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A psychoanalytic therapy

I thought at length about whether to present here various other clinical cases or give a detailed account of this one single case, a patient I had in my care for a long time and who, despite an obstinate and dangerous attachment to psychosis, made good progress. In the end, I opted for the latter, as it seemed more suited to conveying progress and regression in long-term psychoanalytic therapy and to showing how important it is not to become discouraged by the many difficult moments. I hope that my account of this analysis allows the clinical material to be connected with the concepts I have sought to discuss in the previous two parts of the book.

Beginning of treatment

When Francesco came to me, he was about thirty years old. He had been abroad doing an in-company master’s programme and while there, had a psychotic breakdown and was hospitalised; once back in Italy, he was under the care of a psychiatrist and took a medium dose of psychotropic drugs for several years from then on. Even before going abroad, where the psychosis exploded, there had been worrying signs. Francesco had gone to the south of Italy for a short holiday, and in the resort he had been staying at, he was afraid of being kidnapped by the local mafia: he had seen clear signs of danger and was sure that a helicopter hovering above was there to kidnap him. His stay became unbearable, so he rang his parents and went back home. This instance was not a cause for worry for Francesco or his family. No one had felt the need to consult a specialist, and so Francesco went abroad to do the master’s programme, but even there he thought he was being followed and monitored by individuals who looked like Italian southerners belonging to the mafia.

I must state here that the very last part of Francesco’s undergraduate studies in Italy had been difficult for him: throughout university, he had been euphoric, was a success with his peers and, having joined a student drama group, was convinced he would become a successful actor. But then, when he finished his studies, he took a downturn, lost his enthusiasm and found himself all alone. He fell into depression for a while; a friend he had had an important bond with started to keep his distance, and Francesco began to worry that he would not find work while he watched his university friends manage to do so. This period of uncertainty saw the euphoria he had felt at university deflate.

Then he received a call from a big multinational company, and he left for Germany, where he began an in-company master’s programme. At this time, he was convinced that a brilliant career lay ahead of him: the breakthroughs he was to make would make him a saviour of mankind in others’ eyes. To prove to himself how great he actually was, he felt he needed to win girls over; on one occasion, a girl, perhaps irritated by his insistence, left a small party he had organised and went away with an Arab peer. The following day, Francesco went to express his objections to this person who had ‘stolen’ his girlfriend. In order to seem more threatening, he took an Italian from Sicily along with him to make the Arab believe he was backed by the mafia.

Sometime later, once he realised that the Arab was no longer at the college, Francesco thought that this person had fled because of the threats, but he also remembered that when he had confronted him, the Arab had not even batted an eyelid and said that the matter concerned the girl and Francesco, and that, if he wanted to try to go out with her, he could do so no problem. This chap’s apparent indifference really seemed threatening to Francesco: during this period of calm, who knows what he was plotting to do?

The delusion proper exploded several weeks later when Francesco, while at a conference in another city, realised that three Arabs were there. Immediately, a conspiracy came to mind: the three Arabs were there to kill him and avenge their fellow countryman. A persecutory delusion proper manifested at this point, with death anxiety to the extent that the organisers of the master’s programme were so concerned that they had Francesco hospitalised. From that moment on, the delusion flourished and invaded every minute of his days. Once back in Italy after this short stay in hospital in Germany, Francesco kept on seeing enemies everywhere; he was sent to a psychiatrist who suggested analytic therapy, and, given that his mother had undergone analysis, this was willingly accepted.

When he came to me, I immediately had the impression that he was in an advanced psychotic state and thought I could not begin an analytic therapy there and then because of his mental condition (he was plainly delusional and hallucinated) and because of the great effort it took him to come to my office. I therefore decided to see him once a week to try to understand what could develop between the two of us and how in that case I could help him.

During his first sessions, Francesco, deeply distressed, gave me an alarming and fragmentary account of his persecutory perceptions. Although I was only trying to listen to him without interfering with what he was saying, I found it extremely difficult to follow his speech but understood that the persecution was expanding right there and then: his enemies were everywhere and were conspiring to make an attempt on his life using every diabolic trick in the book.

For example, he could not go to the coffee bar because he was sure that the waiter would lace his drink with poison; he suspected everything and everyone. The doorman’s wife, bribed by his enemies, could have allowed them to poison the drinking water at his home; mysterious figures would constantly appear in the street to spy on him. He was suspicious of me, too: he would not tell me where he spent his weekends and kept secret the location of the country house Iris father invited him to. Implicit was that I could have given the address to his enemies. I would listen to him carefully, knowing that if I doubted the reality of his delusional experience, I would jeopardise my neutral position, and Francesco would certainly think that I was denying the danger to make his persecutors’ task easier.

I continued to see him once a week; I was interested in how the psychotic breakdown had arisen and in reconstructing it chronologically. In addition to telling me about the delusion, Francesco also told me, albeit quite patchily, about his life -some episodes from his childhood and youth, for instance. I came to learn that before the persecutory delusion that had led to his undergoing therapy, there had been two other alarming episodes. The first was when he had tried to sell his car: the potential buyer, a southerner, seemed strange to him, making offers that did not seem so transparent, and Francesco immediately thought that he was from the Camorra; he was so frightened that he asked his father to see to the sale of the car.

The second, which was more serious, happened, as I have mentioned, in the south of Italy when he had decided to spend a week’s holiday there before leaving to do the master’s programme. As soon as he disembarked from the plane, he saw a chain in the boot of the car belonging to the driver who had come to pick him up at the airport. What was the chain for, if not to immobilise him in order to kidnap him? Suddenly, in his mind, the driver had become a delinquent, and Francesco felt so small, helpless and shaky in his presence. In the resort where he was staying, strange, threatening individuals who frightened him roamed around. His holiday had become so difficult that he hardly ever left his room, and when he risked doing so, he interpreted the staff's kind exchanges as dangerous invitations that he absolutely had to decline. His persecutory terror reached its peak when he saw a helicopter fly over the resort: he immediately thought it was a means of transport sent by the local mafia to kidnap him. It was in fact merely a spectacular means of transport used for a wedding taking place in a nearby town. Terror stricken, Francesco rang his family, described what had happened and was persuaded by them to return home. For many more months to come, even when he was abroad, just the sight of any individual with dark skin and a moustache struck fear into him: he was sure that mafia spies were following him because he had uncovered their secrets, and they therefore had to do away with him.

All these facts were of course narrated in fragments during the first months of therapy, which were filled with his distressing accounts of delusion threats that were clearly everywhere all day long. He circumspectly looked at each and every object around him to identify what hidden danger to his life lay in it. While at his part-time job, he would spend much time trying to understand whether a colleague with a black moustache and piercing look was part of the ‘gang’; he believed that his persecutors had trespassed his property to leave poison there, or, rather, he was quite sure about it as he had found traces of the powder. The patient no longer-lived in reality but was projected onto something that he himself had built outside awareness and which seemed to bear a quality of indisputable reality; it was as if he had projected himself into a film plot where he was the main character, and things could happen such as an ordinary sandwich in a café being wrapped in a toxic paper napkin, put there to poison him.

I then began to see the patient twice a week at his request but still face-to-face. Approximately six months after beginning therapy, during the summer holidays, he took the initiative to go to a tourist resort again, and there his delusion grew out of all proportion. It was clear that Francesco had denied the precariousness of his condition, feeling that he was better and certain that he had overcome the psychotic episode.

I willingly agreed to his request for two sessions per week. I thought that his coming to sessions would allow him to deposit in me the anxiety that constantly tormented him, which was a good thing: Who else could he have spoken to about it in order to have some respite, albeit temporary? And in addition to any apparent improvement, it was useful for me too in order to understand his delusional system: that is, how it formed and persisted. Several months later, Francesco asked if he could come three times a week, and at this point I suggested lying on the couch, which he did without any difficulty; subsequently, we increased the number of sessions to four per week.

During this period, I continued to listen to him carefully; I only gave some meaning to his experiences, to his feeling of terror and above all to the megalo-maniacal, omnipotent and murderous character that his persecutors had. Fear was always present: in one session, he told me that he had had a good English lesson, which had cheered him up, but then a friend had told him that there was a website on the internet where you could see bodies being butchered. The peaceful English lesson was replaced by a secret place full of hatred and mortal danger, and the terrorising and persecutory world was once more set in motion, making him feel in danger. He told me that ever since he was a child, he had been tormented by macabre visions; he remembers he dreamt that he had tried to put back together again a young cousin of his who had been dismembered and chopped up.

After the summer relapse of the first year in analysis, during which he had gone back to being delusional, Francesco would not distance himself from Milan: far away from his home and his analysis, he feared being easy prey to persecutory anxiety when faced with the unfamiliar and the unknown.

Revelations

At times, I was able to describe to Francesco how his persecutory visions consisted of actual revelations of hidden truths. I had realised that Francesco did not use thought but functioned by means of constant, sudden revelations. Things and people around him were not free of preconceived ideas but placed on a set path. Francesco realised that first came his idea of a conspiracy, and then all his perceptions were organised around this original idea: the revelation shaped everything and acted to manipulate his thought that became an anti-thought, a place already saturated with content that expected facts to adapt to his revelation and not vice versa. The delusion perception presented itself as if it were reality, an unquestionable truth that asserted itself through absolute perceptions.

During this same period, when I could, I would underline his transformation of the persecutors into inhuman beings with unimaginable cruelty, a kind of absolute

A psychoanalytic therapy 103 wickedness. It was like an endless struggle between good and bad for Francesco, in which he believed he represented being good, honest and not at all aggressive, whereas others - the persecutors - were greedy, domineering and vindictive. It was significant that his persecutory delusion had been preceded by self-idealisation: in his exaltation during his master’s programme, he had convinced himself that he would have become like Gandhi and eradicated world poverty and inequality.

Francesco’s delusion about the Mafiosi traces the life of the main character in the novel Dream Story by Schnitzler, in which fluctuation between reality and delusional fantasy is described:1 the main character feels persecuted because he goes to a party, discovers that it is an orgy that must be kept secret and fears having seen things he should not have. Francesco, too, had come into contact with a mafia organisation and had ‘seen’ things he should not have. The content of the persecutory delusion had then expanded to include the whole Arab world. From that time on, a narcissistic entity aimed at killing whoever dared challenge it settled in his mind; this grandiose entity, hating whoever threatened its power, was similar to that which could be harboured in an omnipotent child’s mind.

It could stand to reason that the persecutor corresponded to a split-off and projected narcissistic part, which Francesco knew existed, given that he had felt omnipotent in the first stage of the delusional expansion. This kind of interpretation, advanced several times, was, however, unable to halt his tendency to continuously build delusional content.

During sessions, Francesco did not even trust me; on one occasion, I was included in his delusion. It was when, once our session was over, I left the office quickly, and, sitting in a nearby bar, he noted that I was in a hurry. The next day, very hesitantly and visibly distressed, he told me that he had seen me walking quickly and thought that I was going to report him to his persecutors, who were waiting for me in a small nearby shop. Aware of the danger that the analysis might be in, I tried to help him transform the delusion transference, and luckily, I was able to. This circumstance confirmed that the organisation of delusional thought was like a vortex that, with all its swirling might, swallowed up and destroyed everything that came into its orbit. The death threat was omnipresent.

I began to note that the invasion of the delusion happened verbally: words, verbal assonance and contiguity links took the place of things and created connections that endlessly dilated his delusional vision. For example, the father of one of his female friends, who had been to the German city where Francesco had attended his master’s programme and an engineer who worked in the oil industry (Saudi Arabia being a major producer) immediately became potential assassins and were therefore feared and avoided. Identifying his friend’s father with the persecutors occurred via a geographical coincidence and that of the engineer via verbal association (Saudi Arabia-oil). The persecutory black hole attracted and contaminated people and places, who became bearers of terror merely through proximity and verbal assonance.

My speech, too, when not carefully calibrated, met the same fate. One day I said to him that he was like a character doomed to the death penalty, and I quoted a film in which the main character was on death row in the United States, waitingto be executed. He replied that the company that had called him to do the master’s programme, which became included in the persecution when he was hospitalised, had its headquarters in the same region as the prison in that film, which meant that I too was in contact with this company. Naturally, I took advantage of this opportunity to describe his way of connecting facts and news to linguistic links that provided his delusional imagination with a quality of reality: words in place of things.

Another example was an episode in which a girl he had gone out with spoke to him about a friend of hers who lived in Strasbourg, and Francesco then felt that she too was part of the conspiracy, given that the Arab had told him that he had been invited to a party in Strasbourg. Francesco’s thinking functioned by creating contiguous associative links, as in phobic constructions in which the terrifying object contaminates other contiguous objects.

In that period, sessions were full of distressing references to everything that happened to him throughout the day and to how diabolic his enemies were in their constant efforts to devise means of striking him: messages on the internet, waves coming from his computer and conspiratorial dialogues all intertwined in his mind.

The delusion would enlarge every time Francesco undertook a new initiative. He decided to enrol on a postgraduate course, but this decision then began to frighten him: it was as if he felt projected right into the middle of a dangerous conspiracy. The first time he ate in the college canteen, he was in fear of being poisoned; he had to check the pile of paper napkins the waiter was using because he was sure that those destined for him had been poisoned. He then decided to take food with him from home but thought that this would have exposed him even more to his persecutors. I too - his analyst - was capable of reporting this to his enemies. Conversations his fellow students would have seemed full of intentions to kill him. Extremely discouraged and frightened, Francesco decided to drop out. This distressing atmosphere of persecution was attenuated when, back home again, he met people who were his friends; he saw a cousin of his who had come back from abroad, and he was once more able to find a safe haven.

In Francesco’s opinion, the Arab had shown that he was selfish and wicked by wanting to take the girl away from him. Francesco really believed that this person had dropped out of the course because of his alleged threat and also because of the Sicilian’s presence; the Arab was the son of a very wealthy family that had made its fortune in oil, and, since he was unable to bear defeat and had enormous wealth, he had taken bitter revenge. Francesco was really the one who had been unable to tolerate the stinging disappointment at failing to win the girl over; he was so confused by his endless fantasies and the delusion construction that he was unable to understand who had offended whom.

Grandiosity

It became increasingly clearer that the delusion explosion had been prepared by the grandiose mental state which had driven Francesco to clash with megalomania. Aspirations of a brilliant career had led him to cut ties with the meaningful people in his affective life: he had left his home and friends without feeling much regret.

Frustration at not winning the girl over was unbearable as it had occurred at the height of the megalomaniac expansion, and having transformed the rivalry into a clash with omnipotent, vindictive enemies, he had become an angry victim. We may say that his grandiosity was projected onto the rival who, furious about the narcissistic wound caused, was ready to draw on enormous wealth to seek his revenge.

As you may remember, the euphoric excitement at doing the master’s programme came after Francesco’s downturn, when he had not found work and his feeling of being successful was waning fast. Francesco mixed up being great with being grandiose: being great for him meant being superior, as opposed to being able to tolerate frustration and life experience. Francesco remembered that once when he was little, and faced with frustration while at the beach, perhaps due to being told off, he had tried to bury his head in the sand; another time, the only time in his life that he had been smacked (by an uncle - his parents never smacked him), he had beaten his head against a wall for hours afterwards.

What was particular about this therapy was that even though my interpretations on his grandiosity were accepted, the situation did not change: the delusion continued to influence the main aspects of his life, and he was unable to retain the insights gained during his sessions. At times, I was able to make him see how his projecting evil onto his persecutors represented a major falsification; the reason he had seen himself as the victim of his Arab peer was that he had considered the girl as his: that is, a possession that could not be taken away from him. It was a display of his power, success and grandiosity. Even the fact that he had been called by an important multinational company in Germany had represented his merging with an omnipotent object, which then turned into a state of persecution.

The big company was after him now: Francesco was sure that an elegant gentleman he had seen leaving my office was an agent from the multinational company, who had come to spy on him. First, he had identified with the multinational, which represented an omnipotent object; then, however, he understood that the multinational commanded a secret organisation to eliminate all those who strayed. The big multinational did not tolerate frustrations either and felt challenged in its omnipotence.

Delusion projections were everywhere. For example, Francesco was convinced that his university professor (he had been appointed to teach college lab courses), certainly in league with the group of persecutors, had asked him to teach a lesson on his own with the aim of making him get it wrong to humiliate him and triumph over him. He always felt at war with his enemies, like a soldier that had been dispatched to hostile territory, with no protection whatsoever and enemies all around. His mother and aunt, who said it was better for him to continue living at home, were experienced as reassuring and protective figures; had I proposed the benefit of moving out of the family home, I would immediately have been considered someone who was going to expose him to his enemies, with whom I was in cahoots. In one session, he told me about his grandfather dying in a city hospital. I replied, trying to anticipate him, that part of him might have believed that his grandfather had perhaps died not of natural causes but at the hands of his enemies; he firmly denied having thought this, but the next day, he came to his session distraught at the fear of having to go into hospital and dying, just like his grandfather: that is, poisoned. I was amazed at this sudden change of opinion.

He told me that he had gone to renew his expired identity card, and, since the clerk had made him sign various different forms, Francesco thought that he wanted to duplicate the document for illegal purposes and place the blame on him. It was during this period that the aforementioned psychotic transference had developed, and Francesco was terrified by the idea that his persecutors had coaxed me into reporting him through bribes and blackmail. When I asked him why in the world I, his analyst, would report him and hurt him, he replied that anything was possible, and thirst for money could win anyone and everyone over. I replied that that was not how things were: some things were possible, others improbable and others impossible and that everything was possible only in omnipotent thought and in an imaginary world. The omnipotence of thought made him believe that anything whatsoever imaginable to him was actually possible.

I frequently realised, as mentioned earlier, that new persecutory themes could emerge out of simple contiguity or verbal assonance links of everyday occurrences. Psychotic terror was like a black hole that Francesco feared being sucked into by the sheer volume of associative links; he was also convinced that his persecutors acted with no restraint whatsoever, using great means to harm him; for example, the Ar ab was not just any chap, but the son of an extremely wealthy emir who had made his fortune in oil and therefore had the power to do anything he wished. Francesco showed readiness and submissiveness towards the delusion also because of the size of his persecutors, who loomed within him. Anything whatsoever that was unexpected, such as when he had seen me outside my office, unleashed persecution. Once he had gone to a party for young people of his own age, but he saw an elderly person there, and immediately, the persecution exploded. What was that person doing there? Had he come to spy on him? Or an anonymous email was without a doubt sent by his persecutors, or a modest nosebleed was a clear symptom of having been poisoned.

I also analysed his tendency to consider good objects weak and corruptible: he, Francesco, was good and fought pure evil, but he felt threatened by wicked persecutors who were everywhere. The split between good and bad, however, was not invariant: there were rapid changes of what was good and what was bad; even his analyst could become bad.

During this period, which corresponds to the end of the second year of analysis, Francesco spent much of his time at home under the bedcovers because he felt helpless and perceived the world as a jungle full of malicious beings. My impression was that his megalomaniac competitiveness had torn his mental skin, letting the hated world get beneath it, where it could hate and attack him.

Now and again his distrust of me would reappear; if he sensed during a session that I knew something that, in his opinion, he had not told me, he would immediately think that I belonged to the organisation that was persecuting him. Once, when he came to his session and had not seen the previous patient, immediately he went into a panic at the thought that I had reserved a little time in order to get some persecutory ruse ready. During his session, he then made the association

A psychoanalytic therapy 107 that ever since he was little, he had developed profound distrust of his parents; he thought of them as people who did not speak openly to him and secretly kept an eye on him.

I had never seen his parents, to whom I would have liked to speak at the beginning of Francesco’s therapy; I had, instead, met an aunt Francesco got on well with. Only once, when Francesco had a very acute delusional break, did I meet his father, who came with the aforementioned aunt.

Francesco was sure he could pick up on his persecutors’ intentions at a mere glance; with this divinatory skill, he only needed to look at the position of their hands as they spoke to understand what their hidden intentions were, and he would cite books that confirmed that this was possible. From my point of view, the omnipotence he exercised was certainly connected to his childhood, when he categorised people as good or bad without even needing to speak to them.

Francesco was very alone, and complained that no one, not even his old friends, ever contacted him; for this reason, he had decided to organise a party and invite various people, some mere acquaintances. It ended up being a disaster, as Francesco found himself in a conspiratorial ambience organised by the CIA and the KGB. His anxiety was so acute that it prevented him from staying at home (a studio flat he had moved to), and he was forced to flee to his parents’, where he felt more protected from the risk of conspiracies. It was on that occasion that his father and aunt asked to speak to me.

During that period, at the end of the third year of analysis, I was striving to help him think of his anxiety as a subjective problem. I felt that if Francesco understood that his anxiety was created by his mind, he could have tolerated it better, but he would tell me that the danger was there before his very eyes, that it was real and not a product of his mind. He told me that before going to Germany, he had worked in France, where he had met a married woman who had two children. She liked him and would invite him to her home to spend time with her and her children. At a certain point, he began to fear that the woman’s husband, who worked away from home, would have suspected a secret affair between his wife and him and would therefore have tried to kill him. I expect that a colleague, perhaps jokingly, had told him that the woman’s husband had already killed a rival.

Even this short episode followed the same pattern: the persecutor was a male whom Francesco had challenged, either in or outside awareness. This character resembled an overbearing and vindictive father, almost paranoid, and this was also the image that Francesco partially had of his own father: in his opinion, his father dominated his mother, who would bow to his will. He too, following in his father’s footsteps as a child, would make a younger female cousin obey his every command.

The middle period

In the fifth year of analysis, a period began in which insights were more frequent, and Francesco’s childhood experiences could be assessed and the infantile origin of his psychosis reconstructed.

During one session, when he had several minutes of clarity of mind, he plainly saw that his fantasy world had been created through omnipotence; he even sensed that his parents, whom he dearly loved and admired, had been mentally absent, consequently making him feel uncontained from a very young age and letting his imagination wander freely. Thus, he had been unable to learn anything from real experience.

He told me of a meaningful experience he had had in his adolescence: he had wrapped up a notebook on sex in which there were many pornographic images but then was no longer able to find it; he was sure that his parents had found it and confiscated it. but neither of them ever mentioned it in the slightest.

During this same period, Francesco brought a very meaningfill dream. He was at the cinema with his parents and some friends of theirs. During the film he needed to poo, which he did immediately with great pleasure. The adults smelt the odour and complained out loud, and at the end of the film they cleaned the excrement. Not one of them asked him about it or merely said in passing that that sort of thing was not allowed. Francesco connected this dream to the fact that his parents never confronted him but let him live as freely as he wished; for example, as a child, when he spat at his grandfather, he would not be told off by his father, who would just turn it into humour by saying that he would become dehydrated if he kept it up. In the dream, what struck him was that none of the adults commented on him pooing, and he associated this silence with that of the Arab, who had been silent when Francesco objected to what he had done. That silence, and the fact that this person did not look him in the eye, bothered him afterwards to the extent that he feared revenge.

I told him that perhaps his parents’ silence made it impossible for him to understand their emotional states, which might have induced him to develop a tendency to interpret things he did not understand and to imagine them as being threatening. His persecutors plotted against him silently, and it was up to him to interpret what their intentions were. Naturally, this genetic hypothesis, despite Francesco listening to it and taking it into consideration, could not in itself produce any substantial change to his tendency to be delirious. And although he had begun to consider his megalomaniac fantasies with a critical eye, his propensity for delusion, as I shall later illustrate, would not let up: a new delusion would come hard on the heels of those that had preceded it.

My work consisted in making constant comparisons between delusional thought and healthy thought in a bid to differentiate them and strengthen the healthy part of the personality in order to examine the psychotic functioning. Whenever possible, I would re-examine the psychic conditions in which the delusional experience had developed. This was a difficult task because Francesco, as soon as his distress had been overcome, would forget all the connections we had found. Once, while we were working together on his Tittle worm’ (this is what he called his aptitude for reality transformation) and on how it acted inside him, Francesco told me that he realised he tended to forget the work we did together: when he left his sessions, he immediately forgot everything we had analysed.

There were also times when Francesco was free from psychosis. For example, he told me of a film he had seen about some Spanish anti-fascist actors who had gone to work in Nazi Germany during the Spanish State and had been subjected to a series of checks by the German police; he said that he was calm when he left the cinema, relishing his freedom and placing persecution in the past. On that occasion it almost seemed as if Francesco had managed, helped by the film, to reacquire the ability to distinguish between the dream and reality. I drew his attention to the fact that he had recovered his ability to think and to rediscover his identity. At other times, however, films were like powerfill evocative machines that caused him to lose his identity.

He reflected genuinely on the period that had preceded his psychotic explosion and said he understood that his flight into megalomania had been his only expedient to create distance from the pain he felt when he realised he had fallen behind and lost contact with his university friends. It was as though the delusional construction resulted from his fall from the maniacal state; the confrontation with his Arab peer, together with losing the girl, had threatened to throw him back into his previous feeling of failure. It became clear too that his delusional wish to be adored because of his fame corresponded to his wanting to restore the ecstatic state of the little child who was venerated by his parents.

In part, this had been Francesco’s real childhood experience as he had never received the frustrations needed to structure the mind in order to deal with life and its vicissitudes. When frustrations arose, he experienced them as unjust: he was just; his rival was unjust. Gradually we were able to establish continuity between the state of infantile excitement, which was neither modulated nor contained by his parents, and the development of the delusional dream; Francesco admitted that ever since he was small, success had been like a drug to him and that he had sought only to receive continuous gratification from others.

Islands of clarity

At times, some ‘islands of clarity’ would emerge, followed, however, by moments in which Francesco’s insight would vanish. His failure to pay constant attention to the emergence of delusional intuitions meant that they constantly recurred. Being captured by the delusion, which was understood as a force that could change reality, fascinated but then terrorised him. This is well represented in the following dream: He is in a tunnel similar to the ones in the Underground. He is trying to get outside and so has to climb up a long, fanciful flight of steps, similar to those in Mho’s paintings. Once outside, he sees a man who shows him a threatening message; someone from behind sprays liquid all over him, and he is then grabbed by other men who jump on him and start kicking him. The words of the stranger’s message are: ‘These last five minutes will be the worst of your life!’

This dream helped to understand Francesco’s construction of the delusion; his way of constructing persecution can be traced in the manifest content. The delusion preparation is represented by the Joan Miro-like fanciful flight of steps: that is, by the action of fantasy dissociated from reality. Transforming reality, which corresponds to creating new forms as in surrealist painting, is idealised by Francesco.

We worked a lot on this dream which enabled us to understand the difference between revelation and intuition: the former appears as such and asserts itself beyond all doubt; the latter is immediate but is followed by questions and answers that substantiate and confirm it. As represented in the dream, the delusion has two phases: the first is exciting, the second distressing. Francesco had always said that he would hear a click in his head, and when he did, there would be no escape as he would then fall prey to the delusion.

Each time the delusion appeared, Francesco having learnt to speak about it openly by now, I would seize the opportunity to tell him my observations on its construction and on the difficult task of coming out of it. It was a time in his analysis when he would come to his session and tell me about his being delusional the previous day, or he would describe a dream that he defined as psychotic; during the session we would be able to deconstruct the delusion, and the session would end with a sense of relief. However, transforming the delusional experience during the session, which was similar to working through a dream, was not stable, unfortunately: our work brought Francesco relief from anxiety connected to the delusional experience, which would constantly recur, though, because after each session Francesco would end up forgetting all the work we had done together.

The delusion constructions were thus only apparently transformed by the analytic work, remaining etched in his mind, ready to be reactivated. Francesco temporarily rid himself of the delusion, but he was unable to transform it. I understood that the delusion fantasies were not transformable as they were real constructions based on upheaval to perceptions and thought.

Francesco’s persecutory projections were aimed at people unknown to him: strangers and potential enemies, not family members or friends, and no longer at me, given that our bond by this stage had been strengthened; emotional bonds functioned as a barrier against the expansion of the delusion. Francesco’s delusional anxiety had even activated physical illness, ulcerative colitis, which manifested as a loss of mucous and blood in his faeces. In part, he denied the illness, and in part, he attributed it to his persecutors who were poisoning him; it took him quite a while before deciding to go to the doctor, who then prescribed medication. This illness, at times mild, at others severe, lasted for quite some time, disappearing only when the analytic therapy had produced a substantial improvement that brought a reduction in anxiety.

From a certain time on, at the beginning of the sixth year of analysis, I saw that Francesco had begun to reflect more on his own mental processes and was aware of having an alter ego that distorted his real world. The delusional experience no longer had that immediate and automatic quality about it. My function continued to be important though; Francesco would begin to worry at holiday times because he feared being unable to fend off the return of the delusion.

I considered the reappearance of a certain vital aggressiveness as a sign of improvement. The following dream bears witness to this change: There is a ferocious cat that goes into his house and torments him; he grabs it and hurls it from the fourth floor. He feels relieved when he sees it flat on the ground.

During this phase, he had learnt how important it was to be helped to understand one’s emotions, and so he began to write a book on the subject and bring one chapter after another to me. He seemed convinced that he could classify

A psychoanalytic therapy 111 emotions on a single chart, where all the various feelings combined could form others as if they were chemical elements that reacted, generating yet other compounds: that is, other emotions; he also had in mind to form a work group with a female friend of his who was studying psychology and then go around primary schools teaching children how important emotions were. Although I knew his wish was nurtured by omnipotence, I thought that the well-being deriving from it together with the chance to have persecution-free experiences would make it worthwhile. I knew that Francesco was repeating with me in the transference the childhood experience of the adored father he had tried to imitate; I therefore sought to keep this space open so as not to dampen his enthusiasm, kindly commenting on his ideas. In addition, and in spite of the fact that I had tried to make him see the difficulties, he enrolled at university to study psychology in order to then work as a psychologist, but after two years, during which he just barely passed two exams, he dropped out. The line between fantasy and reality was still quite fine, and often grand projects destined to peter out would supplant reality.

Although Francesco’s relational world was improving, his psychotic world was not regressing to the same extent, and many random stimuli could reactivate the delusion. Once he had gone to the theatre to see a play set in the slums of Tokyo, about a depressed alcoholic whose wife was detached and cynical. He felt afflicted by the evilness in the world as this representation had become real; it had lost its imaginative and symbolic quality and become a concrete experience of a frightening reality in which he was the main character.

He had met some girls and arranged to see two of them, one of whom was foreign, but they did not show up; he felt distressed at the rejection and immediately went to the swimming pool where he noted a suspicious individual who had certainly opened his locker; perhaps this person had gone to the two girls to convince them to stand him up. Unforeseen setbacks definitely depended on some persecutor; at the bottom of this belief was the idea that someone was competing with him, envied him and wanted to make him fail.

During the summer of the seventh year of analysis, Francesco had a severe psychotic breakdown during his holiday abroad with the foreign girl mentioned earlier, whom he had started to go out with. The delusion preparation had begun before their departure. What follows is how I was able to reconstruct it after his return to analysis.

Francesco had idealised the relationship with this girl, thinking that they were a perfect couple and wanting their relationship to last forever. The girl, who had come to Italy through work and whose return home was scheduled, wanted to meet people while here who were interesting to her personally and professionally. Before going on their holiday, the girl had been invited to a party and asked Francesco to go with her, which he did unwillingly. During the party, he noticed a man, clearly sexually aroused (Francesco had seen his erection!), who began to chat to the girl. While on holiday, Francesco was convinced that this girl was in a sexualised mental state and that she masturbated and had sex with other men when she got up at night to go to the toilet. Francesco kept this idea to himself until oneevening, while they were having dinner in a little restaurant, it became so clear to him that the waiter, who seemed rather intrusive, had been hired to kill him.

Once back in Italy, he remained in this delusional situation for approximately one month, during which time he refused to see the girl as the delusion had flared up the only time that he had tried to meet her; what had happened was that the girl had suggested listening to a song, and Francesco had taken this as a clear warning of death. The girl, too, worried and disheartened by Francesco’s condition, preferred to keep her distance after this.

While reconstructing this episode, I thought of the euphoria-persecution sequence I had come to recognise: far from his analysis, his improvement and the new relationship turned into a state of mental expansion that made him feel superior and in conflict with other men. Francesco, who had not wanted to go to the party, transformed his feeling of exclusion into a terrible condition of sexual betrayal: he thought of the girl as a sex addict who wanted to rid herself of him with the waiter’s help.

When considering with me the onset of his psychotic episode, Francesco remembered that his girlfriend, before the delusion flared up, had seemed detached and much too interested in going out with her Italian colleagues. A non-psychotic individual in this same condition would have had a dream in which he saw himself being betrayed by his partner.

Francesco, who was unable to ‘dream’, saw the girl sexually aroused and the guy with an erect penis while at the party. In the face of this emotional delusion, he demonised the person who had frustrated him and substituted the concrete reality of the delusion for emotional reality. Had he been able to dream the same scene, he would have understood his emotional state and been able to work through it. In order to do so, though, he would have needed to have an inner emotional space where he was in contact with the complexity of his emotions; instead, he was captured by his need to triumph and had idealised the relationship with this girl, which he turned into a triumph over other men that he then feared being ousted by. In the delusion, the rival appeared with his erect penis (the image of a phallic father) and defeated him with the help of an unreliable girl who wanted him dead.

I mentioned to Francesco that he lacked a mental apparatus that could enable him to tolerate frustration and that he would go from megalomaniac excitement to persecutory anger because of the humiliation he had endured. He replied that, throughout his life, he had always tried to avoid conflict. At university, he was kind and everyone’s friend so as not to be at odds with anyone; after university and after he and his best friend had fallen out, his ascent began towards a state of superiority in a bid to stifle his suffering at the hands of others.

His return to a severe psychotic state made me see firsthand just how fragile and unsteady his apparent improvement had been; it was clear that Francesco could not yet deal with a romantic relationship, given all the doubts and uncertainties that ensued. This short romance turned into a maniacal state that inhibited Francesco’s ability to think and to perceive emotions: Francesco even came to believe that this girl was in Italy to seize his wealth (which was not his but his parents’, who even paid for his analysis), a delusion theme he often had.

Reflecting on the megalomaniacal fantasies, Francesco admitted that they could possibly be unlikely, but he entertained the idea that being megalomaniacal and crazy meant being original; for the first time, he told me that he thought of this mad part as his ‘secret private garden’.

Following that, another romantic bond towards the eighth year of analysis unleashed the same delusional pattern: Francesco began to think that the woman in question, a professional who incidentally earned handsomely, was only interested in his money, was cold and devoid of emotions and was also determined to kill him. Besides Francesco’s tendency towards delusion (this was not an acute episode), other issues made the relationship with this woman quite difficult; Francesco felt very motivated by her on an intellectual level, but he was also very disturbed by her intemperance.

When he decided to split up with her, it seemed as though he had reached a clear and rational level of thinking. During the session in which he had spoken to me about his decision to break off1 the relationship, he had shown no sorrow. But the following day, he told me he had been delusional: they wanted to kill him, and a pain in his groin was his proof. I told him that he had once again plummeted into the cruel, persecutory world because he had wiped out the world of affects so as not to suffer. As an explanation for Francesco’s maniacal inclination, I began to think that perhaps he had suffered great infantile pain and that in order to tackle it, he had become a megalomaniac child withdrawn into a fantasy world. Wiping out the emotional world, which it seemed he had done, had not eliminated the trauma; rather, it had created the preconditions for it.

Sometime later, he told me that he had found out from his aunt that when he was nine months old, his parents had gone away and had left him with someone he did not know; he lived at this person’s home quite some distance from Milan for a fortnight, and when his parents returned from their trip, they found him run down, inappetent, and unable to recognise his mother.

Had he feared dying, abandoned by his parents?

For sure, since then he had never been sad, but quite the contrary: that is, a cheerful, maniacal child. His parents’ behaviour is hard to understand, given that they were very attached to him. The hypothesis I formulated and kept to myself was that this abandonment was due to his mother’s depressive state; perhaps she was too worn out from looking after her son.

His father

I often asked myself whether the delusional threatening figure could somehow be connected to the past or to his father; at times I felt that in childhood Francesco had experienced the paternal figure as threatening and vindictive, perhaps feeling small and helpless and always at risk of being crushed or intruded upon by him. And yet, in his childhood story, it seemed there had been no events to that effect, even though the father had sometimes defeated and humiliated him in his teenage years when he had taken him on at games or sport.

At certain times, it was possible to analyse his pathological identification with a domineering father towards a good, submissive mother. His father had certainly contributed to the construction of Francesco’s infantile megalomania, nurturing his sense of omnipotence through rewarding him and treating him like an adult and turning him into a sort of confidant in the process. Frequently, Francesco would imitate his father, trying to dominate girls younger than him - his young cousin, for instance - just as he had seen his father do with his mother. Moreover, his father, who was unable to understand Francesco’s problems and share in his distress, tended to behave in a way that made the child get mixed up with him. When Francesco the child told his father that he was afraid, his father would reply that he had to behave like a hero, or he would tell him stories in which the main characters defeated evil without ever giving in to fear, encouraging Francesco to be strong since the world was a bad place.

Francesco remembered that when he was little, he had intervened to break up fights between his parents; he would take on the role of an adult who reproached other adults. One evening, for example, after waking up because his parents were fighting, he got out of bed, shouted at them and went back to bed, convinced he had settled their dispute. It is likely that his parents had instead understood that it was better to put their fight off to another time so as not to disturb him. Francesco had not introjected his parents as protective, structuring figures because they really were quite absent psychologically.

Worthy of mention is the fact that Francesco’s episodes of persecution appeared more often when he improved, as though a domineering figure who hated his vitality had lodged in his mind. Francesco’s only solution was to remain passive and submissive, also because he was unable to distinguish between growth and maniacal expansion. I thought that in his eyes personal emancipation was dangerous because it would turn into a competition against an omnipotent and testy father. Clearly, in his delusion he felt threatened by a despotic and arrogant father who considered his growth an attempt to oust him; this threat resulted in Francesco becoming small and helpless and therefore even weaker still when facing his persecutors.

Even at an advanced stage of his analysis, as I shall relate next, Francesco suddenly became afraid at an exhibition where he had sold two of his paintings and had heard references to as well as actual death threats against him. It was as though he thought that when he was successful, he invoked the wrath of the gods, offended by his superciliousness, almost as if he had defied God to dethrone him. It was clear to me that his persecutory ideation strengthened when he achieved success; there was an immediate reactivation of the antagonistic power of a vindictive part that threatened him for his resourcefulness. Once, for example, he had a short fling with a girl, and then, afterwards, he felt dangerously exposed to the rays that came from his computer.

In a dream during this period, a tendency to disown the megalomaniac part began to appear. An important figure offered him the opportunity to be part of a

A psychoanalytic therapy 115 grand trafficking ring in radioactive material. He was afraid to turn the offer down for fear of retaliation, but, in order to overcome his subjection, he decided not to accept, telling this person to find another partner.

Challenging authority had been a constant factor in Francesco’s mental life ever since his childhood, when he would run away from school to defy his teachers and parents; his hyper behaviour, particularly on those occasions when he ran away from school, must have caused his parents concern. Francesco remembered somewhat vaguely that he had been taken to a psychologist.

Later, around the ninth year of analysis, Francesco began to be more aware of his maniacal state. In his dream, he was riding his bicycle and realised that he was doing sixty kilometres per hour. He pedalled even faster and reached seventy, then had to go downhill and went even faster again. At a certain point he saw a traffic light and some cars that were coming from the side; he didn’t want to brake as he was doing something extraordinary. He leaned sideways and rode across the junction frightened that he may fall off and crash to the ground. Francesco’s association was his being able to feel special by manipulating reality; in fact, in the dream, he reached a very high speed because he was pedalling downhill.

In a subsequent dream, excitement and falsification were once again represented:

I was playing pinball and realised that by tipping the machine a little I was able to get higher and higher scores. I was excited because of my success, but above all for being admired by those present. I was winning and could have continued to do so for hours on end.

After these dreams, we were able to connect the state of excitement, obtained through falsification, to his childhood attempts at seducing his mother. Being the eldest out of a whole host of cousins, he would organise contests in which, considering his age, he was sure to win; at times, he would magnanimously concede to sharing the prize with one of the younger ones. When he was young, Francesco was, in fact, idealised by his mother who, even when he was unable to do things because of his psychosis, would continue to sing his praises.

Clearer reflection on the father's personality began in this period when Francesco started to see his limits, his intemperance and his high opinion of himself; now he thought that his father too had a truly narcissistic component that came through in his work and in the family. He was, however, also aware that his father-kept his feet on the ground (his father was a property developer), whereas he would take off with his head in the clouds. When he was little, Francesco had identified with his father and believed himself to be a little genius; for example, he had asked his father to explain binary logic to him, thought he had understood it and boasted about it in class.

During his adolescence, Francesco’s father had become interfering and argumentative, to the extent that Francesco admitted having wished him dead on several occasions; when they played each other at games, for example, his father would systematically beat him and humiliate him to the point of exasperation. His mother, on the other hand, was always very gratifying, but uncritically so, and inone of Francesco’s dreams he captured this flimsiness by making her whirl around in the air without any gravitational pull.

Despite still being conquered by delusional thought, Francesco was developing greater intuitive abilities as well as a new approach to assessing human qualities in people. In a dream, as a journalist, he was covering a running race and watched the fastest with admiration as they ran past the others. He sent a helicopter to collect two women, perhaps his mother and aunt, who were among the last ones. Much to his surprise, he realised that the two women were not interested in competing in the race but only wanted to be in others’ company.

Unlike the dream in which his mother was floating in the air, here he realised that the two women were interested in other human beings, and they most likely also represented his parts that were developing in analysis. This occurred in parallel to his keeping a distance from a competitive, dominant father figure and to his appreciating the maternal figure’s qualities, now seeing her as an intelligent and cultivated woman who was not interested in competing in order to succeed. In the dream, the excited and megalomaniac part - the helicopter that should have taken the two women to the positions out in front - was unable to capture Francesco’s human and relational part.

Thinking the delusion

In this period, it was not uncommon to see Francesco reflecting more deeply on the dynamics of the delusional construction. In his opinion, the delusion was built in two steps: it began with a fantasy, such as when he thought that someone could have pointed a laser device at him to strike him while going down into the Underground; at a certain point, this fantasy left consciousness but was on hand should there be any unforeseen circumstances or ‘anomalous’ events, ready to re-emerge with all the force of the delusion.

The fantasy served as the cast to give shape to the delusional theme, which could appear suddenly because of purely random events. For example, he heard a young man on a tram say to his friend that he had been to the casino with his father: immediately Francesco felt persecuted; he detected, in his revelation, that this person was bad and could commit crime out of his attachment to money.

Thinking about his persecutor, imagined as a furious and murderous individual, Francesco connected this figure to his childhood tantrums at his frustrations. In his opinion, his persecutor was mad in a certain sense, too, believing that Francesco had committed sins even though he had not. Something of this sort had happened in France, when he thought he was being persecuted by the lady’s husband; this man was going to kill him because he was convinced that Francesco had had an affair with his wife.

Francesco believed that betrayal was common practice; the first girls he had briefly gone out with had betrayed him; he had caught them in the act. In fact, as we then reconstructed, Francesco would believe he had seduced a girl when what he had actually done was extort a sort of consent, just to feel more at ease. This is what had happened in Germany with the girl the Arab then ran away with; she had said yes only to appease Francesco’s insisting but then ran off with the Arab guy as soon as she could.

Francesco told me that when he was twenty, he felt fairly happy and peaceful; he played on the computer and saw some friends. Then he looked for love and sexual relations. He was attracted to a female friend of his who told him from the start that she had promiscuous tendencies, and in fact, she betrayed him right from the very beginning of their relationship. Francesco was indifferent to this. He adapted to her ways so as not to lose her and to keep going out with her; clearly, he was proud to be able to say that he had a girlfriend. When she left him, he suffered terribly and began to have relationships without becoming emotionally involved; he was sure that once he became a powerful man, he would have lots of women at his feet.

Once he said that he was struck by a comment I had made that concerned his being unable to defend himself; he was referring to my comments on his behaviour when he had accepted his childhood friend's attacks without reacting, a child he saw at his parents’ insistence. Usually, he would be unable to handle conflicts with vital aggression, getting excited in fantasy instead and ending up feeling empty and fragile. At other times, he would project hate onto the other, who was experienced as an enemy who wanted to harm him, but he was never able to defend himself.

A small event made us see clearly how persecution followed Francesco’s state of excitement. He told me he had spoken to his aunt and uncle, whom he was very close to, and who were having a heated discussion; his aunt, annoyed with her husband, remarked that Francesco, unlike her husband, understood her. He immediately felt a thrill of excitement at this acknowledgement, but then just as immediately, he was afraid that his uncle would be deadly furious with him. On this occasion, too, the same pattern was set in motion: Francesco challenged an omnipotent rival who became a persecutor. This episode certainly draws attention to an oedipal situation and to wanting to take the father’s place; it is a psychotic Oedipus, full of violence and deadly revenge. Francesco did not feel guilty about having eliminated the father (in this case, his uncle) and consciously triumphed over his defeat. The male figure was not, however, transformed into a castrating father but a murderous one. Receiving acknowledgement, in Francesco’s mind, unconsciously equalled gaining the upper hand over a rival that he subsequently felt hated and persecuted by.

Working with Francesco totally convinced me that a persecutory delusion cannot exist without being preceded by megalomania. My impression was that Francesco had experienced his parents not as a couple but as two psychologically separate people. He had certainly been worshipped by his mother, and he returned this by deeply idealising her; he thought of her as his true partner and, despite never having been aware of this, it is likely that he feared his father's resentment. He probably believed that his father thought of him as a brother, not a son, and perhaps this is why he experienced his mother and his father separately, as opposed to one united couple.

Francesco now realised that he had never had the feeling of being treated like a child, but as someone special, worshipped by both parents. He had grown up always believing that he had great creative talent; even during his analysis, he loved painting and was convinced that sooner or later he would become a famous artist, exhibiting his work in the world’s most prestigious art galleries. He was always inclined to overestimate his abilities: once he made ice cream that his girlfriend really liked, and immediately he was sure that he was good at it and could therefore open a successful ice cream shop in Milan. Not considering my observations, it took him almost one week to understand that this kind of project required financial investment and working in conjunction with others. Francesco’s grandiose side would not yield easily; it would doze and then wake up again for other enterprises that were destined to fail or be left unfinished.

Emancipation from the father figure proceeded arduously. In one session, Francesco spoke of a Chinese girl who lived and worked in Milan and sent all her earnings to her parents in China. Comparing himself to her, he felt really guilty: his parents paid for his analysis, his father worked very hard, whereas he still had no job; he was also sorry for the fact that, of late, he had been at variance with his father. I underlined that he had to learn to distinguish love and gratitude towards his father from possible conflicts that might arise along the path of differentiation. At this point, Francesco remembered that when he was a child, he thought he had to be perfect to comply with the wishes of his father, who often made him feel inadequate.

A double reality

At this point in time, now in the tenth year of his analysis, an important stage in Francesco’s life began. He met a girl, Anna, who seemed to have many good qualities. After getting on well for several months, they decided to live together. Anna had a good impact on his life: she motivated him to be more active, pushed him to look for a job and took him out of that cloud that had kept him withdrawn and at home.

‘Free intervals' were longer, and generalised persecutory anxiety had disappeared, allowing him to relate more competently. Francesco began to reconstruct his personality and no longer lost his self-boundaries. After a while, he began to work part time.

Naturally, at a certain point, the relationship with Anna started to be contaminated by the delusional distortion. Francesco became very suspicious and thought that Anna was with him only for his money. When Anna told him she was pregnant, he heard gunshots coming from the street and convinced himself that they were a signal from his persecutors, who were celebrating their triumph. This girl had managed to trick him by getting pregnant in order to take possession of his wealth and would then kill him with the help of her relatives. (He had just seen a film in which the main character was assassinated.) His delusional anxieties aside, Francesco did not want a child and tried everything to persuade Anna to have an abortion; then, since she refused to, they decided the pregnancy should go ahead, and when the child, a boy, was born, Francesco grew fond of him and willingly took care of him.

I would now like to give you a clear picture of this last delusional experience centred on Francesco’s family life, the woman he lives with who bore him a son, and her relatives. I must explain that this woman is Sicilian and has very close ties with her brothers and sisters, who moved to Milan, as she did, a long time ago; the fact is that it is a very close-knit family. Francesco never tried to conceal his difficulty with these in-laws, whom he did not really understand and who made him feel ill at ease; they belonged to a more modest social and cultural environment than his, which prevented him from developing an empathic relationship with them.

Usually, when Francesco found himself in any group context, he expected to be the centre of attention, in tune with the rest of the company so that he could boast about his talents. This expectation came to disappointment, even for socio-cultural reasons, and Anna’s relatives behaved kindly and formally towards him without there being a particularly spontaneous or close exchange; as a result, Francesco felt marginalised from the group. When in their company, he would be passive, trying not to go beyond their cultural and social differences, and therefore social exchanges in order to get to know these people better were minimal.

At a certain point, these mysterious and distant relatives became the characters of a conspiracy against him: they had decided to kill him to seize his ‘wealth’, and what greatly perturbed him was that Anna was in on it. It seemed that, at this point, Francesco was able to live two separate realities, the delusional one and the normal one. This would begin by his healthy part being frightened by the delusion as it burst in, threatening to overwhelm it:

Doctor, it’s frightening. I started to think that Anna had taken sides with her brothers to rob me and knock me off. When I looked at her, the power of the delusion was so strong that I didn't recognise her and no longer felt anything for her.

His conviction that Anna was leading a double life, one that she shared with him and which he enjoyed and another that was secret and diabolical, lasted for quite some time.

Francesco was sure about his partner being involved in the conspiracy: he had caught her giving him a strange smile and once, on the phone, had heard her say that the time had come to do a certain thing. And the previous evening, he had heard his brother-in-law, a great steelworker, tell a nephew behind his back that he was going to buy a new car ‘when... the time was right’. That evening, he had tried to be friendly with them; he had made a great effort to be kind, but then all the scaffolding came away, and the delusional terror shot to the fore.

He admitted to me that he was unable to sleep at nights, that he was afraid of being killed and that he constantly examined his partner’s face, like an entomologist, to understand whether she was a murderess or a caring mother who took good care of her child.

At the height of his anxiety, he asked if he could have a fifth session before the weekend, and I said yes. The Easter break was coming up, and I was worried about him; with one extra session, I hoped to help him get over this distressing situation. I had my serious doubts, though; whereas in the past I had analysed many times the dynamics of the delusion, this time I felt I was without any means to help him.

Besides the terror that was overwhelming Francesco and the unpleasant surprise that it was for me, the delusion bore its usual recurring pattern: one or more figures, unfriendly and male, whom he experienced as powerful, could do whatever they wanted to him. This time it was the girl’s family’s turn: Sicilians, so closely knit as to form a true clan, in which, to Francesco’s dismay, there were some very powerful people (a lawyer and a coroner!). Given Francesco’s inability to distinguish delusional perceptions from real ones, while I listened to him, I asked myself which criterion I could use to help him tell the difference. After giving it some thought, I made this comment: In his delusional world, there were no emotional bonds that held people together, and life was a jungle governed by power and greed. (That was how he portrayed his persecutors.) Without an emotional bond that can keep people together, I said to him, thoughts, no longer contained in a human dimension, became unmanageable, like wild horses; the real world, however, unlike the delusional world, was full of solidarity and emotions. I told him that when he spoke of his partner as someone who took care of their child, he had in mind a real emotional world, but he would then create another delusional world in which she became inhuman, a murderess who was thirsty for money; I added that there was a constant passing from one world to another so that two opposite and incompatible perceptions existed together (the good mother and the killer partner). The difference between the real human world and the delusional inhuman world may have served to help him distinguish between delusion and reality. I shall not go into whether Francesco used this attempt of mine to distinguish between the delusion and reality, but in the following session, he told me that he did not go to the bed where he had been sleeping alone but returned that night to his partner’s side and that of his child to feel some human warmth.

In the following sessions, I took up the point I had always considered important: the simultaneous existence of two incompatible realities. On other occasions of delusion, I had insisted upon this point with Francesco, but I now went back to it with greater firmness. During these sessions, Francesco said he realised he had a bi-ocular vision of reality. I noted that he expressed himself with great precision: he did not say binocular but had used the term bi-ocular to signify that his vision lacked integration, and thus the two visions, delusional and real, remained distinct and separate. Both, however, retained the same sensorial quality of reality.

We worked together to bring out the steps in the delusion construction process: usually Francesco would be disoriented when he was with people who were different from him, and this made him experience them as dangerous. In the case of his Sicilian relatives, there was a real difference in their histories, habits and mentality, but there was also something else: before the delusion exploded, Francesco, outside awareness, had disparaged his partner’s relatives, who then became the persecutors. With an attitude of narcissistic superiority, he had judged them as being inferior and envious and therefore well placed to relieve him of his

A psychoanalytic therapy 121 privileged position. A constant feature in the delusional construction was that, in a world dominated by evil people, there were no institutions for protection and justice or for defending the weak against oppression by the violent; in his emotional world, he could not find a parental regulating function, an absence that brought to mind the psychological and emotional absence of his parents, who had left him over a long period in his omnipotent infantile withdrawal.

Many times in the past, I had been able to reconstruct the course of the delusion and recognise its constituent parts, but at this point, I realised that my work had not removed its readiness to recur; it was as if it had left an indelible trace that would form again and again. Instead of being erased, the delusion was encysted and coexisted with normal mental functioning. When it returned, Francesco was unable to sleep because of the terror he felt; death anxiety was so overwhelming that, as you may remember, he became ill with ulcerative colitis. His illness was most likely a psychosomatic consequence of his terror, and when Francesco improved, his illness eased and then cleared up completely.

I felt that during these sessions, Francesco was fighting the power of the delusion with more resolve. He would say to me that when he was with me, he would be aware that it was something ‘invented in his mind’, but then, as soon as he left, the power of the psychosis would influence him again, making him believe in the reality of the persecution. The voice of the delusion would convince him that his vision was superior to mine - it was sharper than others’ vision. And this same voice at times would suggest that I, his analyst, wanted to demolish his conviction because I had taken sides with his enemies to make it easier to kill him.

Several weeks later Francesco skipped a session, something quite rare for him, and the following session he apologised for not coming and said he had really forgotten to come. I pointed out that this was very unusual since the times of the sessions had always been the same over the years, but he was unable to explain why he had forgotten; then, however, he remembered that that day he was so busy doing a job that the rest of the world, his analyst included, had vanished from his mind. He said that this self-isolation was very similar to the way in which the delusion was created: in these conditions, his mind functioned in a monotasking not a multitasking mode (his words); it was as if mental space shrank and he found himself shut in a ‘mono-space’ mind, where all communication with the outside world and with himself disappeared. When he was delirious, he was unable to launch other thoughts in his mind, and precisely because of his being so self-absorbed, the delusional thoughts recurred endlessly. In other words, it was as if the delusion were like a maelstrom that sucked in all other mental activity, nullifying it.

Never before had Francesco seemed so interested in unlocking the mystery of his delusional transformation; in every session he would take up the theme of the delusion without dropping the subject. I felt that this time he really wanted to rid himself of the seduction and colonisation of the psychotic part for good. He was determined to work hard in his analysis until he gained more awareness of the mechanisms, both internal and external, that gave rise to the delusion and which were an intrinsic part of his personality that needed to be transformed.

In the meantime, he had become better at speaking to and cooperating with his parents; he helped his mother manage their real estate, and, when he could, he assisted his father. He brought this dream: He was in a car with the foreign girl (the one he had had the psychotic episode over). He was driving, and after a while he wanted to park the car but realised that the girl’s mind was elsewhere, and she didn’t give him any help. It seems that, in this dream fragment, Francesco recovered his ability to see what he had not seen before the onset of his delusion: that is, his partner’s emotional distance. At this point, Francesco was able to distinguish his ‘true’ dreams from his ‘psychotic’ dreams, which expressed delusional themes.

Once he said to me that he had been able to go against being colonised by delusional ideas about several strangers in a bar, normally a typical sign of a conspiracy against him. This was very important because Francesco was now beginning to differentiate between healthy thoughts and mad thoughts. During childhood, he had been unable to do this, given that, in his opinion, he had been allowed to do and think anything; his mother did everything he asked her to without ever saying no and without understanding that he had already been captured by a withdrawal of grandeur. It seems that the mother’s mental absence and obligingness, together with paternal grandiosity, had played a significant role in the development of Francesco’s infantile megalomania.

He dreamt that he had to get married in a castle that belonged to the family of a friend, but he realised that his parents were absent and he got angry. Francesco commented that, for the first time in a dream, he had been angry with his parents. Although the dream contained the grandeur of the castle and no bride, the patient’s emotional reaction towards his parents’ absence was significant.

Yet another important transformational feature appeared in a dream in which he was able to distance himself from his mad part. He is in a group of people, tied with an elastic band to a kind of carousel that projects them into a space where you can perform any kind of acrobatic move. At a certain point, the elastic snaps, and a girl falls to the ground. The group, himself included, hesitate at length over whether they should keep whirling, and he talks about this to the owner of the ride, who is trying to persuade them to continue. The fraudulent portrayal of the ride’s owner is evident here, representing the exciting psychotic part that wants the wild display to go on. His association was his having been an omniscient child, a little dictator who thought he knew everything and believed that the world should revolve around his wishes.

In this period, he began to have clearly transferential dreams: He came to his session, and I asked him whether he could have his session with some girls. He said yes but was not terribly convinced about the whole thing; the girls spoke to each other about schoolwork and after-school tutoring. The session was held outdoors, and at the end, the girls thanked him and even wanted to pay him. Represented in the dream is a parent who had no specific place for him or for girls his age. His mother had actually been a teacher; therefore, I imagined that her son could have seen her working with other boys and girls. In the dream, Francesco is unable to communicate his displeasure at having to share his space with the others.

In another dream, I (the analyst) was with him and his female cousin. I caressed and cuddled him while slides with the writing ’I love you' were being projected. Francesco said to me that he was a little disconcerted or, rather, surprised by the affection between us. Apart from the current of love and gratitude that Francesco was beginning to feel towards me, the dream highlighted once more that privileged affection he had always had for his mother.

In two subsequent sessions, he brought dreams that referred once more to his parents. In the first, his father had organised a big party, but in the wings of the house, several guests were making a mess, spitting on the ground and flicking ash on the floor. He was angry and argued with them. In the dream, Francesco was describing a father who was unable to judge or set out rules, thus favouring his son’s excited and aggressive parts.

In the second dream, Francesco was masturbating outdoors while looking at pornographic magazines. His mother passed by and saw him, said hello and apologised for her interference. In the dream, he felt anger at the fact that his mother looked the other way and did not reproach him.

In this period, hints of the delusion were still there, but discreetly, like passing clouds. For example, once Francesco told me that while he was speaking to his mother on the phone about his father going into hospital, he heard some interference on the telephone line and thought that it was a delinquent listening in to obtain information so as to kill his father. A girl from his gym he had given his telephone number to had not come back to the gym, and perhaps she had given his number to his enemies.

The problem remained of understanding how the delusion exerted power on his mind despite our efforts. In one session, Francesco said there was a sort of threshold functioning: he explained that, as with neurons, firing was all or nothing. The delusion was triggered when this threshold was crossed, and he could no longer do anything to stop it; he could not use his reasoning to turn back. It was not like a dream that you wake up from and understand that it is virtual reality.

I agreed with him but thought that what caused this threshold to be crossed was his tendency to suspend his attention and become passive; then, when the delusion burst in, he would lose all contact with reality. I reminded him of the two realities in which he still lived: that of the relational world and that of the fantasy world, the latter just as real as the former in his eyes. The threshold was crossed when the fantasy world replaced the real world; he would then lose all relational ties and find himself in a world populated only by persecutors. Francesco continued to say that he was not aware of passing from one mental state to another; this very lack of discrimination was at the root of the delusional transformation in his mind. When I reminded him that ever since he was a young child, he had built a virtual reality that he could withdraw to, he specified that, early on, he had confined himself to touching up existing reality, and only later did he end up inventing it completely.

Francesco was pessimistic about life and people: his apparent trust and friendliness towards the other could quickly change into the reverse: that is, into an experience that bordered on or paved the way for the delusion. He had taken up again one of his hobbies, painting, and went to a former close friend of his from his youth in order to buy a good deal of material. After this, he began to suspect that his friend had charged him more than he ought to have, and so he checked some prices on the internet. Having confirmed his suspicion, his trust in the world was shattered; everybody was a crook, untrustworthy and evil, and he immediately felt shrouded in the persecutory atmosphere by now familiar to him. In this case, the delusion originated in his loss of trust in his friend and in the world, and a sort of black atmosphere then invaded his whole environment.

It was clear just how difficult it was for him to understand others' intentions and behaviour. Francesco was so sure of his mental organisation that, when reality did not match his schematic expectations, he plunged into confusion and paranoia; when he misjudged people, he immediately felt disoriented and invaded by catastrophic anxiety; at this point, he would demonise reality, and people would seem bad and hostile towards him. Similarly, he would deny suffering from ulcerative colitis, and, when his symptoms recurred, he would come to the usual conclusion that he had been poisoned. The past did not provide him with information in order to understand the present: hence, his inability to learn from experience.

In the last years of analysis, now in the twelfth year, besides working on delusional falsifications, Francesco was committed to building his identity. He dreamt he had to climb Mount Everest, which, however, seemed tamer that it actually was. A female friend of his suggested he take a helicopter. Once at the top, he found some coins left by people who had been there before him. He took lots of them, but then at a certain point, he wondered whether it was right to appropriate money belonging to others. It is clear that in the dream, alongside the symbols of grandeur, such as Mount Everest and the helicopter, there is a genuine wish to better define his personal value and give up the personality ‘theft’ he was so used to. We may recall that he would imitate his father when he was young, and in analysis, he had wanted to become a renowned psychologist to imitate me.

During the last period of his analysis, caring for his son had enriched Francesco’s affective world and distanced him from new delusional productions. His days were now busy as he would get up early in the morning and help Anna take care of their child. He would often look at his child and think about how different his own childhood had been from his son’s. I felt he had treasured the analytic work on his childhood experience and that he wanted to be an affectionate and present father, who could positively contribute to his child's growth and development. His son rewarded him with affection and the fact that he was growing up well. In both his family and his working life, Francesco had made steady progress: he had acquired a greater sense of responsibility and a deeper understanding of others and was no longer interested in megalomaniacal initiatives, which would certainly have ended in failure.

Francesco often drew and painted, a hobby he had pursued since childhood and which he had kept up during his analysis; he had also enrolled at art school but left without a qualification. He no longer felt special, though, believing that someday he would become a great artist, the grandeur of his ideation having significantly lessened.

To demonstrate how the underlying delusional structure could still reawaken, I would like to mention the following episode. Francesco had managed to have some of his paintings exhibited and to sell two of them. It was the first time this sort of thing had happened, so he ought to have been happy about it; instead, after the sale of the two paintings, the surrounding environment became threatening, and he heard a conversation that two women were having, which, in his mind, certainly alluded to a death threat. I was struck by the fact that even after many years of work, Francesco could still plunge into a delusional atmosphere. But then again, as stated previously, each time Francesco improved, persecutory threats were unleashed as if some envious demonic being were hostile towards his achievement. This time, Francesco’s fear had been that of having unveiled some secret through his paintings or of having challenged someone’s reputation, thereby deserving to be punished. Clearly, he felt like a little David who had challenged a gigantic Goliath. I did not understand why this dangerous dynamic of provoking a powerful rival who then persecuted him had reoccurred.

It seemed that Francesco mixed up legitimate success and megalomaniacal triumphs (which triggered the persecutory response); that is, he mistook what was permitted for what was transgressive. Once again, I realised that I needed to explore in greater depth this area of Francesco’s mind; I needed to frilly prepare for ploughing land that I was under the impression had been cleared but which was still rocky underneath.

I carried out this work methodically, re-examining all the most significant past delusional episodes. Francesco, while this work was carried on and the past and present compared, continued to be struck by how childishly he presented himself in the world and by his megalomaniac constructions and use of words as revelations about imaginary and delusional worlds.

Two dreams seemed further progress towards freedom from his grandiose false-self personality. In the first dream, they are interviewing him about art. While he is speaking to the journalist, he wonders whether or not he should admit that his knowledge of modem artists is limited. During the dream, he decides to be himself and admit his weak point. When commenting on the dream, Francesco added that he had always falsified who he really was in order to seem perfect in others’ eyes.

In the second dream, the analyst is speaking constantly and intensely to him because the end of his analysis is approaching, as if he were trying to fill him with advice now that life would have to be faced alone.

In fact, the preparatory work for the end of the analysis lasted a further two years. (Francesco finished Iris therapy in the fifteenth year.) The content of sessions was now more centred on everyday life; this constant connection to real life made me think that the danger of his returning to psychosis had passed. Common topics were the relationship with his partner and his parents, inevitable conflicts with them, his son’s upbringing and the need to renew friendships that had been wrecked during the many years of his psychotic state.

These last two years saw Francesco constantly thinking back over his past in search of meaningful connections between his childhood, so full of triumph and pathological identifications with his parents, and the development in adulthood of the delusion and persecutory megalomania. One important aspect of re-elaboration was understanding better what the psychic premises were that had determined the onset of the delusional experience. Helpful to us was his reaction of anger and hatred deriving from disappointment that his much beloved aunt had caused.

Francesco understood that his violent reaction to emotional frustration was one of the factors that pushed him towards the delusion. When this happened - after graduating and when he lost his best friend, for instance - violent anger that led him to hate the world would be unleashed; then the feeling would come over him of being totally alone against everyone, at the mercy of others, leaving him pervious to the persecutory experience.2

Francesco returned many times to the past to understand what had made him feel persecuted by his partner's southern relatives. It seemed that he had found it difficult to integrate their good and their frustrating parts; in other words, he had been unable to hold inside the idea that people are human beings with specific limits and not diabolic objects. Significant work that Francesco did was comparing subsequent delusions in order to identify the roots and constants of his delusional constructions.

An important acquisition was his acknowledging the psychotic operation as a two-stage process that was initially pleasant but then distressing.

Francesco was always wanting in the capacity to foresee the negative effects of psychotic transformation, which explains why the psychotic crisis, once overcome, never seemed to worry him; he was oblivious to it, neither mentioning it nor discussing it with me. As I have frequently underlined, after the psychotic experience had been overcome thanks to analytic work, it was as if it were ‘forgotten’ or, rather, set ‘aside’ somewhere in the mind, in a sort of implicit memory that made the content inaccessible and therefore unusable.

During a session in the last part of his analysis, Francesco spoke to me about a further delusional crisis. He told me that while leaving his session the previous day, he had seen a big car outside that was there for him: in fact, it left as soon as he detected it. Then he went to the swimming pool and after a while saw two women having a lively chat with one another. He was sure they were criticising him and referring to the fact that he had gone to the pool just to look at girls. A man there was wearing a T-shirt with an eye inscribed in a triangle: for Francesco, this carried disquieting but clear overtones.

I was really dispirited during that session, having had to note that once again Francesco had ‘relapsed’ into psychosis. I just said to him, without being too convinced, that since he had told me that those were his days off, perhaps a holiday meant an absence of thought, losing touch with himself and being taken back once more to an alien world.

The following day, Francesco took me by complete surprise with his unexpected ability to process what had happened. He said he realised that for him, having almost reached middle age and having a son, going to the swimming pool to eye up girls was absurd, but this was not the point. Going to the swimming pool meant looking for mental excitement, the swimming pool therefore representing

A psychoanalytic therapy 127 the land of milk and honey, built, however, in opposition to the world of relations. That day, he had been invited by a group of friends to spend the afternoon with them, but he turned the invitation down, seeing the pool as an alternative and superior world of pleasure. He remembered that he had done the exact same thing during his first analytic holidays when he had been very ill; he had gone back to being delusional and then decided to ask me for two sessions. On that occasion, he had turned down a sailing holiday with some friends as he wanted to go to a tourist resort by himself to look for girls, and when there he relapsed into delusion.

He told me that in the past I had repeated to him many times over that the persecution delusion followed his maniacal excited state; on this occasion, however, he was convinced that this concept had come to his mind without me telling him. He had listened to me on those previous occasions, acknowledged what I had said, but nothing stayed with him. Only then did he realise that his creating a world of excited pleasure was to wipe out all human relations, and he understood that the result following this operation was catastrophic.

This step was very important because it meant that Francesco could finally understand the nature of psychotic excitement and its aftereffect. Not until he was able to visualise psychotic development as a two-stage event (exciting and persecutory) that was the product of one and the same mental state could he manage to contain the delusion. In fact, he had told me many times that he found it difficult to catch the initial aspects of the psychotic transformation in time to defend himself from it. After this session, Francesco’s perception of the insidiously dangerous nature of that mental excitement was sharpened, and he began to control it and escape its power.

Prior to the persecution delusion, Francesco had had an individualistic vision of the world and a narcissistic-grandiose projection of the Self. Ever since he was a child, he had felt superior to others, seduced by maternal appreciation and paternal licence, and had seen his peers as rivals. The good-bad, friend-foe divide stemmed from here.

His deep conviction of rivalry that pits men against one another and can even lead to their wishing the other dead nurtured his persecution delusion. Always lacking in him was the idea of basic brotherhood that ties people together beyond conflict. In people, destructive envy prevailed, even when there were affective ties or common interests, as had been clear to him from the delusional experience that included his partner, who had borne him a son. In a continuous antagonistic confrontation, even success, such as when he sold two of his paintings at the exhibition, meant stirring up others' hatred and greed.

Simultaneously to his general improvement, in this period Francesco began to conduct what I refer to as the deconstruction of the delusion. Not only did he think back to his great past delusional constructions, identifying the single constituent parts, but, by being able to foresee their nature, he also managed to halt even the slightest delusional or interpretative cues. He made a distinction between delusional component and delusional process. The delusional component is a thought, a suspicion or a fantasy that appears in his mind by itself and which is not yet a delusion. If he does not capture its psychotic nature, this delusion componentbroadens and merges with other psychic constructions to produce a psychotic process proper. It is therefore important to understand the nature of the delusional component immediately in order to deprive it of its power, given the danger it poses.

At times, it was possible to understand in vivo, moment by moment, how the delusional transformation occurred, in that a mental transition which seemed absent or not consciously registered was rendered representable.

The following example can illustrate this.

During a session after a weekend break, Francesco told me that he and his son had been invited to a party by his son’s classmate’s mother. It was at a nice house with a swimming pool; Francesco chatted to the host for a while and discovered that she was a psychologist. While speaking to her, he thought she seemed a very insecure and anxious mother. His curiosity was aroused by the fact that she worked at a school, and so he asked if he could listen to some rap music that this psychologist’s young students were keen on. After a while, the repetitive and relentless music began to bore and annoy him; he did not ask to stop it and passively took it in. At a certain point, he perceived that the lyrics threateningly referred to him. Here, I said to Francesco that the delusion transformation had been facilitated by his passiveness as well as his submitting to the context, which he had been unable to change. I added that on other occasions, too (and reminded him of a few), he had tolerated situations imposed by others in which he had not adopted an active mental attitude, and from there, a delusion then developed. I believe that this passive state of mind, which many psychotic individuals have, can trigger a delusion when others' wishes are felt as being dangerously invasive and persecutory. On that occasion, Francesco wiped out his emotional intuition that up until that moment had enabled him to understand this lady’s personality; without this intuition his persecutory delusional ideation was nourished yet again.

Particular to this therapy was the patient's recurring delusional experiences, as constant relapses, I believe, are not the norm for all psychotic patients. Once, when I asked Francesco why he thought his being delusional recurred so frequently, he said that he felt like a river whose banks had burst, entirely flooding adjacent plains. Thanks to therapy, the riverbanks had been rebuilt, but channels that had opened up during the overflow remained, and now and again, water would spill out. Francesco also added that he had clearly been withdrawn for too long in his grandiose fantasy world during childhood and adolescence and that his overflows of thoughts ended up just being out of habit.

I think this is true and that the duration and recurrence of various psychotic forms may differ according to the expansion and duration of the infantile withdrawal; the deeper and lengthier the withdrawal, the more conditions favouring psychic modifications will be created, which in turn will facilitate reality alteration and the production of delusional experiences.

Despite Francesco's delusional tendencies not having been curbed completely, it set my mind at rest to see him grow as a free person, no longer seduced by the anxiety and megalomania of the past. His healthy part had developed progressively, and he had acquired sufficient ability to train himself to reflect on and

A psychoanalytic therapy 129 examine what occurred in his mind. In one session during the last part of his analysis, he told me that before falling ill, he had understood nothing about others because his only purpose had been to make himself liked; he had been unable to consider others or understand what they were like. Now he felt able to do so and to learn from experience.

Notes

  • 1 This subject matter was transposed to Kubrick’s film Eyes Wide Shut.
  • 2 In my book Vulnerability to Psychosis (p. 108), I have described the case of a psychotic patient, who, when he felt sad and isolated, would make violence and hatred against the world grow inside him. The peak of his hatred coincided with the collapse of his psychic border, resulting in the production of perceptual holes through which aggressive hallucinatory people who terrorised him came in.
 
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