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The setting and transference in psychosis

The setting

The cases described in analytic literature, summarised earlier, mainly concern psychotic patients who spent long periods in hospital and were treated psychoanalytically, irrespective of the severity or duration of their pathology. These parameters are extremely important, however, for prognostic purposes as the psychotic process becomes irreversible once a certain threshold is crossed; this means that mental functions enabling contact to be restored with reality weaken, if they don’t disappear altogether. Moreover, prognosis is more complex when the psychosis develops in childhood than in adolescence or adulthood.

Establishing a formal setting (tunes, the patient's position, frequency of sessions and so forth) that is right for that patient’s treatment is important. Generally, the number of analytic sessions with a psychotic patient need not differ from that of any other kind of patient; that too high a frequency of sessions will destabilise the patient, something that is occasionally heard, is quite untrue. The result of treatment instead depends on how the analyst listens to and understands the patient’s functioning and anxieties. A suitable number of sessions enables tire therapist to enter into close contact with the analysand and understand his psychic dynamics; symmetrically, it allows the patient to focus his attention on the content of the session and to memorise and work thr ough it. Furthermore, a suitable number of sessions reduces the frequency of relapses, given that for quite some time the analyst functions as the patient’s auxiliary Ego, preventing the psychotic part of the personality from winning back its power.

Often, the optimal formal setting (number of sessions and position on the couch) cannot be prepared right from the start but must be built up gradually. Asking the patient to lie on the couch at the beginning would confuse if not frighten him altogether. The fact that he finds it difficult to stay in touch with reality means that lying on the couch, which reduces visual stimuli so that attention may be more focused on his inner world, would risk making him feel even more disoriented and confused. Besides, the analyst cannot expect the psychotic patient to follow the basic rule of free association as he is immersed in a world of sensorial images, disoriented and prey to confusional states.

As for the number of sessions, therapy can usually begin at one session per week face-to-face and then gradually be increased. More than any other, the psychotic patient needs to familiarise himself with the therapist, and this takes quite some time. As sessions are gradually increased, the therapist, when he feels that the time is right, can suggest that the patient lie on the couch, a position that enables both patient and analyst to communicate more freely. The patient must have built up trust in the therapist and feel that therapy is useful to him for this to occur. In some cases, such as when the patient is experiencing considerable anxiety or has just been through a psychotic breakdown, a higher number of sessions may be suggested from the start.

Establishing a traditional formal analytic setting is not always possible, nor, I shall add, is it always necessary. If the therapist has understood the dynamics of the treatment via the key elements he has gathered together, the patient can be helped with fewer weekly sessions and without using the couch. As mentioned earlier, the analyst functions as a strong ally to the patient’s healthy part and can thus contain the action of the psychotic part; when this function fails, the risk of relapse is greater. The higher-risk moments are when sessions stop - at holiday times, for example - as the patient’s healthy part is no longer supported by the presence of the analyst, and the patient can therefore fall victim to the psychotic part. Face-to-face therapies at one or two sessions per week do bring undeniable benefit and unexpected improvement, but it is harder for the therapist to restructure the patient’s personality so that the emotional skills needed to carry out the more complex tasks of relational life can be developed.

With patients who have had a psychotic episode, patience and caution are needed to create and maintain the necessary conditions for therapy. I can remember a patient who did not come of his own accord but was persuaded by his parents and the psychiatrist he had seen after his hospitalisation. Given the clinical conditions, I decided to see him face-to-face once a week. I can recall that during the first consultation he was severely distressed, visibly delusional, suspicious and perturbed by ‘voices’ and was a victim of persecution in an international conspiracy. I remember also how difficult it was for me to understand his fragmented delusional speech and to gather together elements from his past, as well as intuit how he had entered the psychotic state. In particular, I remember his uncertainty when signing the cheque to pay for his sessions, which took him several minutes, his hands shaking all the while. Some years later, and after an obvious improvement (the analytic setting had stabilised at four sessions per week), it came quite naturally to me to remind him of how he had suffered during those first months of sessions, and I happened to mention his difficulty when signing the cheque. Much to my surprise, he answered that his awkwardness had not been due to anxiety but to the fact that a voice would tell him at that moment that it should have been me, the analyst, paying him because he was much more intelligent than I was. This is to show that the patient, despite having agreed to undergo therapy, had not at that point developed the subjective conditions to put his therapy to use, given the persistence of his omnipotent thought.

On a related note, it goes without saying how important it is in the psychotherapy of a psychotic patient to collaborate with a psychiatrist, who needs to see the patient regularly and intervene should there be a new breakdown; even when the patient has not had a psychotic breakdown and has never been hospitalised,

this kind of collaboration is necessary. The referred psychiatrist must have trust in the analytic method and not interfere, even outside awareness, with the analyst’s role. It is up to him to evaluate at a later stage of the analysis whether to reduce or stop the patient’s medication. In their clinical practice, not all analysts keep psychotherapeutic and pharmacological treatments separate: for example, if they are competent in psychopharmacology, such as analysts who are qualified psychiatrists, they themselves administer medication when the patient gets worse or a psychotic episode is impending. Making this therapeutic decision is not easy, though: when the analyst resorts to medication, he runs the risk of a concentration lapse with regard to the analytic therapy and to understanding well the reasons behind a possible episode; his decision to resort to medication can be influenced by the countertransference and may also be understood by the patient as a lack of analytic skill at a critical moment during the analysis.

It is important to reconstruct from the start of therapy the ‘history of the psychosis’ in order to understand how it developed and prevent the risk of it repeating. Some information on how the original episode was triggered is provided by family members and additional information by healthcare workers, who can help us see how the patient, until a certain point in his life, maintained a balance, albeit unstable, between the psychotic and the healthy parts. Then an emotional trauma; the loss of a special friendship; frustration at being abandoned by a loved one, even only in fantasy or a serious conflict that thrust towards a state of imbalance may have occurred, which in mm propelled to a delusional experience. The patient usually tries to conceal his attraction to psychosis from the therapist, so it is imperative to do everything possible to make this tendency emerge and stop the healthy part of the personality from being invaded by the psychotic part. Together with the patient, the analyst must retrace the original psychotic episode to help the patient gradually broaden his awareness of his vulnerability.

When work first begins with a psychotic patient, the therapist cannot expect there to be dreams, associations, fantasies or transference development, through which conflicts and anxieties of neurotic problems are understood. The neurotic patient moves within the dynamic unconscious, uses repression and possesses a clear distinction between conscious and unconscious. In the psychotic patient, however, we find a totally different unconscious, without any symbolisation or repression; repression of emotions and awareness is not perceived in this kind of patient, and what we see instead is the transformation of psychic reality via the alteration of perceptive and thought functions; outside awareness, the psychotic patient creates a new world he painfully becomes prisoner of. The principal issue of treatment is, therefore, to discover how the psychotic patient transforms his perceptive world and self-awareness.


According to Freud, the analysand forms an image of the analyst onto whom he transfers his past childhood experiences, which is why transference work is important as it permits a return to the past; the nature of conflicts that featured in the patient’s childhood and condition his present can thus be clarified. It was Melanie Klein who broadened the concept of transference, considering it not only a reproduction of the past but the result of the patient’s projection of parts of his Self (unwanted or idealised) onto the figure of the analyst, who comes to represent them through projective identification: hence the analyst temporarily being an object of the present and the past in the neurotic transference, assuming, as a transferential object, an ‘as if’ position halfway between fantasy and reality. The conflict nucleus therefore needs to enter the transference so that it may be interpreted.

In therapy for psychosis, transference cannot be employed as a tool for quite some time because these patients are unable to symbolise or to represent their own history and think at a concrete level only. A psychotic transference risks being formed because of the delusion activity. This kind of transference is detrimental to therapy as it includes the figure of the analyst in the delusion, tending therefore to invade the space of the analytic relationship. This is why the psychotic delusion transference must be transformed as early on as possible.

There are two kinds of delusion transference: the psychotic transference and transference psychosis. The psychotic transference forms when the psychotic nucleus invades the patient’s healthy part and destroys his intuitive and reflexive capacity. The delusion invades the setting and the analytic relation; the analyst becomes the subject of the delusion, his interpretative function can no longer be fulfilled, and the analytic process grinds to a halt. Excitedness can characterise the psychotic transference, as in the love-type delusion in which the patient believes the analyst is taken with a love passion for him, or in the persecutory type, when the patient experiences the analyst as an enemy that wants to make an attempt on his life.

As an example of this pernicious event, in the third part of the book, I have written an account of the analytic situation of Francesco, who had a very complex persecutory delusion. His psychosis began abroad after a conflict with a colleague, and from that moment on, the patient felt persecuted by a conspiracy on the part of that colleague’s fellow countrymen, who were planning to kill him. Once, I happened to leave my office after one of his sessions and walked briskly to a nearby office; the patient saw me and interpreted my haste as proof of my going to report him to his enemies. In the following session, he very anxiously spoke to me about this perception, which for him was real. Worried about the direction that the analysis could have taken, I immediately began to talk to him about the reasons that had led him to believe I could have collaborated with his persecutors; he replied that I might have done so because I had been threatened by them or paid a huge bribe. While I knew that the psychotic transference bore early signs of the main elements of his delusional system, I made him reflect on the fact that he considered me an emotionless puppet in the hands of his enemies. I learnt then that the therapist can be incorporated into the persecutory delusion the moment he tries to demolish the patient’s delusional belief; the patient at that point believes that the analyst wants to shatter what for him is reality, as he has come to some sort of arrangement with the persecutors. When trying to demolish the delusion, great care must therefore be taken.

As for the second kind of delusion transference, the transference psychosis, here the delusional ideation is purely about the analyst, and so it is a psychosis in the transference', that is, a psychosis limited to the transference. Before developing the transference psychosis, the patient is not delusional, and he continues not to be so, at least with respect to the outer world. This kind of transference usually develops after a prolonged period of incomprehension by the analyst, with repeated interpretations that are wrong or out of context; in other words, it is an impasse of a psychotic nature. The patient convinces himself that the therapist purposely wants to harm him and is fully aware that he (the analyst) is attacking him (the patient); the figure of the analyst thus deteriorates to the point of becoming persecutory.

That the transference psychosis can be due to iatrogenic intervention therefore requires vigilant awareness on the part of the analyst; should it occur, he must try to understand how it developed and then talk to the patient about possible distortions in analytic communication. Usually, if the analyst shows that he can go back to his wrong interpretations and acknowledge them as such, the transference psychosis may be overcome, and the analytic process can get back on course.

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