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Kleinian contributions

In the previous chapter, I have illustrated the therapeutic work of six authors who, in different periods, treaded the path of psychosis therapy unhindered by theoretical assumptions; these authors believed that psychosis was governed by laws that lay outside all previous theories, the illness therefore needing to be understood intuitively. As can be seen, their techniques were very personal and stemmed from each of their specific visions of the nature of psychosis. Their purpose was resti-tutive: starting from the idea that the illness was a form of regression to a primitive stage, they sought to recreate those psychological structures that had existed before the psychotic episode. Lacan should be considered separately as he incorporated psychosis into his particular theoretical model.

Melanie Klein insisted on the need to work only in an analytic setting without any external interventions, her contribution leading to an approach to psychosis that was anchored to theory. Next, I shall try to summarise the position of the Kleinian group, which gave impetus to the theoretical and clinical study of this mental state.

For the systematic models, I shall consider the therapeutic techniques that derived from Melanie Klein’s thought. This great psychoanalyst created a theoretical system that rests on infantile anxieties that characterise primitive mental development and which, in her opinion, also help our understanding of psychotic symptoms. Her intuitions were subsequently developed and systematized, giving her pupils the chance to apply them to the therapy of psychotic cases.

These post-Kleinian authors, convinced they could analyse psychotic patients during both acute episodes and chronic stages, highlighted how specific pathogenic elements are active in the psychotic process, such as massive projective identification, loss of symbolisation, attacks on objects, the fragmentation of perceptive functions and confusion between inner and outer. Transference is the indispensable treatment tool with which to analyse pathogenic manifestations.

Melanie Klein

Dedicated to the therapy of severely ill children, Melanie Klein encountered the problem of psychosis at the very beginning of her analytic work; it was therefore easier for her to get a feel for the early illness, almost at onset. Regarding little Dick’s therapy, Klein (1930a) described the main dynamics of the disorder: in addition to his love relation with his parents, the child had also developed a destructive relation; he attacked them in phantasy and consequently feared that they would do the same to him. His anxiety reached such high levels that he had to block out thought to avoid allowing further aggressive phantasies to take up even more space.

Klein believed that schizophrenic psychosis derives from an excess of sadism that then turns into persecution. In order to protect himself from this excess, the child resorts to many defence mechanisms, including splitting, denial, idealisation and various forms of identification.

Klein’s most important work is Notes on Some Schizoid Mechanisms (1946), which saw the start of a specific therapy for psychotic patients. Here, Melanie Klein wrote of psychotic anxieties that appear during breast-feeding and which constitute fixation points for psychosis. In particular, she concentrated on how the child develops oral-sadistic phantasies towards the mother’s breast to rob her body of its contents; these are the impulses that give rise to persecution anxiety, which underlies the development of paranoia and schizophrenia. Melanie Klein conceived anxiety as the result of the death instinct going into operation and being perceived as fear of annihilation; this destructive instinct is projected onto an object that becomes omnipotent and uncontrollable. Anxiety connected to being annihilated by an inner destructive force results in the fragmentation and splitting of the Ego: the more sadism predominates in introj ection, the greater the fragmentation of the incorporated object, the Ego splitting correspondingly.

Another important process is object idealisation, which, on the one hand, defends from persecution, but on the other, it expresses the omnipotent desire to have a breast infinitely on hand. This process occurs in the infantile hallucinatory world and is created by virtue of the splitting of the object, denial of frustration and persecution. All this leads to psychic reality being blotted out. In this early stage, splitting, denial and omnipotence perform a function analogous to that of repression in more advanced stages of development.

Melanie Klein claimed that these infantile world primitive modalities are reproduced in psychosis, and here she connects back to Freud and his assertion (1924a) that, whereas in neurosis ‘the loss’ follows repression, in psychosis the more radical mechanism of ‘disavowal’ is in operation. It is not the drive that is repressed in psychosis but the perception of external reality.

An important contribution to understanding psychosis is the concept of projective identification. Melanie Klein sustained that when the infant projects destructive impulses into the mother, she is perceived not as a separate person but as part of the Self, often a persecutor. The splitting and projecting of parts of the Self onto objects concern the good parts of the Self, too, consequent confusion ensuing between what belongs to the subject and what to the recipient of the projection.

Melanie Klein spoke openly about the early origin of psychosis and the determining action of the destructive drive; in addition, as I have already mentioned, she considered child development and psychotic development as analogous, asserting that splitting and fragmentation, despite being physiological in the child, if overly frequent and prolonged needed to be considered as signs of infantile psychosis. In adults, depersonalisation and psychotic dissociation are nothing other than the manifestation of regressing to disintegration that was present in the infant.

In particular, when projective identification is massive, the impulses that control the object from inside him arouse fear in the subject that he in turn shall also be controlled and persecuted, and it becomes difficult to take back possession of the projected parts. When emotions and parts of the self are alienated and placed in other people, besides confusion between self and object, emotional voids form in the patient’s inner world. The feeling of psychic death experienced by psychotic patients derives from the loss of important parts of the self and from the evacuation of the emotional world.

Another of Melanie Klein’s contributions (1930a, 1930b, 1946) is having identified two phases that are also two mental functions underlying psychic development: the paranoid-schizoid position and the depressive position. The former is characterised by the impulse to react aggressively to any kind of frustration, the infant therefore hating the mother when she does not protect him or when she exposes him to frustration. In the depressive position, on the other hand, the infant lets the mother be a separate object, with her own needs and wishes, and he tries to repair the damage caused by his aggressive attacks. Such attacks towards the ‘bad mother’ will, if unresolved in childhood or adolescence, constitute the fixation point for subsequent illness. It is clear that for Melanie Klein, the psychotic process is nothing more than the exacerbation of infantile physiological states, and therefore in her vision the primitive is equated with the pathological.

With Melanie Klein began the articulated theorizing of psychosis linked to infantile phantasy events; indeed, in her cases of severely disturbed children, Melanie Klein (1929) highlighted extreme aggressive and sadistic phantasies as well as strong persecutory anxieties, to the extent that she came to sustain that the psychotic patient was imprisoned within his illness due to an excess of primary sadism. Her model, which sees the illness as deriving from primitive anxiety and corresponding defences, may be defined as continuous, as it links psychosis to primitive forms of mental organisation.

Her theoretical innovations allowed her collaborators to begin treating psychotic states in a setting identical to that of neurosis, as can be seen from the authors I have cited here.

Herbert Rosenfeld

Rosenfeld, one of Melanie Klein’s most important pupils, left numerous accounts of his therapies undertaken with psychotic patients. In his book Psychotic States (1965), he described how both acute and chronic patients may be treated using psychoanalytic technique; specifically, with acute patients, the analyst needs to be guided by clinical experience with children. His assumption is that psychoanalytic method based on analysing the transference can be used to treat psychosis:

In our approach to schizophrenia we retain the essential features of psycho-analysis; namely, detailed interpretations of the positive and negative transference without the use of reassurance or educative measures; the recognition and interpretation of the patient’s unconscious material; and, above all, the focusing of interpretations on the patient’s manifest and latent anxieties. It has been found that the psychotic manifestations attach themselves to the transference in both acute and chronic conditions, so that what one may call a ‘transference psychosis’ develops. The analyst’s main task in both acute and chronic schizophrenias is the recognition of the relevant transference phenomena and its communication to the patient.

(p. H7)

Rosenfeld, who approached psychosis clinical work according to all of Melanie Klein's core teachings, thought that schizophrenic patients concretely experience the feeling of entering the analyst at the beginning of the session via projective identification, to then be expelled at the end. Splitting and projective identification at work in the psychotic state would explain the patients’ lack of a sense of identity, their loss of emotions and difficulty using symbols.

In his first paper, ‘Analysis of a Schizophrenic State with Depersonalisation’ (1947), Rosenfeld described the case of Mildred, a young woman with schizoid symptoms. The traumatic event in her childhood had been the birth of a brother and her being distanced from her mother as a result; Mildred then stopped talking and walking, and in both childhood and adolescence, she presented other difficulties related to development and learning. As an adult, she often took to her bed. found it hard to get up, and withdrew from her friends.

The course of her analysis was complex and very difficult. Mildred often missed her sessions, or she would arrive late looking dim and sleepy, only half-conscious and stating that she was separate from the world, dead. Particular about her was that she would not accept transference interpretations, be they positive or negative. Of the many fantasies she had, Mildred related one that was connected to her difficulty to collaborate: it was about a devil that attacked good people, tied them up and gagged them, and if these people managed to free themselves just a little, the devil tied them up even more tightly; it was unclear whether the victims were killed because you couldn’t tell whether they were dead, and there was no point putting up a struggle because the devil was the strongest of all. Rosenfeld considered this fantasy as a possible risk to there being a negative therapeutic reaction: in the transference, the analyst is the devil that personifies the bad father. When he tried to interpret her feelings of love and hate, the patient cancelled them by entering into a state of depersonalisation. At a certain point, a misunderstanding arose in the analytic relationship to the extent that Mildred began to suspect that the analyst wanted to push her into thinking along his lines. Rosenfeld’s reflection was that when Mildred was little, she reacted sadistically towards her mother when she was expecting her brother and then omnipotently idealised and controlled her; part of the sadism was projected onto the father, who was transformed into a persecuting devil.

As can be seen, in this early period, Rosenfeld considered the fantasy of the devil not as an internal object - that is, as a pathological structure that dominates the patient - but as a transferential distortion of the paternal image caused by the patient's sadism. He also thought that the destructive impulses were directed against the patient’s own self and were responsible for the depersonalisation and fragmentation of her personality: as opposed to attacking and destroying the object, the destructive impulses attacked the vital part of her personality. With events alternating between moments of vitality and phases of draining away, the analysis proceeded, with Rosenfeld always being directed towards interpreting the transference. The analysis finished when Mildred, who had greatly improved, got married and went to live abroad with her husband.

From the distance of many years on, we may say that Mildred did not seem to suffer from psychosis proper, but a marked psychic withdrawal that made returning to reality tiring. As a child, Mildred was certainly not sufficiently accommodated emotionally, and after her brother’s birth, she was in fact looked after by a series of nannies and then sent to boarding school. There she excelled as a pupil. A self-destructive force then took the form of a devil that prevented her from speaking or functioning.

Another important point in Rosenfeld's clinical research on psychosis regards confusional anxiety. In ‘Notes on the Psychopathology of Confusional States in Chronic Schizophrenia’ (1950), he wrote that when destructive impulses predominate, mental states are created in which good objects can no longer be told apart from bad objects, and libidinal impulses and destructive impulses become mixed up.

The patient he gives an account of in this paper is in his second analysis: he is an artist who took a painting he had painted for the previous analyst to his session, the analyst having made a reference to the dark colours in the painting, connecting them to the patient’s desire to soil with his faeces. The patient felt persecuted by this interpretation, and from that moment on, was convinced that he could no longer paint. Rosenfeld observed that the confusion derived from a sadistic-oral attack against the mother who was mixed up with faeces; the destroyed breast mixed up with bad faeces had become a persecutor who attacked and confused the patient from within. Rosenfeld’s work analysing confusion between good and bad, between food and faeces and between parts of the body was to be extremely helpful to this patient.

Rosenfeld noted, however, that when interpretations were poor and imprecise (above all negative, I should add), the image of the analyst who is felt to be a persecutor becomes real. Persecution in the case of the painter derived from his perception of the first analyst as a persecutory and scornful Super-ego. Patients of this kind have internalised a Super-ego that constantly accuses and confuses them, and therefore wrong or negative interpretations help to project this internal object onto the analyst.

In his subsequent paper, ‘Notes on the Psychoanalysis of the Super-Ego Conflict of an Acute Schizophrenic Patient’, Rosenfeld (1952) wrote of the clinical benefit of forming a psychotic transference during therapy: ‘The success of the analysis depends on our understanding of the psychotic manifestations in the transference situation’ (1952, p. 65).

This position, as we shall see, would later be abandoned (1987), when Rosenfeld claimed that the psychotic transference is dangerous as the delusion can incorporate the figure of the analyst, thus paralysing his analytic function. For Rosenfeld, the schizophrenic patient has never overcome the earliest stage of object relations development; his dynamics, characterised by the splitting of objects and persecutory states, feature anxieties that are typical of the paranoidschizoid position as well as unsuccessful attempts to gain access to the depressive position. Despite this inadequate level of functioning and symbolisation impairment caused by excessive projective identification, Rosenfeld felt it was beneficial to use interpretations in the acute and chronic psychotic patient alike: interpreting the projective identification tended to make it easier for the patient to understand the analyst’s communications.

In order to understand how Rosenfeld worked in this early period, I shall cite part of an analysis undertaken in hospital, at five one-and-a-half-hour sessions per week with a patient suffering from mutacism, who at times would have aggressive outbursts and had found himself in a severe psychotic state for thr ee years. Once, the patient had attacked a nurse and felt depressed and distressed immediately afterwards. According to Rosenfeld, the patient believed he had destroyed the world, had then taken it inside himself and needed to restore it; under the pressure of his guilt and the persecutory anxiety of the Super-ego, his Ego began to fragment, and it split into many men who perceived the anxiety and guilt. This situation also appeared in the transference: during the session, the patient showed how he had projected his own damaged Self not only onto all the other patients, but onto the analyst, too, transforming him into a damaged object. He became very suspicious towards the analyst and refused food, probably because he would have felt even more guilty had he eaten it. This was interpreted by Rosenfeld, and immediately afterwards the patient gave a grunt, but by the end of the session drank a glass of fruit juice that had been on his bedside table, his first sign of feeding himself after days of fasting. For Rosenfeld, it was important that this patient, despite being in a severe hallucinatory state, had been able to benefit from an interpretation that made him understand the relationship between his acute psychotic state and his feeling of guilt.

This short extract is just one example of how Rosenfeld constantly interpreted the fragmented, distressed and persecutory state in relation to the transference and to projective identification dynamics; in particular, he placed emphasis on the aggressive phantasies towards the analyst, on the Super-ego's corresponding death threats and on manifestations of primary envy This patient's analysis was then abruptly interrupted upon his mother’s arrival in England; she had decided to seek other treatment for her son, including a lobotomy. The analytic therapy had lasted only three months: the patient felt less persecuted, splitting lessened, his depression emerged more on the surface, and there were also periods of lucidity that lasted several hours, in which the patient was able to communicate normally.

An important problem though concerns patients’ ability to receive and understand interpretations. As can be seen, these were patients who had been in a psychotic state with hallucinations and delusions over a long period of time and who moved in a sensory reality far from the relationship. Could these patients have understood interpretations, often containing symbolic meaning? It seems

Rosenfeld was convinced that the patient would be able to restore his sense of Self if he could understand his mental functioning through interpretations. Rereading the writings of that time, one has the impression though that the patients who were in an acute stage of the illness, often having hallucinations and delusions, were exposed to an excess of interpretations. Rare were the descriptions of their inner world and their conditions prior to the analytic therapy; importance given to interpreting the psychotic transference and to projective identification content overshadow other clinical considerations.

Rosenfeld realised that much clinical experience was needed before acquiring the necessary skills to treat psychotic patients. On this he wrote:

At this state of our research we shall not over-estimate the therapeutic possibilities of psycho-analysis in severe acute and chronic schizophr enic conditions. ... At present therefore we can only hope to be successful in a minority of cases. However, this does not invalidate the psycho-analytic approach. Every acute or chronic schizophrenic patient, even if he is being treated for a short time only, enriches our understanding of the psychopathology and makes the analysis of subsequent patients easier.

(1965, p. 127)

Wilfred Bion

Second Thoughts (1967) is a collection of Bion’s papers on psychosis from the 1950s onwards, which integrates retrospective reflection with Bion's previous vision and shows extraordinary originality in the field of analytic theory and technique. Bion examined in depth and broadened several fundamentally important topics to aid our understanding of the psychotic state, such as projective identification (of which he gave a more radical description than that of Melanie Klein), the formation of the bizarre object, the psychotic part of the personality, the theory of thinking, the alpha function, the hallucination and so on.

The cases presented are patients with psychosis in the active phase. Bion did not provide information on patients’ personal history, nor did he mention onset or the development of the illness; not even the patient’s mental state before the session was taken into consideration. He confined himself to an in vivo presentation of the patient in the consulting room and to discussing the transference that develops with him. For example, he made no comment about a patient who was clearly hallucinating and almost delusional, who said he had ordered a coffee before the session but that the lady who served him had something against him, perhaps because of his voice and that coming through the mews the walls were bulging outwards but that, when he went back to check, everything was fine.

The importance of projective identification, which assumes a more destructive nature inclined to disintegrate the object, is central in his writings.1 This process, when used indiscriminately, results in splitting the analyst in two (one positive and one negative and persecutory), in deforming and fragmenting language and in no symbolisation; consequently, it becomes indispensable to describe to the patient the process that is taking place.

Bion tried to shed light on the causes of frequent relapses that occur in the course of therapy and on the difficult nature of recovery. He hypothesised that when the patient improves and can think, he feels a psychic pain come so much to the fore that he shies away from his regained ability to understand, it being intolerable to him; by fleeing, however, he loses those tools that would permit personality integration and the employment of verbal thought. When integration is successful and the patient once again obtains consciousness of psychic reality, the danger is that he will begin to hate the analyst, who, in the patient’s opinion, is to blame for having brought the disaster that occurred to his awareness. For two of the three cases considered, Bion did not speak of recovery, but of improved adapting to reality or, rather, of a particular kind of improvement.

Another important concept introduced by Bion here is the difference between the psychotic and the non-psychotic personality, which exists from birth and determines the subject’s destiny. Bion highlighted four main features of the psychotic personality: the predominance of destructive instincts, hatred of inner and outer reality, the dread of imminent annihilation and a fragile and rash transference.

During the psychotic process, the child’s sadistic attacks on the breast are directed against his perceptual apparatus that is connected to verbal thought, which is minutely broken up and then expelled. In the patient’s phantasy, these parts of the perceptual apparatus, fragmented and expelled into external objects, continue to live autonomously and uncontrollably and are perceived as being full of hostility directed against the mind that expelled them. As a result, the patient feels surrounded by bizarre objects.

According to Bion, it is not possible to treat a psychotic patient if his destructive attacks against his Ego are not analysed and his perceptual distortions in operation via projective identification constantly clarified. Whereas the non-psychotic person uses repression and can therefore ‘dream’ the repressed content, the psychotic patient resorts to projective identification.

The technique Bion used was to directly interpret the destructive mechanisms by describing the patient’s use of his own bodily organs. When sense organs are used to evacuate, hallucinations are formed. To a patient who was very detached during a session and said that perhaps he had heard incorrectly, Bion replied that his interpretations had entered his ears to then be transformed into a destructive mouth and expelled via the eyes. His exact words were ‘You are feeling that your ears are chewing up and destroying all that I say to you. You are so anxious to get rid of it that you at once expel the pieces out of your eyes’ (1967, p. 76).

Bion’s interpretations were frequently so bold that they seem subjective, almost bizarre and quite difficult for the reader to understand; moreover, it is not clear how the patient could have taken them in and understood them. For example, in one case, Bion said to a patient that when he suffers, he wants to achieve anaesthesia to get rid of memory and pain, to which the patient, after having said his head was splitting, exclaimed, ‘Maybe my dark glasses’. At this point. Bion remembered that approximately five months earlier he himself had worn dark glasses and that this image had been engraved on the patient’s mind like an ideograph. For Bion, the glasses hint at a baby’s bottle and the lenses being two, to the breast - the lenses are glass to punish him for trying to look through them when they were breasts; being dark means frowning and angry. They are dark also because they need to be in order to spy on his parents during intercourse. Bion told the patient that the dark glasses were like his sight and felt as a conscience that punished him for getting rid of them to avoid feeling pain and because he had used them to spy on his analyst and his parents (pp. 57-58).

The interpretation, as one may see, derives not so much from the patient's associations, but from the mechanisms that Bion places at the base of the psychotic process: hatred towards the breast, an excessive use of projective identification, the creation of bizarre objects, envy of the parents' intercourse, guilt and a persecutory Super-ego. So the dark glasses come to mean an agglomerate of bizarre objects due to an excess of projective identification and the resulting fragmentation of the Ego. What is interesting about this extract, which I have described succinctly, is that, according to Bion, the patient subsequently showed an improvement, which was confirmed by his use of verbal thought and more positive consideration for the figure of the analyst, who became a human being. Bion attributed the change to the fact that the patient managed to decrease destructive attacks against his own Ego and restore, at least partially, his use of repression in place of projective identification.

Another important concept is the attack on linking or, rather, on dependence, on the parents’ relationship and on the link between words. In the sequence of a session that Bion (1959) cited, a patient said that a piece of iron had fallen on the floor: ‘My interpretation, as far as I could judge, was felt by him as if it were his own visual sense of a parental intercourse; this visual impression is minutely fragmented and ejected at once in particles so minute that they are the invisible components of a continuum' (p. 309). T said that he felt so envious of himself and of me for being able to work together to make him feel better that he took the pair of us into him as a dead piece of iron and a dead floor that came together not to give him life but to murder him’ (p. 310).

For Bion, the attack on the link is the main obstacle to progress: it is an attack on the analyst’s peace of mind and originally on that of the mother. Through constant projections, objects (the breast, the mother and the analyst) are perceived as greedy, eager to devour the patient’s projective identifications.

An important change was Bion’s conceptualisation of projective identification. Up to a certain point, he considered projective identification as a negative mechanism belonging to the psychotic part of the personality that hinders development; later, he theorised a form of normal or communicative projective identification that, alongside introjective identification, constitutes the basis for mental growth and psychic progress.

Bion wrote that, in a session with a psychotic patient, he had interpreted his attempt to rid himself of death anxiety that was so powerful he could not keep it inside; subsequently, thinking again about the material of the session and the exchange that had occurred between the patient and himself. Bion realised that the patient had not used projective identification as a destructive mode, but had placed his anxiety inside the analyst in the hope that he could have modified it so that it could then be safely reintrojected.

The patient's associations in response to the interpretation demonstrated how Bion had not sensed the anxiety of his communication; the patient’s subsequent effort to force the projections onto the analyst then became increasingly desperate, and the more violent his projections, the more the analyst, unable to accommodate them, became terrible in his eyes.

Bion hypothesised that an analogous event occurred at the start of life in the child destined to become psychotic. The violence of the attacks is greater when maternal receptiveness is lacking, whereas it is milder but never absent when the mother is able to introject the child’s feelings without being overwhelmed. A normal degree of projective identification serves to let the child understand the namre of his own sensations through the effect produced in the mother once they are projected onto her. If the projection is prevented because the mother is unable to accommodate the child’s communication, the link between him and the breast is destroyed, and curiosity is seriously compromised; following the destruction of the emotional link between mother and child, prerequisites for the destruction of emotional life are created.

Bion, however, thought that the mother’s poor receptiveness to the child’s communicative projective identifications was not the primary cause of psychotic disorders, despite its importance in producing the psychotic personality, and that congenital aggressiveness and primary envy bore more weight in this respect. In other words, Bion thought that psychotic disorders originated in an excessive congenital predisposition to aggressiveness, hatred and envy, together with the environmental factor concerning the mother, whose lack of emotional receptiveness prevents the patient from using projective identification as a means of communication.

In Bion’s thinking on psychosis, two lines may therefore be captured: the first can be defined as constitutional and the second environmental, which, despite being conceived one after the other, continuously intersect. The constitutional component is predominant in the first part of Bion’s work, which is more connected to Melanie Klein's thought. Bion believed that the psychotic part of the personality, a destructive mental state in which the death instinct and pride nourish arrogance, is present from birth. In the psychotic patient, attacking the link, envy and arrogance all destroy a convivial encounter with the object and deny access to the world of symbols and emotions.

The environmental viewpoint instead places emphasis on the poor introjec-tion of fundamental functions for affective symbolisation because of a container defect: that is, a defect of the object originally destined to accommodate the nursling’s projections. The psychotic part of the personality finds nourishment in a lack in the mother of the intuitive function that accommodates the child’s communicative projective identification. Poor maternal receptiveness deprives the baby’s communication of its value, burdening him instead with unbearable anxiety and thrusting him headlong into nameless dread.

Normal projective identification has entered post-Kleinian conceptualisation, many analysts using it widely. In my opinion, however, a veil of uncertainty surrounds the use of the term, given that two mental operations - one psychotic and the other normal - bear the same name. For Melanie Klein, projective identification represented a psychotic mechanism in which the patient projected unwanted parts of his own personality onto another person and stole others he desires: resulting from this was confusion between self and object and the perception of being spied on and controlled by the object into which the projection was directed. None of this occurs in normal projective identification, the purpose of which is to project onto the object not parts of the self but emotions that are difficult to tolerate so that they may be shared and understood.

Bion’s intuition of projective identification for the purposes of communication is the basis of his conceptualisation of the relationship between container and contained, which is essential to understanding emotional growth and development.

Hanna Segal

In ‘Some aspects ofthe analysis of a schizophrenic’ (1950), Hanna Segal described her first psychoanalytic therapy with a young man who had developed a psychotic episode. The patient, Edward, had been diffident and hypersensitive since childhood; he had cultivated a long fantasy withdrawal populated by idealised women, often princesses whom he had to free from terrible fathers or rivals. While in India doing his national service, he had a psychotic episode. He was unable to carry out his superiors’ orders and was then sent to work in a photographic laboratory, where he began to worry that his eyes no longer worked. Then persecutory delusions appeared that concerned a conspiracy by the Chinese who wanted to take over India and the threatening presence of a biologist who wanted to destroy the world. Once back in England, he spent six months in various military hospitals with a marked deterioration of his symptomatology characterised by delusions, hallucinations, a loss of identity and disorientation in time and space.

Hanna Segal met Edward in one of the military hospitals: he was apathetic, shut away in himself, had upturned lips giving a bizarre smile expression and was afraid that the world was about to be destroyed; he thought he had been transformed by who knows who, he seemed unable to tell the difference between himself and the world, he was hallucinated and heard that voices were in everyone else's head too. After being transferred to a private clinic, it was possible to begin analytic treatment. At first, Hanna Segal did not interpret the delusions and hallucinations; when the patient told her that prisoners in Germany were sending him the voices, she understood that Edward felt like a prisoner and not an ill person.

In the beginning, it was difficult to follow Edward’s disconnected speech, but it could be made out that the delusion of being held prisoner became ever more structured. Edward was convinced his thoughts were produced by his stomach, or, rather, he himself was nothing more than a huge stomach, with arms and legs and a head, like tiny alien appendages; terrible distress was then felt because he thought that provisions would run out, and there would be no food left for anyone.

As early as possible, therapy was continued at the patient’s home. Here, Edward’s earliest childhood recollections emerged: anger over his mother’s pregnancy, his brother having been brought into the world when he was four years old. Edward seemed to have identified with a pregnant mother full of babies (frill of voices), and at the same time, he was also an embryo in the womb, all tummy and no limbs.

Edward did not accept the transference interpretations but remained attached to the analyst, who had become a protective figure; at times, however, he thought that the analyst was an agent working for the hospital and the doctors who had treated him there. Even during difficult moments, Hanna Segal maintained an analytic attitude and did not resort to advice, reassurance or declarations of friendship.

After approximately three months of treatment at home, Edward was able to go to the analyst’s office, despite the fact that at times the delusional persecution included her too. The situation improved after a certain period of analytic work, and the patient seemed to move towards a neurotic way of thinking: he was able to recognise that others did not share in his delusions and hallucinations and that it was better to conceal them. Towards the end of the first year, all the delusions had disappeared at a conscious level; Edward was in touch with reality. He led an apparently normal life, enrolled at university and did some work in the countryside, despite being tormented by distressing fantasies about soil erosion. The only remaining symptoms were poor concentration and an annoying buzz in his ear.

Unfortunately, eighteen months after the beginning of treatment, the ‘voices’ returned. Hanna Segal reported a session in which she interpreted a psychotic oedi-pal conflict that seemed linked to the hallucinatory phenomena. Edward spoke of two relatives who had died a short time before then and of the fact that he had not felt sad at their passing away; then he added that the previous day, while doing ‘eye exercises’, which he counted, an echo in his head had kept track of his counting too. Hanna Segal connected his absence of emotions in relation to his relatives’ death to his distance from the analyst during the weekend and his ‘eye exercises’ to watching his parents being united sexually, with the intention of killing them.

She examined this interpretation in depth using a subsequent dream in which a white figure became brown, and she said to the patient that when he did his eye exercises, he was trying to watch the analyst while she was having intercourse. Then he would angrily swallow her up and mrn her into faeces; she then became a voice that persecuted him from the inside. At the same time, with a glance, he would fill the analyst with the same brown substance, faeces, and she would go from white to brown; at this point, one looking at the other, analyst and patient could not but exchange excrement, illness and death.

Edward's analysis proceeded with accurate interpretations of his anxiety regarding the female figure and his split between idealised and persecutory figures. The relation with the analyst gradually became warmer and friendlier; this was the first close relationship the patient had ever had in his life. Edward remained in analysis for three years, and then, open to his parents' persuasion and his own maniacal attitude, he interrupted his analysis to enrol at a prestigious university outside London. Segal reported that Edward was well after that; he married and pursued a professional career. Approximately twenty years later, however, he had another psychotic breakdown and returned to analytic treatment - not with Hanna Segal, though, as she could not fit him in, but with a colleague of hers.

A second interesting paper that lets us understand how Hanna Segal worked with psychotic patients is ‘Depression in the Schizophrenic’ (1956), in which she claimed that the psychotic patient is unable to tolerate depressive anxiety and regresses when this looms large. The patient was a sixteen-year-old female who had suffered from hallucinations since the age of four and was diagnosed with hebephrenic schizophrenia. The severity of the illness was evident from the first sessions; she would jump and run about the consulting room, bite the sofa, rip her clothes, hear voices and at times scream with fear; from several broken sentences and the fact that she had scratched her neck, Hanna Segal deduced that the patient saw her as a vampire that sucked her brain and blood; at times it was the patient herself who was a vampire ready to suck the analyst’s blood. The patient also had, however, a pleasant delusional world with highly idealised hallucinations: an ‘ideal people’ lived inside her, and in order to build this world, she would become a vampire that sucked the analyst’s vital sap, and in turn, drained, the analyst would suck the patient’s ideal world and take away her good hallucinations. The patient really feared being a vampire that could bring about nothing but death.

In one session, the patient had an insight and asked the analyst if by chance her problem happened to be that of constantly eating and taking things inside her without making any effort to build something good inside. For Hanna Segal, this was the moment of depression. After this session, in which the patient seemed more pensive and mentally healthy, she arrived for her next session with a dissociated, masturbatory and incoherent attitude, ignoring the analyst entirely.

Hanna Segal saw this behaviour as a negative therapeutic reaction: experiencing being solely destructive and draining the breast had made the patient feel unable to repair and reconstruct it. She was in fact depressed, but her solution was to project the depression onto the analyst, ignoring her and making her feel like a useless child; ridding herself of the depressed part, the patient became madder.

Hanna Segal’s conclusion was that, as long as the patient had been able to keep her depressive feelings inside her, she could communicate healthily; when these depressive feelings became unbearable, she needed to project them onto the analyst, resulting in a loss of reality, a return to mad behaviour and the reappearance of persecutory feelings. In this case, the analyst had become the persecutor who carried inside the patient’s depressive part, which she intended to push back inside her. For Hanna Segal, guilt and pain are intolerable to the psychotic, which is why they must be projected onto the analyst.

Yet another paper by Hanna Segal that lays out the vision of Kleinian analysts on psychosis and its therapy is ‘A psychoanalytic approach to the treatment of psychoses’. Hanna Segal told us that psychotic illness has its origins in early childhood when the bases of mental functioning are formed: that is, during that time when the infant progressively acquires differentiation between the inner and outer world. Development occurs through projection and introjection, splitting the object into a good and a bad part, then their integration and identification with good objects. Simultaneously, the prerequisites for symbolic thought and language are developed. At times, something disturbing occurs in these earliest stages of development, the essential functions for growth thus being disturbed or destroyed, and the development of symbolisation processes hindered; the line between internal and external is unclear, and object relations become fragmented. Understanding the nature of psychosis is possible only if normal Ego development is considered and compared to the distortion undergone in the course of illness.

The fulcrum of mental stability is anxiety containment by means of an internal object that is capable of understanding: such an object is the product of the maternal function that receives and transforms the infant's anxieties. Mental stability can be destroyed for two reasons: the mother may be unable to receive and transform the child’s anxiety, which then increases, reaching an unbearable level, or her receiving ability may be put to the hard test by the child’s excessive destructive omnipotence.

Since the psychotic patient tries to project his terror, evilness and confusion onto the analyst, he develops an almost immediate transference, which is usually violent. After this projection, he experiences the analyst as a terrifying figure whom he immediately wants to distance himself from: this is where the fragility of the transference is created. Interpretation is perceived very concretely as a reverse projective identification, as if the analyst wants to push the unwanted parts inside the patient, leading him towards madness. The concrete nature of the experience of the patient, who feels that he is omnipotently changing the analyst and that the analyst is omnipotently trying to change him, is a fundamental point in analytic work.

The main themes of the psychotic patient’s analysis, according to Segal, concern language, concrete thought, confusion between subject and object and the psychotic transference. She reconfirms the usefulness of the Kleinian model with the paranoid-schizoid position and the Bionian model with the mother who is able to contain the infant's projective identifications, these being at the heart of the analytic technique used by her group.

Segal offered the opinion that, in cases when conditions are favourable, psychoanalytic therapy is the best treatment as it deals with the psychotic personality disorder from the roots. Moreover, therapy of psychotics has a value that goes beyond the therapeutic aspect proper in that the study of thought, perception, symbolic thought and object relation disorders can allow processes outside consciousness that support and develop these functions to be examined.

Lastly, a very important concept is Hanna Segal's symbolic equation (1957), which is the psychotic patient’s inability to symbolise or, rather, to distinguish symbols from concrete objects. In the symbolic equation, the paranoid-schizoid position prevails over the depressive position, which instead would allow the object to be perceived as separate from the Self.

Legacy of the past

Among the many who have been committed to the therapy of psychotic patients, I chose the work of those analysts I believe are most meaningful. Mentioned separately is Lacan, due to his original perspective.

I placed therapists into two categories. The first follow an intuitive and non-systematic approach, and the second may be defined as theoretical and systematic.

In the first group, I mentioned Frieda Fromm-Reichmann and Harold Searles, who manoeuvred skilfully with rare courage and enthusiasm. No pre-existing theoretical system was there for them to refer to: they were true pioneers who relied mainly on their clinical intuition and were able to confirm that all the rules and guidelines deemed valid for the therapy of neurosis were unsuited to treating the psychotic patient. Their sensitivity and intuition led to their finding a different path into the relationship with this kind of patient. I also mentioned the original contributions by Madame Sechehaye, Federn, and Lacan, each of whom inserted their study of psychosis into their own unique theoretical system.

Different is the case of Melanie Klein and her collaborators. Taking the study of primitive infantile anxieties as her starting point, Melanie Klein was committed to constructing a theoretical system that could explain normal psychic development and its deviations. Within this theoretical system, psychosis had a place, too, or, rather, clinical data gathered on the study of psychosis even helped broaden knowledge of child development. Since it was a serious illness, it was logical to find as a starting point for psychosis the earliest stages of development, in particular the paranoid-schizoid position.

Melanie Klein’s pupils then applied her theoretical frame to clinical work: projective identification, an absence of symbolisation, no repression, a difference between the healthy and psychotic parts and the psychotic transference are indispensable concepts for understanding and treating psychotic patients.

Technique then applied by Bion and Segal derived directly from these theoretical assumptions. In their opinions, psychosis stems from a child’s early developmental stage and depends on his tendency for destructive phantasies towards the maternal figure. If destructive phantasies remain, without being transformed by processes of reparation, mental structures that contribute to the onset of the illness are created. Psychosis is considered a destructive process that originates in the death instinct prevailing over the life instinct. This makes integration, which could lead to recovery, extremely difficult. Segal clearly stated her idea that the recovery process can sometimes be complicated, as reparation becomes an extremely hard task in the face of such destruction. Bion, too, expressed a similar concept: over the course of improvement, the patient acquires the ability to understand psychic reality but cannot tolerate awareness of the destruction that occurred.

Neither author denies the existence of environmental factors that concur with the development of the illness. Bion put forward the idea that the mother’s inability to act as a good container of the infant’s anxiety projections is one factor contributing to the disorder. This hypothesis provides an understanding of psychosis development within a relational matrix, but his writings also include a hypothesis of the endogenous, destructive nature of the illness when the mother may be incapable due to the extremely aggressive nature of the nursling. Bion seemed more explicit when identifying the nursling’s hatred towards the breast as the main determining factor in psychosis. Common to both analysts was their clinical approach, centred on constantly working on the transference. This regards patients in an acute phase (Segal) as well as those who have most likely been in a psychotic state for many years (Bion).

At that time, analysts from the Kleinian group believed that transference work was essential to obtain positive transformations in the psychotic patient, and only later, sustained by Rosenfeld, did the idea prevail that the delusional transference was extremely negative. When included in the patient’s delusion, the analyst loses his analytic function, and the relational space that the analytic process needs consequently collapses.

Segal and Bion gave their patients very detailed interpretations on the omnipotent use they made of their bodies and organs. Rejection, expulsion, object destruction and projecting intolerable states of mind onto the analyst occur via the projective use of sense organs: mouths that swallow, ears that grind up, eyes that project.

Despite this broadening of the theoretical perspective by Melanie Klein and post-Kleinian analysts, we have not witnessed a corresponding and hoped-for development in clinical results. This might be one cause of the drop in literature on clinical work with psychotic patients over recent decades. As mentioned earlier, and as I hope to expand on later, psychosis therapy encounters knots that are difficult to transform. I do not have in mind so much the difficulty, even though it exists, of tolerating the depressive position, as was underlined by Bion and Segal. When these patients improve after having lived at length in a psychotic state, it is not rare to see that instead of even embarking on the path towards the depressive position and the sorrow and regret for what has been lost, they prefer to go back to denying reality and to the delusional state.

As I shall tiy to illustrate further on, other elements also make the recovery from psychosis arduous. One of these is certainly the nature itself of the delusional experience, which deeply encysts in the mind and seems to resist any kind of transformation.

My viewpoint

I shall briefly outline here some of my thinking on the psychotic illness and the difficulty in treating it.

It is my belief that psychosis has its origins in a dissociated world, an alternative reality that begins to form in childhood; in some cases, but not in all, this construction is fostered by trauma and abandonment that necrotise the child’s personality, causing obvious splits in and damage to his mental functioning. The child constructs a new reality where he can live; at times the split-off parts are transformed into an aggressive internal presence, and from here hallucinatory and delusional phenomena, which may at times even start in childhood, begin.

In my opinion, it is not so much a case of the child destined to become psychotic being stimulated by aggressiveness as by a particular tendency to isolate himself from the relational world so that he may build with his imagination another dissociated world. Placed in the service of his fantasy, this dissociated world is appealing because there the limits of existence and frustrations of reality never need facing up to.

The destructive effect is not primary but the consequence of flight into unreality from which it is difficult to return. In order to construct a dissociated world, the patient must alter his sense organs and abolish his thinking capacity; given that this process is usually accompanied by a pleasant state, the subject is unaware of the dangers this operation can lead to, the withdrawal turning into a prison with little possibility of escape and the pathogenic structures, once set in motion, ending up looming over and dominating him.

What I have just described is similar- to the story of ‘The Sorcerer's Apprentice’, the well-known ballad written by Goethe in 1797, set to music by Paul Dukas one hundred year’s later and played by Mickey Mouse in Disney’s famous movie Fantasia.

The story is very simple: a sorcerer’s apprentice, taking advantage of the temporary absence of the sorcerer, casts a spell to get out of doing chores he had been ordered to do. But at a certain point, the situation gets out of hand, and due to his lack of experience, he cannot break the spell that then turns against him. Luckily, the old sorcerer comes back, immediately restores normality and with a lash of his whip punishes his careless apprentice. In the therapy of a psychotic patient, there is no sorcerer who can restore order with a lash of his whip and cast his careless apprentice back to his junior role. In psychotic transformation, the patient does not act on a whim; unfortunately, his story goes back long before the signs and is nourished by longstanding mental functioning. The patient himself can no longer distinguish between psychotic and normal functioning: omnipotence is in command, and its first victim is the patient.

Therapy needs to begin from this point, and the analyst’s task is to creatively understand how to strengthen the patient’s healthy part in order to contain and reduce as far as possible the omnipotent part, which exercises great power over the patient; a complete change has taken place in the patient’s mind, which is no longer a tool for thought but a sensorial organ that constantly produces impressions perceived as being real. The world of dissociated reality cancels out the mind's primary function: that is, its understanding mental processes and external reality.

The analyst is in a difficult position because he cannot expect to take the patient back to a previous stage of mental health with interpretative work, assuming such a stage ever existed; the analyst is not after all the sorcerer that can scale back a careless usurper.

This work requires much time and patience to discover the tools the patient uses outside awareness to distort his mental functioning; considerable imaginative effort is needed to enter into worlds so far away from our own. Even great competence acquired throughout the analyst’s clinical experience may not be sufficient when having to deal with the field of psychosis.

The following pages aim to offer a picture of the salient points that are needed for the therapy of the psychotic patient. I believe that boosting research and clinical application in this field can be helpful for patients and can constitute a powerfill stimulus for the development of psychoanalysis as a clinical and theoretical discipline.


1 Only later did Bion introduce the concept of projective identification used for communication.

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