The psychic withdrawal and the psychotic part of the personality
Analysts who work with children can observe that in several cases a process which may develop into psychosis is already up and running. These children, usually indicated by teachers as having learning problems or difficulty relating with classmates, are only apparently but not actually in touch with others. In reality, they live a secret life parallel to the real one, where they are shut away in an infantile withdrawal rich in sensorial qualities: that is, an alternative world to real life often populated by imaginary characters that at times are nourished by obsessively watching television cartoons. The most serious consequence of this life in fantasy is that the child does not structure a psychic apparatus capable of understanding psychic reality.
At times, when listening analytically to an adult patient, the childhood elements that triggered the psychotic state can be found, and early conditions that laid the foundations for vulnerability to the illness may be traced. It can therefore be assumed that detachment from reality began long before the clinical manifestation of the illness.
When Freud described the psychotic patient’s isolation, he spoke of autoeroticism as a pathological process in which the newbom’s primitive developmental experience, sensorially withdrawn into his body, is repeated. The term autoeroticisni therefore describes both the psychotic withdrawal and the objectless stage of human development: that is, the primitive phase in which the infant, focused on his own bodily sensations, ignores the presence of his surrounding world. Freud's intuition is still useful in order to understand several aspects of the psychotic state: for example, when a patient who has totally detached himself from emotional reality then withdraws into his own body and produces perceptions from scratch. In this case, hallucinations originate in and have as their stimulus bodily sensations; there is no thought in the withdrawal, only dissociated sensory content that wipes out psychic reality.
My hypothesis is that the child who is prone to becoming psychotic may have had parents who were unable to accommodate his emotional communications or who invaded his mind with disturbing emotional projections; in this case, the withdrawal creates a dissociation from reality that serves as a defence against contact with the parents, but also against the relational world.
By dissociation, I do not mean a vertical split of the personality in which one part does not know the other, but rather that the world of psychic withdrawal is fed only by sensorial fantasying that is separated from the world of relations.
The psychic withdrawal is a mental organisation that can be a continual source of illness during an individual’s life: not only is it a place for taking refuge from anxiety, as Steiner (1993) sustains, but above all it is a forge where worlds alternative to the real world are produced. Constantly creating an imaginary sensorial reality saps energy from emotional and affective development, hamstringing experience the individual needs for growth and compromising to various degrees the development of personal identity.
In this connection is the case of a fourteen-year-old girl indicated by her school as having difficulty studying and integrating socially: isolated from her schoolmates, she had an attention deficit, making it difficult for her to study. During her consultation with the therapist, she spoke about her malaise and the other world she lived in: in this fantasy world, where she spent most of her day, she had two children and was married to a very successful man. At home, too, when having dinner with her parents, she would get up and go to her room to enter this world that would summon her and continually seduce her: she had to tend to her children. This dissociated life, existing in parallel to her real one, eliminated her need to relate with peers and. when she was alone, made her believe she had a stimulating adult existence. In a case like this, it is foreseeable that the withdrawal will turn into a clear delusion when the imaginary world gains the upper hand and presents itself to the patient as being real.
It is extremely important not to underestimate the progressive and pathogenic power of the infantile withdrawal and to explain to parents the difference between withdrawal and other mental states of fantasy typically found in childhood: the child who spends most of his day at home alone, often in front of a television or computer without seeking the company of his peers, is not merely quiet and reserved but may not have developed a need for relations and have lost pleasure in social play.
When a child plays, he can distinguish between play (make believe) and reality; the child who lives in a psychic withdrawal loses this ability to distinguish between the two because fantasy assumes the quality of being ’real". Whereas play enriches the emotional world, sensory withdrawal stunts the child’s episte-mophilic drive and captures him in a closed and autarkical reality.
O'Shaughnessy (1992) described this process well when she differentiated between the child who could overcome frustration using the precursors of thought (crying until the mother rushes to comfort him, for example) and the child who is less fortunate, who evacuates frustration (and reality) instead of modifying it. This second type of child does not cry but remains silent and focuses his attention on some sensorial detail; this is the beginning of withdrawal, which uses sensorial channels, creating a pleasant reality that removes the child from dependence that can foster his relational and emotional development.
Today, it is widely held that abnormal and maladaptive behaviour is formed when a child has not received sufficient sensory stimuli or competent emotional attunement during the critical period for the formation of the Self. If things go well and needs are met, sensory gratification comes to be included within an emotional context: physical tenderness, cuddling and kisses become typical relational exchanges.
But what happens when things go wrong? When emotional input is lacking on the part of the caregiver, the child uses his own body for the purposes of arousal; sensation, devoid of a relational quality that develops only within good affective caregiving, deviates. To combat a sense of disintegration, the deprived child clings to a series of sensations (a light, a voice, a smell and so on) that can serve to hold together the scattered parts of the personality, or he uses the body in mas-turbatory terms.
The sensorial world remains split off from the real world over a long period of time, and the individual can live in one world one moment and then in the other. The psychopathological construction of the withdrawal can be kept on an even keel indefinitely, but it usually tends to expand and dominate the rest of the personality. Several kinds of withdrawal, in particular those that lead to psychotic development, become the means with which to create sexualised, grandiose and persecutory omnipotent worlds.
The psychopathological structure of the withdrawal corresponds to the psychotic part of the personality (Bion 1957), the purpose of which is to conquer the healthy part: the more the process moves towards incorporating the individual’s life in the withdrawal, the more he runs the risk of being conquered by the psychosis. Instead of developing thought and nourishing psychic reality, the mind is used as a sensory organ, which, in the advanced stage of the psychotic process, will cause hallucinations. Typically, the situation becomes evident when the sensory constructions that have been built up in the withdrawal but kept dissociated for a long time begin to invade the healthy part of the personality; it is at this point that the psychotic patient is brought to the attention of psychiatry, but it is important that the long preparation which got its start in childhood receives marked attention.
Meltzer (1979, p. 42) drew attention to the pathogenic significance of withdrawal in the development of delusion: ‘We must in my view not lose sight of the worrying possibility that this tranquil and silent process may be present in anyone during the course of development and that, alongside the development with which we are familiar, the delusional system may therefore also be silently developing’.
This possibility is implied also in Bion’s conceptualisation when he hypothesised that, in parallel to thought (the development of which he outlined in the grid), one can develop a delusional system (which he described in the negative grid). This ‘calm, silent’ world presents itself as an alternative to mental growth and communication with the world outside us.
Not by chance did Rosenfeld (1971) highlight that the patient perceives himself as living in a world or an object that totally separates him from the outside world. The delusional withdrawal creates the conviction of being able to find absolute pleasure in a condition of total anarchy; this is why the delusional nucleus ends up attracting the healthy parts of the personality, persuading them to distance themselves from the relational world.
A description of the delusion system’s construction process can be found in the Schreber case, in which Freud (1910) outlined how the psychotic individual destroys the psychic world and uses the debris to reconstruct a delusional world he can live in.
Schreber was convinced he had destroyed the world and built another in contrast to the one wanted by God. He also believed in an external world where he could continue to live and publish his memoirs; this means that he lived simultaneously in a real and a delusional world. Meltzer (1979) wrote that the world built by Schreber had no connections whatsoever with reality and therefore could be situated anywhere at all.
And now a few words on the approach to adopt in order to help the patient leave the withdrawal. As previously stated, the patient is unlikely to tell the analyst about the existence of the withdrawal and the fantasies that animate it; usually he defends it as a secret and precious place, so it is up to the analyst to identify its existence and contents in order to transform it.
When the patient does begin to describe his life in the withdrawal, the analyst can then explain the purpose that this pathological organisation serves and show the patient how it makes his life deteriorate. Although the patient is conscious of leading a secret life in the withdrawal, he is not aware of the destructive effects caused by his retreat.
In addition to distorting emotional development, the withdrawal offers an alternative to the relational world, and it is no accident that in their social life these patients seem lacklustre, indifferent to their surroundings and unable to fulfil life tasks; every commitment in the real world becomes a source of fatigue and anxiety.
I would like to stress that what characterises psychosis is the construction of a separate world, usually in childhood: that is, an alternative world dissociated from real experience that corresponds not to a world of dreams and fantasies or ‘make believe’, but a psychic withdrawal in which the new reality created in fantasy is sensory and conveys the same perceptual depth as the real world.
Not all forms of withdrawal lead to psychosis or delusion. As I mentioned, some may remain silent throughout life without turning into psychosis. One of my patients, who presented a rich phobic symptomatology, always idealised life in fantasy at the expense of real life. When she met a man she liked, she would not seek a relationship with him but would use him to nourish her fantasy life: she would keep away from him and use him in her inner world as a character who would be with her always and love her passionately; then, once the fantasy began to fade, she would feel the need to see him again in the flesh to replenish the fantasy relationship.
In cases destined to become psychotic, the breakdown manifests when the sensory constructions created in the withdrawal dominate the healthy part of the personality. Silent energetic activity precedes the psychotic break: just as a wooden structure suddenly collapses, eaten away underneath by a colony of termites busy at work, so, too, is the psychotic breakdown sudden, after much long, constant labour.
The psychotic part of the personality7
This is how Freud put it (1940, 1938c, p. 201):
Two psychical attitudes have been formed instead of a single one - one, the normal one, which takes account of reality, and another which under the influence of the instincts detaches the ego from reality. The two exist alongside of each other. The issue depends on their relative strength. If the second is or becomes the stronger, the necessary precondition for a psychosis is present. If the relation is reversed, then there is an apparent cure of the delusional disorder.
Rosenfeld (1969) commented that, despite having formulated the concept of the Ego splitting into a normal and a psychotic part, Freud did not further this intuition in his clinical work.
A new perspective on psychosis and the delusion opened up after Melanie Klein’s (1946) writings on the mechanism of projective identification. In her opinion, the specific pathogenic mechanism of psychosis is projective identification: that is, the projection of aggressive and destructive parts of the self onto an external object. Linked to the paranoid-schizoid position, this mechanism consists in the infant’s phantasy to project split-off parts of the self onto the mother’s body in order to control her from within; these phantasies then become the source of anxiety related to being persecuted and imprisoned inside the object. Melanie Klein thought that when projective identification is massive and prolonged, the projected parts become difficult to retrieve.
We are indebted to Katan and Bion for their explanations of the difference between the neurotic and the psychotic parts of the personality. Katan (1954) described the pre-psychotic phase of the illness in particular, when one part of the personality is still able to control conflicts while remaining in touch with reality, albeit unstably; he referred to this part as the non-psychotic portion (parapsycho tic):
the delusion does not possess an unconscious. One may distinguish between a neurotic and a delusional projection. The neurotic projection selves the purpose of warding off the id. The delusional form of projection has a wholly different structure. To put it differently, although not entirely correctly: part of the id has become outer world. The delusion is a sign that in the prepsychotic phase or in the non-psychotic layer contact has been broken off, and the formation of the delusion is the result of the attempt to repair the break with reality.
Unlike Katan, who provided a clinical description. Bion (1957) proposed a dynamic reading of psychotic as well as neurotic functioning: the neurotic part operates according to assimilation, introj ection and discrimination, whereas the psychotic part violently projects in order to eliminate psychic elements that it cannot ‘digest’. Intolerance to frustration, which Bion connected to excessive envy, creates
The psychic withdrawal 59 hatred towards all couple links: mother-child, analyst-patient, parts of the self etc.; attacking the link destroys symbolic language, which is what generates meaning.
I do not share the idea common to several Kleinian authors that the psychotic part is present, albeit only slightly, in normal and neurotic individuals; in my opinion, it is one thing to speak of psychotic functioning in some neurotic patients, but another to speak of clinically psychotic patients. With clinical work in mind, by the psychotic part, I mean a psychopathological structure that distorts psychic reality and produces hallucinations and delusions. If the patient begins analytic treatment after hospitalisation, then the psychotic part has already carried out its task of colonising the healthy part of his personality; when the patient has not had a psychotic break proper, has never been hospitalised or under the care of a psychiatrist, it is more difficult to bring the progressive action of the psychotic part to light. As mentioned earlier, patients frequently conceal their withdrawal into a psychotic world behind apparently good psychic functioning.
I therefore use the term psychotic part differently from Bion, who employed it to refer to that part of the personality where destructive instincts and hatred towards inner and outer reality predominate and which is nourished by an excessive congenital predisposition to aggression and envy. In my opinion, the psychotic part does not derive from destructiveness, but it identifies with that part of the personality that can create a world dissociated from human relational reality. Using the mechanism of psychic withdrawal is, I believe, more helpful in order to describe and understand psychosis and its dynamics.
Returning to the neurotic part-psychotic part contrast, it is not a case of their merely functioning differently, but rather being antagonistic, with one part (the psychotic one) trying to assimilate and colonise the other; opposing ways of experiencing psychic reality alternate between omnipotence of thought and the use of the mind to accept reality and related frustrations. In individuals destined to develop psychosis, there is an unstable balance between the two, the healthy part of the personality being conquered in the end by the psychotic part.
A female patient who suffered a psychotic episode brought this dream to analysis following several months of apparent remission:
I’m driving my car in a narrow street, quite naturally, which surprises me a little. At a certain point, I decide not to follow the road signs any more, and I realize that I'm driving against the traffic coming towards me. This scares me but excites me at the same time. I think that I really need to take some driving lessons but then I decide that I don't and can just keep going like this. In the end, I feel very distressed, lose control of the car and end up in a desertified land, a Martian landscape frill of cactus-like plants. I feel very alone.
This dream may be considered as a portent of the patient’s capture by the psychotic part, represented here as an excited and transgressive state that pushes her to go against road traffic regulations in a mix of fear and excitement. In her mind there is but a vague awareness of being led by a dangerous and transgressive part; in fact, she asks herself whether she needs driving lessons and then decidesthat she does not. The psychotic part takes over and leads her to a desert land where each and every relation with a human being is erased. The psychotic part’s functioning is well represented in this dream and is of great help to the analyst to prevent a new psychotic episode from occurring. As can be seen from the clinical material, it is almost as if in her dream the patient sees her healthy part (driving, which takes the rules of human coexistence into account) as a pointless habit that can be wiped out by the excitement coming from the psychotic part.
In these cases, it is important to describe to the patient the omnipotent, excited and seductive fantasies connected to the psychotic split-off part in order to prevent, within all possible limits, the patient’s healthy part, with which the analyst has established his therapeutic relationship, from being overwhelmed. Not to be lost sight of is the fact that the psychotic part offers the patient no respite. Whereas the neurotic patient is not easily attracted to madness because he fears it, the appeal (often an offer of omnipotence) that the psychosis entices and leads the psychotic patient astray with is what actually dispels his anxiety. Frequently, the therapist is misled by the fact that the patient keeps his inclination for delusion to himself, and he ends up believing the patient’s explicit communication without making any contact with his psychotic aspects at work below the surface. Anxiety emerges too late on, when the patient has already been conquered by the psychosis and at which point he realises that he can no longer leave the situation he himself has created.
The psychotic part of the personality, as mentioned earlier, is an heir of the infantile withdrawal, a place characterised by sensory fantasies that a certain kind of child builds in order to feel that he is the ruler of the world. Much time goes by before the delusion is clinically evident; Freud (1922) advanced this point when he wrote: ‘it may be that the delusions which we regard as new formations when the disease breaks out have already long been in existence’ (p. 227).
To develop the patient’s awareness, the analyst must repeatedly describe the dynamics with which the pathogenic part entices him into the withdrawal, detaching him from his relationships, the analytic relationship included, and offering him the false benefits of a life alternative to that of reality. Clinical experience has led me to think that intrapsychic interpretations, those that describe the dynamics and mutual relationship between the opposing parts of the personality (in particular, the psychotic and the healthy part) are extremely useful for strengthening the patient’s insight. In other words, it is helpful to treat the psychotic withdrawal, which corresponds to the psychotic part of the personality, as a drugging structure that tends to drain away the person’s vitality and sacrifice his emotional growth for the power of sensory pleasure; a bond can thus be established between the patient’s healthy part, which is always in danger of being weakened by the psychotic withdrawal's enticement, and the analyst, whose objective is helping the patient eventually draw a distinction between what is pleasant but destructive for the mind and what is good and constructive.
I have already mentioned that the psychotic patient does not speak openly about his psychotic part’s functioning (rather, he conceals it), in particular the functioning of the delusion structure, which he sees as precious and does not wish to have
The psychic withdrawal 61 questioned by the therapist. Here, we find ourselves facing a typical problem of the psychotic state: that of confusion between the healthy and the sick part. The delusion can offer the patient the delights of a pleasant reality that is sensorially rewarding; it therefore seems not only useful but indispensable, so much so that it needs to be hidden from the therapist.
Even when the delusion structure is similar to a criminal organisation that blackmails the patient, it can be hidden from the therapist. A well-known example is that of Frieda Fromm-Reichmann (1959), whose patient revealed the content of the delusion during a session but the next day refused to see the analyst because she was terrorised by a voice that threatened her with death for having betrayed 'their' secret.
Besides these patients who do not disclose their withdrawal, there are those who do, either at the very beginning of therapy or at a later stage; the patient who does not reveal his delusional ideation to the therapist runs a greater risk of becoming completely dominated by the psychosis. The therapist must therefore intuit its existence and tactfully point out the dangers; otherwise a psychotic break may suddenly appear as if from nowhere, when in fact it was secretly in the pipeline.
I would like to underline that the ease with which a patient allows himself to be seduced is due to the fact that the psychosis presents itself with exciting and salvific features, and this exciting part that avoids suffering at the cost of perverting reality is considered by the psychotic patient to be good and positive; consequently. the part that is ill is seen not as dangerous, but as a source of well-being.
As shall be addressed in the next chapter, in order to bring to light the pathogenic work of the psychotic part, at times we can be helped by dreams.