human objects such as machines, trees or animals.

He was particularly interested in the psychotic transference, which is often persecutory, as the patient believes that he is hostilely treated by the analyst when, in actual fact, it is he who projects his hostility onto the analyst. Searles believed that the psychotic patient develops a primitive transference similar to that of a nursling who lives in a world of partial objects; the therapist should therefore regress in the beginning and function as a part of the patient so as to then help him differentiate himself and reach a certain degree of separateness and integration similar to that of the neurotic patient.

With regard to chronic patients, Searles recommended creating a prolonged phase of therapeutic symbiosis, in which the patient can use the therapist as an object to constantly project parts of himself onto, like an auxiliary Ego. He also highlighted how important it was for the therapist to be aware of the symbiosis with the patient in order to experience and treat it with a balanced and serenestate of mind. Therapy needed to centre on the description of the patient’s mental state - at times partitioned, at others integrated - to favour the transformation of transference psychosis into transference neurosis and concrete thought into symbolic thought. It was important not to interpret the transference, since the patient would be unable to understand interpretations during this stage.

Searles often adopted bold and unconventional positions, arousing much controversy among colleagues. For example, in his paper ‘Oedipal Love in the Countertransference’ (1959), in which he described a state of mutual dependence in the symbiotic transference as something inevitable, the love countertransference being a signal of such, he then went on to describe his fantasies of falling in love with some neurotic and psychotic patients, male and female, to whom he even communicated his feelings. In his opinion, this technique brought benefit to them, as they felt important and of worth due to their being able to arouse feelings of love in the analyst.1

Searles truly idealised the patient, whom he experienced as a young child with a weak Ego that needed strengthening also through this kind of gratification. There is a degree of idealisation present even in one of his last papers ‘The Patient as Therapist to His Analyst’ (1975), where he again described the intimate relationship between analyst and patient and that despite perceptual and ideational difficulties, the patient has the intuitive ability to understand the therapist’s mental processes. In my opinion, even if the patient is extremely sensitive to the analyst’s understanding of him, this does not mean that he can understand the other’s mind, an ability that, by definition, is compromised in psychosis.

I would like to end this brief summary of Searles’ contribution to psychosis by referring to one of his papers on the relationship between the psychotic illness and the perception of one’s own death. Here (1961), he claimed that terror at the thought of dying triggers psychosis: becoming psychotic is a choice in order not to face up to the thought that life is mortal. Among the various cases of psychotic patients who showed such distress, Searles described in particular one of a woman who, after three and a half years of psychotherapy, was able to acquire a more realistic image of the world and herself. This patient would spend most of her time in the hospital park gathering fallen leaves and dead birds and small animals, which she tried to bring back to life with bizarre magical practices. It was clear that she thought she was like God bringing the dead back to life. One autumn day, while she was sitting beside Searles, it came across that the patient was in a painful state of mind, and then, with tears in her eyes, looking at the leaves she had gathered, she said: ‘I can’t turn these leaves into sheep, for example’. Searles replied, ‘Perhaps you are beginning to understand that human life is like that too; just like the leaves, human life ends in death, too'. ‘Yes’, replied the patient. Searles also said that this woman was convinced that her parents were alive, despite the fact she knew they were dead.

If I were to say something about this case, the patient's intention to reanimate dead things just to resist facing death anxiety is not evident in my opinion. Fascinating as it may be, Searles’s hypothesis that fear of death underpins psychosis has not been proven; if this hypothesis were true, psychotic disorders ought to appear when death anxiety is more evident: that is, after middle age. As clinical experience shows, patients who are very distressed by death do not develop psychosis, and psychotics usually deny time and, consequently, the transitory nature of life.

Frieda Fromm-Reichmann and Harold Searles treated psychosis during the same period at the same institution. They underlined that patients were able to establish a significant relationship with the therapist when the latter was able to understand their communications. Both believed that the analyst was not to be neutral, as was prescribed at that time in the therapy of neurotic patients, but that he needed to be willing to identify with the patient. (We may recall the importance Searles gave to the countertransference, to fantasies and to the therapist’s identifications.)

Their idea was that if the analyst moved towards the patient, then he too would move towards the therapist, leaving his retreat. Recovery was possible for Fromm-Reichmann when the patient could be provided with an object that was different from the traumatic childhood object; for Searles, an intimate relationship within a symbiotic transference needed to be reached with the patient. Both believed that psychosis began in early childhood when the infant is helpless in relation to emotional traumas; it is as if the psychotic patient returns to an early stage of development, and therapy should provide for his regressive needs. Searles underlined the need to experience regression to primitive mental states with the patient to promote individuation processes. Neither Searles nor Fromm-Reichmann ever-stopped taking care of severe and chronic psychotic patients, and all credit goes to them for opening up psychoanalytic treatment to psychosis. Their position helped generate a more positive vision of psychotic patients, who until that point in time had been considered virtually incurable.

Marguerite Sechehaye

Marguerite Sechehaye was born in Switzerland in 1887 and died in Geneva in 1964. She was a very well-known Swiss psychoanalyst at that time in the field of analytic therapy for psychosis. After her psychoanalytic training with Raymond de Saussure, she began to frequent Melanie Klein, Donald Winnicott, Anna Freud and René Spitz. With the publication of her book Autobiography of a Schizophrenic Girl (1951), in which she described her symbolic realisation method, she revived hopes of being able to cure psychotic patients. During her work at that time, she aroused a great deal of interest within the psychoanalytic field and beyond. In the book, the patient, Renée, describes her illness and recovery alongside the analyst’s account, which provides her viewpoint and therapeutic method. Inspired by the book, in Italy the subject of schizophrenia treatment became more widely known thr ough a film (1968) directed by Nelo Risi with the help of Italian psychoanalyst Franco Fornari.

Renée was a severe psychotic patient who began to feel ill in childhood, with distressing mental states that made her see the world as a changed, incomprehensible and strange place. She had been a delicate baby with early trauma: at four months, she was found wasting away so much that gastritis was diagnosed; the cause was in actual fact insufficient maternal milk. A grandmother took care of her but passed away when she was eleven months old; her death triggered acute despair in the child, who manifested violence against herself. Renée continued to live with her family, who were totally incapable of understanding her mental state and, at times, would make fun of and mock her, despite her clear malaise.

During her adolescence, her refusal of food, extreme weight loss and a lung infection led to her being admitted to a sanatorium, where she stayed for two years. Subsequent to this, she manifested acute psychosis with psychomotor excitation, visual hallucinations and delusions of guilt. Her core delusion was that she lived in Tibet, a cold, desert-like region, lit up by blinding light, with no human presence at all; there were powerful, cruel, sarcastic characters there who dominated her and made death threats against her. In the course of her therapy with Madame Sechehaye, Renée was hospitalised on numerous occasions for her acute psychotic breaks featuring destructive and suicidal impulses.

After several years of therapy, the key episode that gave rise to the technique of symbolic realisation was the following. One evening, Renée, who was staying on a farm at the time, told Madame Sechehaye in a mixed-up and delusional fashion that she had been reproached by the farmer's wife, who had caught her while she was picking unripe apples from the trees. When Madame Sechehaye offered her all the apples she wanted, Renée answered that she wanted Mama’s (that is how she referred to Madame Sechehaye) real apples and pointed to her breast; at this point, the therapist let Renée lean her head against her shoulder and offered her small pieces of apple, which she accepted. This moment of intimacy produced an almost miraculous effect: a newfound period of well-being for Renée.

From that moment on, Madame Sechehaye worked to find an indirect and symbolic way to enter into contact with the patient’s unconscious desires. For example, she took care of a small soft toy, washing it, drying it and putting it to bed until Renée herself accepted being taken care of without feeling attacked by blaming inner voices. Madame Sechehaye tried to understand a little at a time what the patient's real needs were, which Renée defended herself so stubbornly against, and what instead were only compensatory wishes; to this end, she created symbolic situations mediated by objects, gifts or words with which she tried to enter into contact not only with Renée’s repressed childhood wishes, but also with unexpressed hatred and grudges harboured against her parents. In this period, Renée’s mental state was extremely dramatic, marked by recovered vitality as well as relapses into psychosis that required hospitalisation, at times even in a secure unit. According to Madame Sechehaye, many relapses were due to her own mistakes, when she confused ‘compensatory wishes’ with real ‘symbolic needs’, for instance.

Although this was a single case, it aroused considerable interest, thanks to the book and the film of the same title. Madame Sechehaye’s hypothesis was that schizophrenic psychosis was a primitive regression caused by early trauma in an environment totally lacking in empathy, leading the patient to build an alternative inhuman world which he would then fall victim to. Her reparative therapy

Non systematic models 23 consisted in identifying essential unmet needs that were actively denied by the patient herself, which needed to be satisfied symbolically. We do not know whether Renée truly recovered from her illness or whether she benefitted from a fortunate remission. From Madame Sechehaye’s account in her book, Renée completed her studies once her therapy ended and went to live with a female friend in a small town near Geneva.

Renée's positive development remains the sole experience brought about using this therapeutic technique. For long periods, the patient had been under the therapist’s immediate care, being looked after by her even physically: Madame Seche-haye put her up in her own home and, when necessary, saw to her hospitalisation. Reading the book, one is taken by Renée’s complex psychotic world and the author's clarity of thought. The patient's recovery, the fortunate release of a recluse from a psychotic prison, does seem almost miraculous. The technique of symbolic realisation did not have many followers, though; it faded with its creator, leaving the impression that this extraordinary outcome had been due to the two players’ exceptional willingness to develop this relationship - a difficult course to repeat.

John Rosen

Today Rosen has practically been forgotten. In the 1960s and 1970s, however, he was well known for his psychotherapeutic method with psychotic patients: that is, direct psychoanalysis.

Rosen sustained that in order to be a good adoptive parent to the psychotic patient, it was not enough to be affectionately kind or warmly welcoming. At times, the therapist needed to be strict and authoritarian, not only to assure the patient that the situation was under control, but also to show him that he (the patient) was not at all able to kill with a wish or at a glance (1962, p. 14).

Rosen thought that a psychotic patient needed to be taken care of as does a newborn: care needed to be round the clock, and given that the analyst could not be there constantly, several assistants were needed to support the patient in the therapeutic unit: a small house with all the basic comforts. The patient could thus have the situation under control and feel that he was being treated like a human being. He was to be seen by the psychoanalyst every day without scheduled time limits, and during this time interpretations, direct and non-symbolic, were needed to dismantle his delusional experiences; collaborators could attend sessions to support the therapist in seeking to impose reality on the patient.

Rosen would often use a direct and aggressive style with patients. For example, if a patient spoke non-stop, the analyst could say: ‘This fake nutrition will not actually help you to have your mother’s breast. You use your mouth endlessly to have something to feed on, but this pretence will not help you at all' (p. 125, author’s translation). Or a patient who would spin around quickly might be addressed as follows: ‘Turning round and round will not make you escape death. If your mother were to say “drop dead”, you would not do it. I am the only one here who can decide between life and death, and I want you to live’ (p. 143, author’s translation).

I have cited these two examples of direct interpretations according to Rosen’s technique (there are dozens in his book) to illustrate how an authoritarian concept of care comes through, aimed at ‘awakening’ the patient from his delusional beliefs.

Yet another exemplifying case is that of a paranoid patient who was convinced he was being pursued by the FBI for having burnt a relic in a church and, hospitalised, believed that he was in prison for a police interrogation. Rosen, together with his assistants, staged a scene. When the patient stopped accusing himself, Rosen said that he himself was the real arsonist and that the patient was a liar in search of publicity. Another psychiatrist also accused himself of the same crime. At this point, two false FBI agents - two assistants dressed up as officers - came onto the scene shouting that all three were under arrest, and then, after pretending to have checked a list of arson suspects, they left exclaiming that the three of them were only seeking publicity since none of them were on the list. Rosen then turned to the patient and reproached him for having made everyone look stupid. He sustained that after four days, the patient understood that he was in a psychiatric hospital and that his ideas were insane.

Clearly, Rosen’s technique was often no more than the application of striking manoeuvres to manipulate the patient’s mind in a bid to make him abandon his delusional ideas. It is no wonder that direct analysis disappeared from the therapeutic scene together with its creator’s notoriety.

This technique, did, however, appear to offer new perspectives on the treatment of psychosis in the 1960s and 1970s. Even Frieda Fromm-Reichmann (1959) said that many of Rosen’s interpretations, although arbitrary, were effective thanks to his convincing and constant intensive approach: what he was doing, however, was not so much treating psychotic patients as helping them come out of their acute psychotic states more speedily; much more is needed to treat the patient when the episode is behind him, and the psychotic process continues to produce distorted thought.

Paul Federn

The most original pioneer and, for a long time, the only European interested in developing a therapy for psychotic patients was Paul Federn, who had begun to treat a catatonic and restless female patient in hospital, whom he then decided to continue the therapy with at his home, where his wife looked after the patient during the day. The patient improved and was well for the rest of her life. This outcome convinced Federn of how important it was to give the psychotic patient in therapy female maternal care (Alanen 2009). Federn’s most well-known assistant was Gertrud Schwing, who wrote a book on working with Federn and even went on to become a member of the International Psychoanalytical Association.

In his writings, Federn underlined that the psychotic patient’s withdrawal from reality was never absolute, and in order to carry therapy forward, it was important to develop a positive transference (nowadays referred to as a positive relation), whereas the negative transference, when it emerged, needed to be interpreted and

Non systematic models 25 transformed. He was convinced that an analysis featuring transference psychosis in which the analyst had become the persecutor could not under any circumstances be carried forward, the only solution being a change of therapist.

Federn, like Frieda Fromm-Reichmann, was of the view that the customary analytic technique, such as using the couch and free associations, needed to be abandoned. He had patients who had become manifestly psychotic during their previous therapy with other colleagues, and so he learned to pay attention to signs that a psychotic break was imminent. In the case of a manifest psychotic state, however, the analyst initially had to share and accept the falsifications operated by the patient’s delusion, and only once a relationship of trust had been built could he then begin to speak to the patient about the delusion distorting or wiping out reality.

The concept of the ‘Ego’ was of cardinal importance in Federn’s writings: the sense of unity and the ‘Ego feeling' concern the perceptual continuity of the self, which remains subjectively the same despite changes that occur over time; the ‘Ego boundary’ separates what belongs to the Ego from what is alien to it; naturally, this is not a real boundary of the person, but a psychological characteristic that can change during the various stages of existence. The Ego boundary would, in the final analysis, be a kind of sense organ that distinguishes between inner and outer and demarcates the Ego from external objects. Federn considered psychosis an ‘Ego disease’ that entails an inability to maintain the necessary boundaries and continuity of the Ego. When the inner Ego boundary is missing, so is the distinction between conscious and unconscious, and in this case, the patient experiences dreams as if they were delusions or hallucinations. Ego boundaries tend to be lost due to an excessive presence of falsified ideas that alter the perception of personal identity. Federn believed that patients did not abandon reality but developed a false conception of it.

Important reflections on analytic technique derived from this model. Federn suggested that therapeutic work with psychotic patients should not consist in interpreting symbolic meaning, including transference interpretations, as this would increase any confusion for an Ego that was already excessively dispersed. What was needed was therapeutic work to reinforce the patient's sense of identity, protecting him from extreme distress and improving his ‘intentional thinking’. Tn psychosis’, Federn wrote, ‘the main damage consists of the loss of cathexis of the ego boundaries’ (1952, p. 166). The Ego, due to its fractured frontiers, is exposed to the invasion of hallucinated reality. Whereas Freud postulated that the delusion was an attempt at reconstruction or, rather, at libidinal recathexis of the object, Federn held that it was the consequence of having falsified reality and lost the Ego boundaries.

A specific therapeutic practice stems from this conception, changing the rule of free associations: if the psychotic patient is beset by an excess of senses and meaning, his imagination should not be encouraged by the production of free associations but kept in check. One of Federn’s most significant affirmations is that ‘in neuroses we want to lift repression, in psychoses we want to create rerepression’ (1952, p. 136). The aim is not to ‘make the unconscious conscious’,

but to ‘make the unconscious unconscious again’ (p. 178). Through the positive transference, in the position of the Ego ideal the analyst must repair the patient’s constitutive deficit and offer him a form of identification that can strengthen his Ego feeling.

Whereas in neuroses the transference is used to make repressed material manifest, in psychoses it is needed to establish a therapeutic relation that can provide support for the patient’s identity deficit. Federn was convinced that the classical analytic method tended to aggravate the psychotic state; in this connection, he cited cases of patients referred to him by colleagues, who had become outright psychotic in the course of their treatment. The therapeutic method used by Federn to help the patient come out of the psychotic state involved the analyst also assuming an educational role: he needed to represent reality and be present in the patient’s relational life when need be. Federn entrusted educational tasks to nurses in the hope that they too could be trained by psychoanalytic institutions; at the same time, he also shed light on the determining role of the family environment, which, if lacking, or worse still, if hostile, offered no hope for the patient's recovery.

What Federn deserves credit for are his highly significant intuitions on the nature of the psychotic process, such as the all-important need to boost the Ego’s healthy part (even using psycho-educational measures) and that all symbolic interpretations need to be excluded from therapy, given that the patient may perceive them as disclosures of other realities and not as implicit and unconscious meanings held within his own psychic reality.

Gaetano Benedetti

Gaetano Benedetti specialised in psychiatry at the Burghblzli clinic in Zurich under the direction of Manfred Bleuler; he furthered his psychiatric and psychotherapeutic training while working alongside Ludwig Binswanger, Madame Sechehaye, Christian Muller and Carl Jung. Taking as his starting point Freudian psychoanalysis, several phenomenological currents and existentialism, Benedetti devoted himself to the theory and clinical work of psychoses, which comes through in his important book La Psicoterapia Come Sfida Esistenziale (1997) (Psychotherapy as the Essential Challenge - author’s translation).

Benedetti thought that psychotic phenomena brought about a Toss’ of Self, in particular the mental and emotional symbol of the Self; this is why the patient withdraws into himself, creating a personal phantasmatic world, and tends to compensate for the loss of human relations by relating with all non-human objects that surround him, multiplying the possible meanings and assonance between words. Given the loss of Self-image and symbols, for Benedetti treatment was a course based on a ‘progressive psychopathology’, by means of which the analyst participates in the human meaning of the symptom, assigning to it symbolic value that is new and positive. Psychotic symptoms have communicative intentionality that activates when the therapist identifies with the patient through empathetic experiences. The encounter between the psychotherapist, with his experience and

Non systematic models 27 personal humanity, and the psychotic patient locked in psychosis is a difficult one; identification and symbiosis between therapist and patient become the engine of therapy, and from this ‘dual’ course, ‘progressive’ development may begin, enabling the patient to feel that kind of differentiation between the Self and the world which underpins psychic life.

Three important moments are envisaged in this course. The first is the establishment of a symbiotic bond with the patient that can be achieved through ‘therapeutic phantasmatisation’: the analyst must provide the patient with proof that he has understood his inner world without necessarily expressing so verbally. Through this process, the patient senses the therapist's willingness to make himself similar to him. In the second stage, the analyst breaks the symmetry created, positively setting out the patient’s negative experiences, thus creating a contrast with the patient's negative image. This ‘positive asymmetry' creates a way out of the autistic shutdown. A third stage sees the patient entering a mutual relation and identifying partially with the coherent and unified person of the therapist.

Given that the therapist does not seek to transform psychotic proto-symbols into concepts by interpretation but accommodates them as important communications, in the patient’s asymbolic world, a process of symbolisation can originate within this dual communication. Every now and then, the therapist can give unconscious representations originating within the patient back to him, once they have been ‘filtered’; taking due precaution, the analyst may also begin to communicate his own dreams, given that despite being fragile and fragmented, the patient is anyhow able to perceive the therapist's or his own family’s unconscious processes.

Hallucinatory and delusion ‘proto-symbols’ may become symbolic nuclei if they can be presented in a representation that is broader and more positive than that of the pathology. Benedetti provided the example of a female patient who was convinced that Jesus and Barabbas were brothers as both were Maria’s sons: in this case, the patient had discovered a maternal principle that placed together a good and a bad part that were no longer perceived separately. This is an example of a positively modified proto-symbol.

‘Positive transformation of the psychotic experience’ is an operation through which the psychotic experience is reflected in the therapist, from whom the patient captures a positive image of himself, as in a mirror. The intimate ffisional experience that the therapist is able to establish with the patient leads to intersubjective transitivism that sometimes generates the death phantom in the patient within the therapist too: the therapist may dream the same anxiety-laden representations that are present in psychosis, such as finding oneself on the brink of an abyss, in a grave or in a bare lunar landscape, devoid of plant life.

According to Benedetti's experience, the patient, despite being shut away in his autism, is capable of perceiving a degree of strength in the therapist that can not only limit and contain death, but also present itself as offering life. In this case, too, the transmission of positive experience occurs through unconscious channels.

As can be noted, Benedetti took up the concept of the fusional forwarded by Searles, enriching it with new and original content. What is fashioned as therapeutic and the engine of transformation is not so much the interpretation inpsychodynamic terms of what the patient ‘feels’, but fusional empathic identification with him to make him aware that his world can be shared. This occurs nonverbally and passes along unconscious channels. Benedetti believed that direct communication between two unconsciouses, the patient’s and the analyst’s, produces a progressive transformation of the patient’s subjective experience and strips psychotic manifestations of their alienating character. This process does not come about through insight, which assumes separateness between the two, but by the patient assimilating outside awareness parts or functions present in the analyst’s mind. Benedetti called this transformation process ‘appersonation’, a term that refers to the patient’s progressive acquisition of human characteristics and functions through his incorporation of the analyst’s psychological qualities, the analyst thus functioning as a developmental component.

Jacques Lacan

For its originality, I shall briefly mention Lacan’s position on psychosis, which is discussed in many of his writings; it was through the study of paranoia that he actually came to encounter psychoanalysis (1932).

One of his most important concepts related to psychosis is foreclosure, which consists in the area of the signifier and therefore of Symbolisation being impossible to access. Unlike the neurotic patient, the psychotic does not suffer from any symptom, but he processes a ‘delusion’ due to never having had any access to oedipal identification, or, rather, to the Name-of-the-Father.

For Lacan, the Name-of-the-Father is the sole position that enables the subject not only to take on meaning, but also to assimilate the specific nature of subjectivity. The Father, for Lacan, does not have real psychological features; it is a metaphorical figure whose foreclosure creates a ‘hole’ in the signifier (the law). The foreclosure represents a reality fracture that can stay that way until the psychosis breaks through. The subject who is destined to become psychotic is structurally injured and can remain so until trauma strikes; for example, he can maintain his rigid or mirror constitution until a third breaks his narcissistic structure.

The psychotic patient is unable to access the symbolic dialectic that organises the real and releases him from his condition of fragmentation. In psychosis, the Father cannot act to organise sense so as to lay down oedipal law; the possibility of reaching the symbolic function therefore remains foreclosed. According to Lacan, psychosis is one of the subject’s possible responses to the oedipal situation. It is the position of an individual who has no symbolic field but builds a signifying void, which explains why the schizophrenic patient, with no access to imagination, equates words with things.

The delusion is an attempt at recovery that seeks to give meaning to language, an attempt that is unfortunately destined to fail for want of the Name-of-the-Father, the only symbol capable of identifying the subject as the sense around which the play of symbols rotates (Tarizzo 2003).

The subject thus remains without any paternal signification on the symbolic front, or corresponding phallic signification on the imagination front, that

Non systematic models 29 would allow access to the unconscious image of the body. The experience of a fragmented body is in fact remediated only by the image of the body that can occur in the mirror stage.

So, for Lacan, psychosis is the result of a basic defect, the effect of which is a failed structuring of the symbolic area, of the Oedipus, and the validity of the law. The symbolic should deal with the real and negativize the invasion of enjoyment, which instead explodes in schizophrenia. The foreclosure of the Name-of-the-Father means that a specular dimension with no bulwarks prevails, sustained by the presence of a powerful Ego ideal, the absolute keeper of imaginary dynamics (Bonifati 2000).

Among the various possible references, Lacan’s considerations regarding the work of Joyce are particularly significant. Lacan claims that the ‘Joyce case’ is a clear example of untriggered psychosis thanks to containment via writing. Through real motivation towards writing, Joyce was able to fill the gap caused by a severely deficient paternal function; by pursuing his vocation as a writer, Joyce managed to ‘make a name for himself’ that served to compensate for his father's deficiency.


1 Naturally, the technique described by Searles was not welcomed by the psychoanalytic milieu. Strangely though a similar technique has been put forward quite recently by several American intersubjective analysts who believe that the so-called self-disclosure of one’s love fantasies to the patient is helpful.

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