The Psychotic Wavelength

The Psychotic Wavelength provides a psychoanalytical framework for

clinicians to use in everyday general psychiatric practice and discusses
how psychoanalytic ideas can be of great value when used in the treat-
ment of seriously disturbed and disturbing psychiatric patients with
psychoses, including both schizophrenia and the affective disorders.
In this book Richard Lucas suggests that when clinicians are faced
with psychotic patients, the primary concern should be to make sense
of what is happening during their breakdown. He refers to this as
tuning into the psychotic wavelength, a process that allows clinicians
to distinguish between, and appropriately address, the psychotic and
non-psychotic parts of the personality. He argues that if clinicians can
find and identify the psychotic wavelength, they can more effectively
help the patient to come to terms with the realities of living with a
psychotic disorder.
Divided into five parts and illustrated throughout with illuminat-
ing clinical vignettes, case examples and theoretical and clinical
discussions, this book covers:

• the case for a psychoanalytical perspective on psychosis

• a historical overview of psychoanalytical theories for psychosis
• clinical evidence supporting the concept of a psychotic wavelength
• the psychotic wavelength in affective disorders
• implications for management and education.

The Psychotic Wavelength is an essential resource for anyone working

with disturbed psychiatric patients. It will be of particular interest to
junior psychiatrists and nursing staff and will be invaluable in helping
to maintain treatment aims and staff morale. It will also be useful for
more experienced psychiatrists and psychoanalysts.

Richard Lucas was a consultant psychiatrist at St Ann’s Hospital,

London. He was also a fellow at the Royal College of Psychiatrists
and a member of the British Psychoanalytical Society. In 2003 he
received an OBE for his services. This is his only book.
THE NEW LIBRARY OF PSYCHOANALYSIS
General Editor Dana Birksted-Breen

The New Library of Psychoanalysis was launched in 1987 in associ-

ation with the Institute of Psychoanalysis, London. It took over from
the International Psychoanalytical Library which published many of
the early translations of the works of Freud and the writings of
most of the leading British and Continental psychoanalysts.
The purpose of the New Library of Psychoanalysis is to facilitate a
greater and more widespread appreciation of psychoanalysis and to
provide a forum for increasing mutual understanding between psy-
choanalysts and those working in other disciplines such as the social
sciences, medicine, philosophy, history, linguistics, literature and the
arts. It aims to represent different trends both in British psychoanalysis
and in psychoanalysis generally. The New Library of Psychoanalysis is
well placed to make available to the English-speaking world psycho-
analytic writings from other European countries and to increase the
interchange of ideas between British and American psychoanalysts.
The Institute, together with the British Psychoanalytical Society,
runs a low-fee psychoanalytic clinic, organises lectures and scientific
events concerned with psychoanalysis and publishes the International
Journal of Psychoanalysis. It also runs the only UK training course in
psychoanalysis which leads to membership of the International Psy-
choanalytical Association – the body which preserves internationally
agreed standards of training, of professional entry, and of professional
ethics and practice for psychoanalysis as initiated and developed
by Sigmund Freud. Distinguished members of the Institute have
included Michael Balint, Wilfred Bion, Ronald Fairbairn, Anna
Freud, Ernest Jones, Melanie Klein, John Rickman and Donald
Winnicott.
Previous General Editors include David Tuckett, Elizabeth Spillius
and Susan Budd. Previous and current Members of the Advisory
Board include Christopher Bollas, Ronald Britton, Catalina Bron-
stein, Donald Campbell, Sara Flanders, Stephen Grosz, John Keene,
Eglé Laufer, Juliet Mitchell, Michael Parsons, Rosine Jozef Perelberg,
David Taylor and Mary Target, Richard Rusbridger, and Alessandra
Lemma, who is Assistant Editor.
ALSO IN THIS SERIES

Impasse and Interpretation Herbert Rosenfeld

Psychoanalysis and Discourse Patrick Mahony
The Suppressed Madness of Sane Men Marion Milner
The Riddle of Freud Estelle Roith
Thinking, Feeling, and Being Ignacio Matte-Blanco
The Theatre of the Dream Salomon Resnik
Melanie Klein Today: Volume 1, Mainly Theory Edited by Elizabeth
Bott Spillius
Melanie Klein Today: Volume 2, Mainly Practice Edited by Elizabeth
Bott Spillius
Psychic Equilibrium and Psychic Change: Selected Papers of Betty Joseph
Edited by Michael Feldman and Elizabeth Bott Spillius
About Children and Children-No-Longer: Collected Papers 1942–80
Paula Heimann. Edited by Margret Tonnesmann
The Freud–Klein Controversies 1941–45 Edited by Pearl King and
Riccardo Steiner
Dream, Phantasy and Art Hanna Segal
Psychic Experience and Problems of Technique Harold Stewart
Clinical Lectures on Klein and Bion Edited by Robin Anderson
From Fetus to Child Alessandra Piontelli
A Psychoanalytic Theory of Infantile Experience: Conceptual and Clinical
Reflections E. Gaddini. Edited by Adam Limentani
The Dream Discourse Today Edited and introduced by Sara Flanders
The Gender Conundrum: Contemporary Psychoanalytic Perspectives on
Feminitity and Masculinity Edited and introduced by Dana Breen
Psychic Retreats John Steiner
The Taming of Solitude: Separation Anxiety in Psychoanalysis Jean-Michel
Quinodoz
Unconscious Logic: An Introduction to Matte-Blanco’s Bi-logic and its Uses
Eric Rayner
Understanding Mental Objects Meir Perlow
Life, Sex and Death: Selected Writings of William Gillespie Edited and
introduced by Michael Sinason
What Do Psychoanalysts Want?: The Problem of Aims in Psychoanalytic
Therapy Joseph Sandler and Anna Ursula Dreher
Michael Balint: Object Relations, Pure and Applied Harold Stewart
Hope: A Shield in the Economy of Borderline States Anna Potamianou
Psychoanalysis, Literature and War: Papers 1972–1995 Hanna Segal
Emotional Vertigo: Between Anxiety and Pleasure Danielle Quinodoz
Early Freud and Late Freud Ilse Grubrich-Simitis
A History of Child Psychoanalysis Claudine and Pierre Geissmann
Belief and Imagination: Explorations in Psychoanalysis Ronald Britton
A Mind of One’s Own: A Kleinian View of Self and Object Robert
A. Caper
Psychoanalytic Understanding of Violence and Suicide Edited by Rosine
Jozef Perelberg
On Bearing Unbearable States of Mind Ruth Riesenberg-Malcolm
Psychoanalysis on the Move: The Work of Joseph Sandler Edited by
Peter Fonagy, Arnold M. Cooper and Robert S. Wallerstein
The Dead Mother: The Work of André Green Edited by Gregorio Kohon
The Fabric of Affect in the Psychoanalytic Discourse André Green
The Bi-Personal Field: Experiences of Child Analysis Antonino Ferro
The Dove that Returns, the Dove that Vanishes: Paradox and Creativity in
Psychoanalysis Michael Parsons
Ordinary People, Extra-ordinary Protections: A Post-Kleinian Approach
to the Treatment of Primitive Mental States Judith Mitrani
The Violence of Interpretation: From Pictogram to Statement Piera
Aulagnier
The Importance of Fathers: A Psychoanalytic Re-Evaluation Judith Trowell
and Alicia Etchegoyen
Dreams That Turn Over a Page: Paradoxical Dreams in Psychoanalysis
Jean-Michel Quinodoz
The Couch and the Silver Screen: Psychoanalytic Reflections on European
Cinema Edited and introduced by Andrea Sabbadini
In Pursuit of Psychic Change: The Betty Joseph Workshop Edited by Edith
Hargreaves and Arturo Varchevker
The Quiet Revolution in American Psychoanalysis: SelectedPapers of Arnold
M. Cooper Arnold M. Cooper. Edited and introduced by Elizabeth
L. Auchincloss
Seeds of Illness and Seeds of Recovery: The Genesis of Suffering and the
Role of Psychoanalysis Antonino Ferro
The Work of Psychic Figurability: Mental States Without Representation
César Botella and Sára Botella
Key Ideas for a Contemporary Psychoanalysis: Misrecognition and
Recognition of the Unconscious André Green
The Telescoping of Generations: Listening to the Narcissistic Links Between
Generations Haydée Faimberg
Glacial Times: A Journey Through the World of Madness Salomon Resnik
This Art of Psychoanalysis: Dreaming Undreamt Dreams and Interrupted
Cries Thomas H. Ogden
Psychoanalysis as Therapy and Storytelling Antonino Ferro
Psychoanalysis and Religion in the 21st Century: Competitors or
Collaborators? Edited by David M. Black
Recovery of the Lost Good Object Eric Brenman
The Many Voices of Psychoanalysis Roger Kennedy
Feeling the Words: Neuropsychoanalytic Understanding of Memory and the
Unconscious Mauro Mancia
Projected Shadows: Psychoanalytic Reflections on the Representation of Loss
in European Cinema Edited by Andrea Sabbadini
Encounters with Melanie Klein: Selected Papers of Elizabeth Spillius
Elizabeth Spillius. Edited by Priscilla Roth and Richard
Rusbridger
Constructions and the Analytic Field: History, Scenes and Destiny
Domenico Chianese
Yesterday, Today and Tomorrow Hanna Segal
Psychoanalysis Comparable and Incomparable: The Evolution of a Method to
Describe and Compare Psychoanalytic Approaches David Tuckett,
Roberto Basile, Dana Birksted-Breen, Tomas Böhm, Paul Denis,
Antonino Ferro, Helmut Hinz, Arne Jemstedt, Paola Mariotti and
Johan Schubert
Time, Space and Phantasy Rosine Jozef Perelberg
Rediscovering Psychoanalysis: Thinking and Dreaming, Learning and
Forgetting Thomas H. Ogden
Mind Works: Technique and Creativity in Psychoanalysis Antonino Ferro
Doubt, Conviction and the Analytic Process: Selected Papers of Michael
Feldman Michael Feldman
Melanie Klein in Berlin: Her First Psychoanalysis of Children Claudia
Frank

TITLES IN THE NEW LIBRARY OF PSYCHOANALYSIS

TEACHING SERIES

Reading Freud: A Chronological Exploration of Freud’s Writings

Jean-Michel Quinodoz
Listening to Hannah Segal: Her Contribution to Psychoanalysis
Jean-Michel Quinodoz
This page intentionally left blank
THE NEW LIBRARY OF PSYCHOANALYSIS

General Editor: Dana Birksted-Breen

The Psychotic Wavelength

A Psychoanalytic Perspective for Psychiatry

Richard Lucas
First published 2009
by Routledge
27 Church Road, Hove, East Sussex BN3 2FA
Simultaneously published in the USA and Canada
by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an Informa business
© 2009 Lynne Lucas
Typeset in Bembo by RefineCatch Limited, Bungay, Suffolk
Paperback cover design by Sandra Heath
All rights reserved. No part of this book may be reprinted or
reproduced or utilised in any form or by any electronic,
mechanical, or other means, now known or hereafter
invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in
writing from the publishers.
This publication has been produced with paper manufactured to
strict environmental standards and with pulp derived from
sustainable forests.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
Lucas, Richard, 1943–2008.
The psychotic wavelength : a psychoanalytic perspective for psychiatry /
Richard Lucas.
p. : cm.
Includes bibliographical references and index.
ISBN 978-0-415-48468-8 (hbk) – ISBN 978-0-415-48469-5 (pbk.)
1. Psychoses. 2. Psychoanalysis. I. Title.
[DNLM: 1. Psychotic Disorders–diagnosis. 2. Psychotic Disorders–therapy.
3. Affective Disorders, Psychotic–diagnosis. 4. Affective Disorders, Psychotic–
therapy. 5. Psychoanalytic Theory. WM 200 L933p 2009]
RC512.L83 2009
616.89′17–dc22
2009003522

ISBN 978-0-415-48468-8 (hbk)

ISBN 978-0-415-48469-5 (pbk)
Dedicated to the memory of Richard Lucas, OBE
2nd April 1943 – 28th July 2008
This page intentionally left blank
Contents

Preface by Carine Minne xiv

Acknowledgements xix

Part One
Making the Case for a Psychoanalytic Perspective
on Psychosis 1
1 Introduction 3

2 The medical model 16

3 Controversial issues in psychosis 25

Part Two
Psychoanalytic Theories about Psychosis:
A Selective Review 45
4 Freud’s contributions to psychosis 47

5 The Kleinian contribution to psychosis 61

6 Bion and psychosis 84

7 A contemporary Freudian perspective on psychosis 101

8 The psychoanalytic treatment of schizophrenia:

lessons from Chestnut Lodge 107

xi
Contents

9 The divided self: evaluating R. D. Laing’s contribution

to thinking about psychosis 115

Part Three
Tuning into the Psychotic Wavelength 123
10 Differentiating psychotic processes from
psychotic disorders 125

11 The psychotic wavelength 142

12 Dreams and delusions 157

13 Utilising the countertransference in psychosis 166

Part Four
The Psychotic Wavelength in Affective
Disorders 185
14 Why the cycle in a clinical psychosis? A
psychoanalytic perspective on recurrent manic
depressive psychosis 187

15 Puerperal psychosis: vulnerability and aftermath 203

16 Managing depression – psychoanalytic psychotherapy,

antidepressants or both? 220

Part Five
Implications for Management and Education 233
17 Developing an exoskeleton 235

18 Destructive attacks on reality and the self 247

19 The role of psychotherapy in reducing

the risk of suicide in affective disorders:
a case study 260

20 Education in psychosis 280

xii
Contents

21 Conclusion: psychoanalytic attitudes to general

psychiatry and psychosis 300

Notes 309
References 311
Index 325

xiii
Preface

In this admirably lucid book Dr Richard Lucas demonstrates that

psychoanalysis has much to contribute to the treatment of seri-
ously disturbed and disturbing psychiatric patients. Dr Lucas’s aim
is ‘to provide clinicians with a psychoanalytically based framework of
understanding to help them in their work with the major psychotic
disorders encountered in everyday psychiatric practice.’ He strongly
believed that only by immersing themselves in general psychiatric
settings would psychoanalysts be able to exert a favourable impact on
the treatment of psychoses and develop psychoanalytic theories with
a proper focus on the very daunting problems found there. This book
is based on his forty years of work in the National Health Service
with patients suffering from major psychotic disorders and demon-
strates his deep involvement as a psychoanalyst and psychiatrist. He
applied psychoanalytic thinking in general psychiatric settings in
a way that no other psychoanalyst has managed to date. Dr Lucas
distils practical lessons derived from his life’s work, condensing and
elucidating his long and rich experience in a captivating way.
His justified refrain is that when clinicians are faced with patients
suffering from psychoses, they must tune into the psychotic wave-
length. He means by this that, in order to best understand one’s
encounters with such patients, one must discern whether one is
addressing the psychotic or the non-psychotic part of the personality.
Dr Lucas emphasises that the book illustrates the ‘vital role that
applied psychoanalytic thinking can play within general psychiatry to
help staff, relatives and patients adjust to the realities of living with
long-term psychotic disorders.’ He felt strongly that psychoanalysis

xiv
Preface

could not and should not be peddled as a cure-all for psychosis.

Clinicians will feel reassured that their apparently faltering attempts to
‘cure’ long-suffering patients are not failures at all but part and parcel
of the long-term management that such stressful disorders demand.
Here, Dr Lucas shows how psychoanalytic approaches to multidisci-
plinary team work can be invaluable in helping maintain realistic
treatment aims and staff morale.
In the 1970s, as a junior psychiatrist and psychoanalyst in training,
Dr Lucas experienced a psychiatric world markedly different from
the one he departed upon his premature death in 2008. In that era
Rosenfeld, Bion, Sohn and other eminent psychoanalysts routinely
read papers on psychosis at the British Psychoanalytical Society,
where he was training for membership. Psychiatric patients treated
at the Maudsley Hospital, where he worked within the National
Health Service (NHS) as it was then, could be seen up to five
times per week for psychoanalytic sessions. Later on, when based
at Claybury Hospital and as a young consultant psychiatrist, Dr Lucas
took charge of the ward for psychotic patients where his applied
psychoanalytic work was not only welcomed but also strongly sup-
ported. His dedication to patients, and to the clinical teams caring for
them, was apparent from the beginning, as was his supple application
of psychoanalysis within these psychiatric settings. This experience
is reflected in chapters that clearly link psychoanalysis historically,
theoretically and clinically with his everyday experiences as a psy-
chiatrist and psychoanalyst, a balance of identities he maintained
throughout his working life.
Over the ensuing decades, though, he became dismayed by the fact
that within the NHS, patients suffering from psychoses were deprived
of therapeutic resources which had been made available earlier. The
rift widened between professionals in psychiatry who were organic-
ally inclined and those who were more psychoanalytic in approach,
to the former group’s advantage, and he detected that the patients had
become the main victims of this rift. This arose following the changes
in the 1980s to a more neo-Kraepelian approach to psychiatric
classification and diagnosis, a shift to emphasise phenomenology in
mainstream psychiatry and a decline in the meaning-based approach.
Patients suffering from psychotic disorders came to be treated mainly
with medication and in a mechanistic fashion, with few professionals
prepared to try to think about their symptoms as meaningful and
understand their predicaments. Dr Lucas was also critical of ‘classical’

xv
Preface

psychoanalysts who complained of a dilution of psychoanalysis when

applied in settings other than five sessions per week on a couch, as
though this was the only ‘real’ form of psychoanalytic treatment. He
challenged those professionals in psychiatric settings who had con-
tempt for psychoanalysis and who insisted on their own treatment
methods as being the only worthwhile ones. In this polarised climate
of conflicting treatment methods, the large psychiatric hospitals were
being shut down to offer so-called community treatments, shorter
and supposedly less expensive treatments (in the short term anyway)
were being sought, and patients assuredly became the victims, not
only of their psychotic illnesses but also of the system. Dr Lucas’s
friendly, approachable personality and diplomatic skills ensured that
he was always heard. Dr Lucas persevered in maintaining that there
was a place for both of the main approaches to treatment, ensuring
that patients received the most comprehensive and up-to-date treat-
ments available in a setting that provided understanding for them,
their relatives and their carers.
The book, written in a wonderfully accessible style, is divided into
five parts. Part One makes the case for a psychoanalytic perspective on
psychosis, emphasising the need to integrate the medical model with
a dynamic approach, the aim being to gain the views of all involved
professionals in patients, especially those who specialise in projecting
and disowning their disturbance. Part Two provides an excellent his-
torical review of the main psychoanalytic theories on psychoses,
including areas of overlap and differences in opinion between main
theoreticians. These chapters could be said to offer the reader every-
thing you ever wanted to know about psychoanalytic theories of
psychoses but never quite understood before! The four chapters
contained in Part Three are perhaps the most important part of the
book’s structure, functioning as the pivot by providing key clinical
evidence to show why clinicians must tune into the psychotic wave-
length of their patients. This is where the book’s mantra is amplified
and exemplified: ‘when approaching major psychotic disorders, we
have always to think in terms of two separate parts of the personality,
the psychotic and the non-psychotic, and ask ourselves which part we
are being confronted by at any particular moment in time’.
If only one chapter was chosen as representing the core of
the book, this would have to be Chapter 11, with its instructive
cases illustrating how to tune into the psychotic wavelength. In my
view, this chapter is essential reading for anyone working in general

xvi
Preface

psychiatric settings or involved professionally with patients suffering

from major mental disorders. This also applies to those professionals
who, for example, may sit on mental health review tribunals and make
crucial judgements based on a patient’s manifest presentation, which
may be loaded with denial and rationalisations but behind which the
active psychosis can often remain camouflaged.
While the emphasis in Part Three, including several fascinating and
informative clinical vignettes, is on schizophrenia, Part Four focuses
on the major affective disorders, including those that arise in the
puerperium. Again these chapters are illustrated with informative and
clinically impressive vignettes providing the evidence for the need to
keep in mind the psychotic part of the patient in any encounter with
the patient, direct or indirect. Part Five is dedicated to the implica-
tions of this psychoanalytic framework in relation to highly topical
issues such as risk management. Dr Lucas emphasises the importance
of attempting to reach a realistic understanding of any patient’s
psychotic and non-psychotic parts in managing risk, rather than rely-
ing on the ‘forms and tick-box’ approach to risk management, which
is more of an anxiolytic for overburdened staff who have to deal with
critical inquiries when an incident arises, such as an episode of
self-harm, suicide or harm to another. Precious time wasted in com-
pleting forms can provide beautifully comprehensive patient files,
which bear little relation to the patient him or herself and have not
contributed to sound patient care. Dr Lucas provides plenty of mov-
ing clinical evidence that a psychoanalytic perspective can support
staff and relatives when tragic events happen. Clinicians might feel
relieved to read so succinctly the reality that when one is involved
with such patients, some tragic events cannot be prevented, no matter
how excellent the care and understanding. Risk cannot be eradicated,
despite the pressure from uncomprehending authorities to do so.
Risk can, however, be managed as effectively as possible using the
integrated approach to psychiatric care espoused by Dr Lucas. Part
Five also includes a section on education, a subject of great import-
ance to Dr Lucas, who was also a highly active and passionate trainer
of clinicians from different disciplines and, in particular, junior
psychiatrists.
Dr Lucas often alluded to Freud’s awareness of the tensions between
the two disciplines of psychiatry and psychoanalysis and his wish to
bridge this gap. In my view, Dr Lucas here has demonstrated to the
reader his own remarkable capacity to do just that. He also has shown

xvii
Preface

the reader why this bridge is so important for patients, staff and
relatives. Throughout the volume, Dr Lucas’s deep compassion for
patients and his concern for staff and relatives pours through. He
was an inspirational colleague who is sorely missed. We can be very
grateful that he left us with such a splendid legacy, which I sincerely
hope will be read by a wide, professional, national and international
audience involved with disturbed and disturbing patients and will
become essential reading for junior psychiatrists and nursing staff in
particular.

Carine Minne
October 2008

Dr Carine Minne is Consultant Psychiatrist in Forensic Psychotherapy

at the Portman Clinic, Tavistock and Portman NHS Foundation
Trust and at Broadmoor Hospital, West London Mental Health
Trust. She is a psychoanalyst and associate member of the British
Psychoanalytical Society.

xviii
Acknowledgements

Sadly, this book is published posthumously and Richard Lucas will

not have the pleasure of seeing his work in print. Knowing how ill he
was gave him the impetus to move forward on this project and we
were grateful that he wanted to make this effort at the end of his life
to transmit the ideas which were dear to him.
Before he died, Richard Lucas was able to discuss his ideas and the
draft of the book with Liz Allison and she has done a wonderful job of
putting the draft into publishable form. I am sure that he would have
wished to express his warmest thanks to her for her outstanding work
as editor of his papers.
Richard would have also wished to thank Priscilla Roth and
Carine Minne for their constructive comments on the draft, and it is
also clear in his writings that he felt he owed a debt to his teachers.

Dana Birksted-Breen
Series Editor

xix
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PA RT O N E

Making the Case for a Psychoanalytic

Per spective on Psychosis
This page intentionally left blank
1
Introduction

This book aims to provide clinicians with a psychoanalytically based

framework of understanding to help them in their work with the
major psychotic disorders encountered in everyday psychiatric prac-
tice. It is written for both an analytic and general psychiatric audience.
It provides theoretical and clinical discussion material for junior
doctors starting in psychiatry, nurses undergoing postgraduate psy-
chodynamic courses, social workers, psychologists and students of
other disciplines related to psychiatry, as well as analytic psycho-
therapists in training who are striving to make sense of their psychiatric
placements. It is also intended for the wider professionally experienced
analytic and psychiatric audience, since it raises for consideration the
important and often controversial issues that arise from encounters
with psychotic states of mind.
The current trend in psychiatry, based on a stress-vulnerability
model, is for psychoanalysts to work in early onset psychosis settings,
with associated favourable outcome figures linked to relapse preven-
tion, avoidance of admission and with medication kept to a minimal
dosage (Cullberg 2001; Martindale 2001).
There is a danger of a split developing between those running early
onset services and those running the general psychiatric services. The
latter have responsibility for many patients at the severe end of the
spectrum of psychosis, who may require significant amounts of medi-
cation and repeated or protracted admissions. In working with this
group of patients, who will at times require containment on the ward
when in a state of relapse, avoidance of admission is clearly not an
issue. The cause of the psychosis, whether viewed theoretically as
constitutional or as a consequence of early trauma, is not the press-
ing issue, neither is the level of required medication. The primary

3
A psychoanalytic perspective on psychosis

problem is to make sense of what is happening in a psychotic

breakdown.
The lament that psychoanalytic perspectives are no longer taken
account of in the area of psychosis (Grotstein 2001) may be a con-
sequence of analysts positioning themselves on the periphery rather
than being prepared to share in the everyday experiences of general
psychiatry. Only work within the general psychiatric setting can
enable psychoanalysts to have a meaningful impact on psychosis, by
developing ideas that they and their fellow professionals can make use
of in this most demanding of areas. Without this vital engagement,
although psychoanalytic theories of psychosis may have their own
academic coherence, they will not resonate for those who are work-
ing at the coal-face.
This book is based on my forty years of experience of working
with major psychotic disorders in the NHS. While also informed by
individual analytic experiences, its primary concern is the role of
applied analytic thinking in a busy psychiatric setting. Though the
theoretical framework outlined here is based on my work in the UK,
in an NHS setting in a deprived area of North London, it is hoped
that a wider international audience will find that they can make use of
it to inform their work in other contexts.
Psychoanalysts have understandably grown fond of referring to the
pure gold standard of individual psychoanalysis. Any application of
analytic thinking outside of an individual analytic setting has come
to be regarded as a dilution of the pure situation. In consequence,
applied analysis, such as that undertaken by many practising analysts
who also work in an NHS setting, has not always received the support
and appreciation that it merits.1
In thoughtfully presented individual case studies, analysts have
more often than not chosen to focus on the early infantile traumas
behind the generation of schizophrenia (e.g. De Masi 2001). How-
ever, addressing the psychoses unavoidably confronts us with the need
to integrate a consideration of constitutional or biological factors
(Yung and McGorry 2007). We cannot rely solely on an analytic
explanation in terms of early childhood trauma. Pioneers of indi-
vidual psychological approaches, which include cognitive as well as
analytic therapists, have tended to be optimistic about the treatability
of psychosis, but the question of whether it is possible to achieve
lasting change remains controversial. Pursuit of this elusive goal can
detract from the requirement to provide an effective containment that

4
Introduction

addresses the psychotic patient’s intense dependency needs (Steiner

1994).
The focus of this book is not primarily on the feasibility of
inducing lasting change, but rather on the vital role that applied psy-
choanalytic thinking can play within general psychiatry to help staff,
relatives and patients adjust to the realities of living with long-term
psychotic disorders.
In relation to the place for the analytic study of psychoses, Freud
(1925) had the following to say:

The neuroses were the first subject of analysis, and for a long time
they were the only one. No analyst could doubt that medical prac-
tice was wrong in separating those disorders from the psychoses
and in attaching them to the organic nervous diseases. The theory
of neuroses belongs to psychiatry and is indispensable as an intro-
duction to it. It would seem, however, that the analytic study of the
psychoses is impracticable owing to its lack of therapeutic results.
Mental patients are as a rule without the capacity for forming a
positive transference, so that the principal instrument of analytic
technique is inapplicable to them. There are nevertheless a number
of approaches to be found. Transference is often not so completely
absent but that it can be found to a certain extent; and analysis has
achieved success with cyclical depressions, light paranoic modifica-
tions and partial schizophrenias. It has at least been a benefit to
science that in many cases the diagnosis can oscillate for quite a
long time between assuming the presence of a psychoneurosis or of
a dementia praecox; for therapeutic attempts initiated in such cases
have resulted in valuable discoveries before they have had to be
broken off. But the chief consideration in this connection is that so
many things that in the neuroses have to be laboriously fetched up
from the depths are found in the psychoses on the surface, visible to
every eye. For that reason the best subjects for the demonstration of
many of the assertions of analysis are provided by the psychiatric
clinic. It was thus bound to happen before long that analysis would
find its way to the objects of psychiatric observation.
(Freud 1925, p. 60)

Many points of interest are raised here by Freud. First, does thera-
peutic success matter in relation to the analytic study of psychoses; or
is it more important to ask whether analytic insights can help those

5
A psychoanalytic perspective on psychosis

who have to manage the most difficult of patients on a long-term

basis? How do we evaluate transference? Do we see it as only coming
from the vestiges of a healthy part of the patient, as Freud implied?
One day, as I was walking down a hospital corridor, a long-stay
patient passed me and said, ‘Hello, Dr Lucas’. She made me feel like a
benevolent and important father figure, with her as one of my cared-
for flock. I felt full of this warm feeling, until she brought me back to
earth by adding as she went by, ‘You stupid old fucker.’
Both transference and countertransference phenomena were clearly
in evidence here. The episode reminded me of the baby who builds
a column of bricks only to knock them down again. The lesson is
that events which can be illuminated by analytic thinking, linked to
transference and countertransference phenomena, are ever-present
throughout the hospital and its corridors. The challenge is what we
do with them.
While we might not be able to change the habits of a lifetime in
patients with chronic psychoses, we can learn a great deal from them.
While Freud noted that seeing patients individually in the early stages
of a developing psychosis may lead to valuable analytic discoveries, see-
ing patients in general psychiatry while keeping an analytic perspec-
tive in mind can also inform the clinician’s thinking in a creative way.
An underlying theme of this book is that the major psychotic dis-
orders present different challenges from borderline and non-psychotic
disorders. Since projective processes predominate in psychosis, we
need to decipher the emotional meaning contained in delusions by
attending not only to their content, but also to our countertrans-
ference experiences – exploring what the patient makes us feel at
the time.
Using one’s ordinary sensitivities is not sufficient in trying to make
sense of major psychotic disorders. One needs to learn to tune into a
different wavelength, what I have termed the psychotic wavelength,
hence the title for the book.
In approaching the major psychotic disorders, both schizophrenia
and affective disorders, it is vital that we always think not in terms of
one person but in terms of two quite separate parts to the personality,
the psychotic and non-psychotic parts. Whenever we listen to the
patient we have to ask ourselves whether we are listening to a straight-
forward communication from a non-psychotic part or hearing a
rationalisation from the psychotic part that is covering up an under-
lying psychosis.

6
Introduction

Bion was reported anecdotally to have said that as a non-German

speaker, he had an advantage listening to Hitler on the radio before
the war. As a result, he was not seduced by the words, but heard only
the sounds of a raving madman. Hitler’s seductive words thus did not
blind him to the dangerousness of the man.
Professionals often remain unaware of the commonest presenting
symptom of psychosis and its diagnostic implication. If one consults a
standard psychiatric textbook, one will find that the commonest
symptom is not, as one might have expected, persecutory delusions
(64 per cent) or auditory hallucinations (74 per cent), but lack of
insight (97 per cent) (Gelder et al. 1998). This lack of insight typically
presents as denial of any problems with associated rationalisations. In
other words, if we are not aware that denial and rationalisation are the
commonest presenting features of psychosis, we are in danger of suc-
cumbing to the rationalisations and missing the underlying psychosis.
This fundamental dynamic is not generally appreciated or taught
within the realm of psychiatry. It remains a controversial issue even
within the field of psychoanalysis, where there is a preference for
thinking in the more familiar terms of defence mechanisms and the
need for reintegration of split-off parts of the personality. However,
the concept of the two parts is of crucial importance in everyday
general psychiatric practice, for example when approved social work-
ers (ASWs) have to decide whether a patient, who is reported by
relatives to be in a dangerous state of mind, but who presents in an
apparently calm and compliant state, needs to be formally admitted
under the Mental Health Act 1983. Similar problems arise when
mental health review tribunals have to decide whether it is safe to
release a patient from a detention order.
The following serves as a striking example of denial and
rationalisation:

A patient came into hospital on a section, having smashed up the contents

of his flat. On admission he was in such a disturbed state that he was placed
on the locked ward. I saw him for evaluation the next day. He presented in a
perfectly calm state and denied having any problems. However, he asked
how he could be sure that I was really Dr Lucas and not an impostor, and
said that he therefore intended to call the police.

Here we can see that it is the patient who is the impostor. He behaves
in an apparently calm way despite the fact that he had been brought

7
A psychoanalytic perspective on psychosis

into hospital by the police in a severely disturbed state only the previ-
ous evening. By the next day, he masquerades as reasonable, while
projecting his awareness of this action into me. Through the process
of projection and reversal into the opposite, I become the impostor
for whom the police are needed.
With a physical illness, the patient goes to the doctor with symp-
toms and the doctor makes the diagnosis. With psychotic disorders,
especially in relapse of chronic disorders, it is the nearest relative, not
the doctor, who makes the diagnosis. It is then a question of whether
the professional workers will believe the relative’s account. If the
professionals succumb to the patient’s rationalisation, they may fail to
take the beleaguered relative’s concerns seriously.
However experienced we are as professionals, we will often be
fooled by patients’ rationalisations. It is therefore crucial to be aware
of the phenomenon and be open to changing one’s mind on receiv-
ing additional information, rather than inflexibly standing by one’s
initial opinion. The following incident is a typical experience.

The patient was a woman with a long-documented history of manic depres-

sion, though I previously had not known her before being asked to see
her on a domiciliary visit. The community psychiatric nurse (CPN) had
requested the home visit because the patient had been defaulting from her
outpatient appointments. When I saw her she denied that she had any
problems, and said that she would keep her next outpatient appointment
and take any prescribed medication. I did not feel that there were grounds
for a formal admission.
She subsequently did not keep the hospital appointment, and I saw her
again at home, but this time armed with more information, which a close
friend had passed on to the CPN. The friend told the CPN that while at times
she presented as perfectly reasonable, at other times she would start shout-
ing, and this was disturbing her downstairs neighbour, who was terminally
ill with cancer. The CPN noted that while the patient insisted that she would
cooperate with treatment, this was not the case. When I again found her in
a seemingly rational state the second time I visited, I changed my view and
completed my part of a compulsory admission order. It was the patient’s
denial of any problems – the rationalisation – that was indicative of the
psychosis.

In the following vignette, an ASW is faced with an understated

psychotic state.

8
Introduction
A patient with a history of chronic schizophrenia had stopped his depot
medication (medication given by injection and slowly released into the
body over a number of weeks), and was becoming more disturbed in the
community. It was known that when he had relapsed in the past, he had
become violent. This time, not wanting to be sectioned, he accepted volun-
tary admission at the last moment, so the ASW did not complete his part of
the section. In hospital the next day, without provocation or warning, the
patient suddenly attacked a nurse with a broom handle, and it took several
nurses to restrain him.
The ASW was called to the ward to complete a compulsory treatment
order, in view of the patient’s unpredictable state. The ASW saw the patient
before speaking to the nursing staff and was therefore unaware that an
assault had occurred. Since the patient appeared calm and said that he was
willing to stay and cooperate with treatment, the ASW decided that the
patient did not need sectioning. When the ASW later met with the nurses,
they described the patient’s unpredictable outbursts, but having made his
original decision, he felt unable to change it, although he was willing to be
called back if a further incident occurred.

As patients in psychotic states of mind tend to project out and disown

their disturbance, when case reviews take place, whether in hospital or
in the community, it is essential to gather together all the involved
professionals and the close relatives. The work of the review is like
assembling the pieces of a jigsaw puzzle, and we cannot know in
advance who might be bringing the most important piece.
Psychotic disorders represent the most extreme and difficult end of
the spectrum of human behaviour. Patients may remain in seemingly
intractable states of mind for lengthy periods. The work can be very
demanding and stressful.
To manage the situation without acting out to the detriment of the
patient, one must not be too rigid in one’s approach, and it is neces-
sary gradually to develop and acquire clinically relevant frameworks
of understanding. Acquiring these frameworks is a lifelong personal
process and one is always looking for additional insights to deepen the
frameworks of reference. No single framework is comprehensive
enough to cover all situations; each has its limitations. We are continu-
ally challenged to find new and meaningful understandings and to
integrate them.
Throughout this book, different theoretical frameworks for under-
standing psychosis will be examined and related to clinical examples.

9
A psychoanalytic perspective on psychosis

Part One of the book introduces the case for a psychoanalytic per-
spective on psychosis. Chapter 2 considers the strengths and limita-
tions of the medical model of psychosis. The medical model is based
on the concept of phenomenology, the attempt to be scientifically
objective over subjective experiences, for example defining hallucin-
ations and delusions and relating them to the diagnosis of psychotic
disorders. The positive aspect of the medical model is that it intro-
duces an element of diagnostic precision, but it has its limitations, as it
allows no room for a dynamic understanding.
Rather than falling into the trap of extolling one approach as
superior to the other, it is necessary to integrate the medical model,
with its concentration on classification and physical treatments at the
biological level, with a dynamic approach focused at the psycho-
logical level. We then need to ask ourselves what is the most appropri-
ate measure to be taken at a particular time, within an integrated
model of understanding. Sometimes medication may be the priority
to aid a process of containment. At other times the priority will be the
achievement of a psychological understanding, while both measures
can be used in conjunction with each other.
The subject of psychosis raises many controversial questions, which
require continued debate. Some of these issues are considered in
Chapter 3, including the question of whether there is a continuum
between normality and psychosis and whether analytic theorising and
input is irrelevant in relation to conditions now perceived by many as
predominantly organically based disorders. Contrasting approaches
to delusions from the medical model, cognitive behaviour therapy
(CBT) and analytic perspectives are also reviewed.
Part Two of the book provides a selective historical overview of
psychoanalytic theories of psychosis. In Chapter 4, Freud’s contri-
bution is reviewed starting with his seminal ideas emanating from
the Schreber case. Particular consideration is given to his ideas on
narcissism, the death instinct, defence mechanisms and the structural
model. Freud thought that patients with psychosis lived predomin-
antly in a narcissistic world of their own creation, thereby rendering
themselves inaccessible to influence by the classical analytic method
of interpretation through the transference. Nevertheless, he made a
plea for future generations to become conversant with both psycho-
analysis and general psychiatry for analysis to make a contribution to
psychosis.
In Chapter 5, the Kleinian contribution is considered. Following a

10
Introduction

brief review of fundamental concepts on psychosis as described by

Melanie Klein, some contributions by others on psychosis from the
Kleinian school are noted. These include the contributions from
Rosenfeld, who introduced the concept of the psychotic transference,
and Segal, Sohn, Rey, Steiner, O’Shaughnessy and Britton.
Chapter 6 is devoted to Wilfred R. Bion’s unique contribution to
psychoanalytic thinking about psychosis. In his book Second Thoughts,
Bion introduced an entirely new way of viewing schizophrenia. He
described in detail the separate functioning of the psychotic and non-
psychotic parts of the personality and the genesis of hallucinations
and their relation to delusions. He also introduced an original theory
of thinking. Bion’s work is not easy to follow, especially for those not
already familiar with analytic theory, so I have taken particular care to
relate his concepts to clinical material in order to make them more
easily comprehensible, as they are of fundamental relevance to inform-
ing our thinking in everyday psychiatric practice.
Chapter 7 considers the work of Tom Freeman by way of a contrast
to the Kleinian approach. Freeman worked closely with Anna Freud,
and developed his own theoretical framework for thinking about
psychosis. After a lifetime working in general psychiatry in Scotland,
he retired to Northern Ireland, where he single-handedly set up the
Northern Ireland Institute for Analytic Studies. Like Freud in the
early days, he provided candidates with both individual analysis and
supervision for their cases, before involving other analysts from
London in expanding the teaching programme.
Chapter 8 discusses the important lessons to be drawn from the
history of Chestnut Lodge in Rockville, Maryland, near Washington
DC, where an entirely psychoanalytic approach to the treatment of
psychosis was used for many decades. Since Freud had reported the
lack of transference in psychosis, the procedure was called intensive
analytic therapy rather than classical analysis, with sessions held four
times rather than five times weekly to maintain a distinction. While
important contributions were made on psychosis by eminent analysts
working at Chestnut Lodge, the story illustrates the need for a more
flexible attitude, including incorporation of medication where indi-
cated, when approaching psychosis. For patients treated with a solely
psychoanalytic approach, the outcome figures were favourable for
more borderline patients but not those with schizophrenia, opening
up the debate as to the relevance of psychoanalysis to psychosis.
In Chapter 9, Laing’s criticism of the psychiatric approach to

11
A psychoanalytic perspective on psychosis

psychosis is briefly reviewed. Laing’s work raises the fundamental

question of whether psychosis should be viewed primarily in terms
of society’s intolerance of difference, or whether there are persist-
ing conditions to be studied in their own right. This is a debate that
continues to this day.
Part Three turns to the development of a psychoanalytic frame-
work for psychosis that can be of assistance to clinicians working in
general psychiatry. Such a framework needs to allow for incorpor-
ation of other modalities of treatment within an integrated approach.
In developing a framework for working with the psychoses, it is
important to differentiate psychotic processes in borderline states
from major psychotic disorders. This is the subject of Chapter 10. It is
necessary to tune into what I have referred to as the psychotic wave-
length to address the specific needs of a patient in a psychotic state,
and this is the subject of Chapter 11. Tuning into the psychotic
wavelength, as already emphasised, requires us to continually bear in
mind the two separate parts of the personality, the psychotic and
non-psychotic.
In Chapter 12, dreams are contrasted with delusions. Within psychi-
atry, dreams can provide important clues during assessment inter-
views, provide markers for progress in psychotherapy, and provide
important teaching for trainees on the working of the unconscious
when arising in their supervised cases. In schizophrenia, typically
delusions replace dreams and the challenge becomes to decipher the
meaning to the delusion.
Since patients in psychotic states tend to predominantly use pro-
jective processes, our countertransference reactions become crucially
important in deciphering the meaning behind delusions. Involved
professional staff need help to familiarise themselves with this process
and gain confidence in processing and using their own feelings, when
exploring presenting material. This is the subject of Chapter 13.
Introducing this perspective not only stimulates interest in the staff
working with psychotic patients, but also adds humour, warmth and
humanity to what would otherwise be unremittingly demanding
work and can help to protect staff against burnout.
Part Four is concerned with tuning into the psychotic wavelength
in working with the major affective disorders, including bipolar dis-
order, puerperal psychosis and depression – the forgotten psychosis.
As with schizophrenia, we cannot rely solely on empathy in relating
to affective disorders. We again need to tune into the psychotic

12
Introduction

wavelength and identify the psychotic part of the patient with its own
belief system, agenda and autonomy of action.
In Chapter 14, I describe a psychoanalysis conducted in the NHS
with a patient with a severe recurrent manic depressive psychosis.
Although I made little impact on the process, the analysis enabled me
to appreciate the underlying dynamics to the cycle. The psychotic
part of this patient would submit to a tyrannical superego in the
depressive phase but her resentment would silently build up like the
tightening of a clockwork spring, until it would unwind in a manic
rebellious stage and then the process would repeat itself. I learned to
appreciate that no one was to be blamed for the repeated admissions
and to respect the non-psychotic part of the patient that had to live
with the recurring cycle. The experience taught me that many times
one may need to remain supportive and tolerant of a patient going
through a protracted psychotic state in hospital with seemingly no end
in sight and let the process run its natural course, without becoming
preoccupied with searching for an ideal physical treatment.
The puerperium is the most vulnerable time for developing a
depressive psychosis in someone with an underlying propensity. Psy-
chiatrists continue to search for hormonal changes to account for this
special vulnerability. In Chapter 15 an alternative dynamic explan-
ation is proposed via consideration of some clinical material. It is
suggested that cases that require admission to hospital are only the tip
of an iceberg; that the condition with its underlying psychopathology
is much more common than is realised, and that community workers
need alerting to the underlying psychodynamics in order to provide
the most effective support for these mothers and their babies.
We use the term depression in several different ways and they need
to be differentiated. There is the Kleinian concept of the depressive
position, a state of tolerating painful feelings, reactive depression,
states of mourning and what is now termed major depressive illness,
previously referred to as endogenous or psychotic depression. In
Chapter 16, the psychodynamics operating behind major depressive
illnesses are explored, starting from the insights of Freud (1917) as
described in his classical paper ‘Mourning and melancholia’.
A spectrum of treatments is available for major depression; some
patients receive psychotherapy, some receive a mixture of psycho-
therapy and medication, and some are treated solely with antidepres-
sant medication. However, even in the latter cases, psychodynamics
underlie their presentation. An experienced consultant psychiatrist

13
A psychoanalytic perspective on psychosis

once said to me that in training he was taught to prescribe antidepres-

sant medication for outpatients, but not how to talk to them. Being
made aware of the dynamics underlying major depressive illness
can help the clinician to find new ways to think about and talk to
their patients, even in busy outpatient clinics, enlarging the inter-
action with the patient beyond just the prescribing of antidepressant
medication.
Part Five of the book turns to the implications of the psycho-
analytic framework elaborated in Parts Three and Four for manage-
ment, including risk management, and education. Chapter 17 discusses
a patient in the early stages of a severe schizophrenic illness arising in
late adolescence in order to make the case for the overriding need to
develop a supportive exoskeleton that can enable the patient to func-
tion in the community. The development of the exoskeleton requires
collaboration of the psychiatric services with the nearest relatives. In
severe cases this can take up to five years to develop, with relatives as
well as the patient needing full support during the early turbulent
period. The role for psychoanalysis in this setting is reviewed.
Chapters 18 and 19 examine the risks that are an inevitable conse-
quence when managing psychotic patients prone to impulsive actions.
With the closure of the asylums and reduction in beds, anxiety arose
about the containment of disturbed states in the community. Tragic
episodes of violence increased the anxiety leading to the introduction
of the Care Programme Approach (CPA). Patients regarded as at spe-
cial risk of violence or self-neglect were placed on enhanced CPA,
requiring close supervision by a care coordinator. Risk assessment
forms were also introduced by management, with great importance
placed on them, which created a climate of blame when forms were
found to be incomplete at the time of an untoward incident. Com-
pleted forms, of course, do not prevent incidents from occurring; we
still have to live with risk and each case will require its own clinical
assessment.
In Chapter 18, a psychoanalytic perspective is provided on risk
assessment. Both acts of harm to others as well as acts of self-harm are
considered, linked to the underlying psychopathology. Even if it is
not always possible to prevent a destructive act from occurring, one
can learn from the experience and it can help in the management in
other cases. Maintaining an analytic perspective can help the psychi-
atrist to provide meaningful support to staff and relatives when tragic
events happen.

14
Introduction

In Chapter 19, a patient with recurrent manic depressive episodes,

but with much less severe psychopathology than the patient described
in Chapter 14, is considered. In this case analytic psychotherapy was
able to have a significant impact once the therapist was able to identify
and tune into the agenda of the psychotic wavelength, thereby
reducing an initially significant suicidal risk.
In Chapter 20, different forums for education on psychosis are
considered. For junior doctors new to psychiatry, weekly psychosis
workshops where problems can be presented in an informal atmos-
phere provide a setting to introduce related psychoanalytic concepts,
make sense of psychotic communications and help the doctors to
explore their countertransference feelings. At the specialist registrar
level, whether training for general psychiatry or psychotherapy, there
is no substitute for deepening one’s clinical experience through treat-
ing a case individually under supervision, ideally augmented by a
personal analytic experience.
Finally, experienced analytic therapists, in charge of supervising
others, can gain from shared discussion of patients with psychosis who
have been referred to them for management. In a changing climate
within the NHS, psychotherapy departments are coming under
increasing pressure to become more involved within the community
health centres in helping in the management of psychotic patients and
this needs further thought.
The concluding chapter provides a summary of the framework of
approach developed throughout the previous chapters. It is hoped that
this book will show how much psychoanalytic perspectives can con-
tribute to the world of psychiatry. I hope to succeed in demonstrating
that in an area often regarded as the most arid for a psychoanalytic
input, applied analysis paradoxically has a centrally important role
to play.

15
2
The medical model

Introduction

In this chapter I will review both the positive aspects and the limita-
tions of the medical model of psychosis, arguing that the medical
model has an important contribution to make within an overall
framework that also needs to incorporate an analytic dimension.
Readers are referred to comprehensive psychiatric textbooks for
detailed descriptions of classification in psychiatry, and guidance on
the conduct of the clinical interview and the mental state examin-
ation (Gelder et al. 2001; Goldberg 1997).

The rationale behind classification

All medical models relate to a background system of classification.

In psychiatry there are two main classifications, the International
Classification of Diseases (ICD-10: World Health Organization
(WHO) 1994) and the American Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV: American Psychiatric Association (APA)
1994). The use of an agreed international nomenclature allows for
research and comparison studies of the incidence of mental illness
in different cultures and different continents.
A classical example of the need for a mutually agreed classification
arose many years ago from a UK–US study on cases of depression.
In England, videos shown of depressed patients were all diagnosed
by psychiatrists as depression. In the East Coast of the United States
they were similarly diagnosed, but as one moved to the West Coast
the diagnosis altered to pseudo-neurotic schizophrenia, a locally used

16
The medical model

nomenclature. Such incidents highlighted the need for an inter-

nationally agreed nomenclature (Cooper et al. 1972).
As well as national and international classifications, used for
research purposes, psychiatrists carry with them their own more
simplistic classification for everyday practical purposes. For some this
may include headings of neuroses, psychoses, personality disorders,
learning difficulties, psychosomatic and adjustment disorders, though
in the formal classifications terms like neurosis have been dropped in
favour of more specific categorisation.
When we turn to psychoses, practically speaking they can be div-
ided into the organic psychoses and those that were once known as
the ‘functional psychoses’, schizophrenia and affective disorders,
where the underlying organic aetiology has yet to be fully established.
Individuals suffering from organic psychoses exhibit a demonstrable
cognitive impairment on mental state examination, related to an
identifiable physical cause. Organic psychoses may be divided into
acute and chronic disorders. The former, also described as acute toxic
confusional states, could relate to infections, drug abuse or metabolic
disorders. They are characterised by confusion, often with visual hal-
lucinations, and have a more favourable prognosis than the dementias.
The need for doctors to have a classificatory system of the psych-
oses in mind is very important at the everyday clinical level, as
illustrated by the following gross examples. Many years ago, I worked
as liaison psychiatrist in a general hospital. At the time, the referring
medical doctors often had no system of classifying mental disorders
in their minds.

One day when I was asked to see a young man in casualty, the message I
received was that he was ‘as nutty as a fruit cake, call the psychiatrist!’
When I saw this young man, he was in a confused state with visual hallucina-
tions, but without presenting any neurological signs. Clearly, he was in
an acute toxic confusional state and I suggested that he was admitted as a
medical emergency. He was later found to have meningo-encephalitis.

In another case, no distinction was made between a reversible toxic

confusional state and dementia.

I was asked to see a 92-year-old woman, who had been admitted the day
before and was in a confused state. All it said on the referral note was, ‘For
senile disposal!’ When I took her history, it turned out that only a few days

17
A psychoanalytic perspective on psychosis
previously her mind had been quite clear, and her confused mental state
was the result of acute bronchitis. With antibiotics she made a full recovery.

The general psychiatric viewpoint on classification in psychosis is

interesting, as described in the Oxford Textbook of Psychiatry (Gelder
et al. 2001). The authors advocate the need for an agreed system of
classification to enable clinicians to communicate about their patients’
symptoms, treatment and prognosis and for research purposes. They
point out that the main critics of classification have tended to be
psychotherapists who are concerned more with neurotic and person-
ality disorders than with the more severe disorders. The critics of
the medical model complain that attempts at classification ignore the
individual patient and their unique characteristics, while the psychi-
atrist’s response is that it is possible and important to consider an
individual’s response to treatment and its prognostic implications, as
providing additional information to work with, complementary to
the classification that they use.
Like neurosis, psychosis is no longer used as an organising principle
in either the ICD-10 or DSM-IV, with the aim nowadays being to
describe individual disorders in more precise terms. Gelder et al.
(2001) note that in modern usage, the term psychosis refers broadly to
severe forms of mental disorder such as organic mental disorders,
schizophrenia and affective disorders. However, since it is difficult to
define what is meant by lack of insight or identify criteria to assess the
patient’s ability to distinguish between subjective experiences of real-
ity and hallucinations or delusions, the term psychosis is unsatisfactory
for classificatory purposes. Further, different conditions placed under
the rubric of psychoses have little in common, so that it is better to
concentrate on the different conditions such as schizophrenia.
They do note that the adjectival use of the term psychotic will
remain in clinical parlance, thus hallucinations and delusions are
commonly referred to as psychotic symptoms (Gelder et al. 2001).
The logic and rationale behind the approach outlined by Gelder
and colleagues is clear and well stated. However, at an everyday clin-
ical level, the term psychotic carries far more weight than merely an
adjectival term recognised as shorthand for certain symptoms. It is
therefore important to think carefully about what we mean when we
use the term psychosis. Recognising a psychotic state is the first step
towards arriving at the understanding that enables the prognosis and
appropriate management to be determined, and this in itself is not

18
The medical model

always an easy task, let alone then identifying a more precise diagnosis.
Where a psychotic state is recognised, a wholesale reorientation in
considering the approach to the presenting situation may be required.
For example, we will approach a patient who we understand as simply
overreacting to stress differently from someone who we see as covering
up an underlying psychotic state with all its implications for under-
standing and management, even though the presenting situations may
be superficially similar.
Nevertheless, it is important to fully appreciate the rationale behind
the medical approach, if one is to feel comfortable in integrating its
contribution within a dynamic approach to psychosis.

Diagnosing schizophrenia

In 1896, Kraepelin separated the organic psychoses, such as general

paralysis of the insane (terminal syphilis), from manic depressive states
and what he called dementia praecox (Kraepelin 1896). Dementia
implied an irreversibility and praecox meant of the young. In 1911,
Bleuler’s term schizophrenia gained acceptance. The use of this term
implied a fragmentation of the mind, that there was more than one
disorder under the overall heading, that the prognosis was not neces-
sarily poor and that the condition did not necessarily occur only in
the young (Bleuler 1911).
Schizophrenia remains very difficult to define. One tends to fall
back on a textbook description of the most characteristic symptom-
atology and areas of dysfunction. Such a description would include
symptoms under general headings such as disturbance of thinking,
disturbance of mood, loss of drive or volition (the so-called negative
symptoms of social withdrawal), disturbance of movement including
catatonia, and delusions and hallucinations. These symptoms would
occur in the absence of an associated organic disorder.
If a patient presents with all the classic textbook symptoms, then
there may be no difficulty in making the diagnosis. However, problems
arise if only a withdrawn state is present or just a thought-disordered,
vague state of mind. Then the diagnosis becomes harder to make.
When it comes to diagnosis in medical terms, there are different
levels of precision (Scadding 1967). We can diagnose through a
cluster of symptoms forming a syndrome, the method advocated by
Hippocrates. We can use diagnostic biochemical tests, or we may be

19
A psychoanalytic perspective on psychosis

able to isolate the specific cause. For example, taking syphilis as a

model, it may present as a genital sore. Yet there are many other causes
for such a venereal infection. One could then look for a positive
Wasserman Reaction, a biochemical test, but a positive result is not
specific only to syphilis. One may then identify the responsible organ-
ism, the spirochaete, Treponema Pallidum, and one has then reached
a precise diagnosis.
In the case of schizophrenia, we remain at the level described by
Hippocrates, namely diagnosing at the syndrome level. The aetiology
of schizophrenia remains a mystery despite all the research with its
suggestions of structural changes to the brain. Many conditions with
differing aetiologies can present with a picture that resembles schizo-
phrenia, such as temporal lobe epilepsy, amphetamine psychosis, por-
phyria, Huntingdon’s chorea, in addition to stress-induced states and
bipolar disorder. There may be many more conditions, as yet unclassi-
fied, all presenting in similar ways and all currently labelled schizo-
phrenia. Thus we can see the limitations of our current knowledge.
Returning to the textbook descriptions of schizophrenia, one
might use migraine as a parallel example to illustrate the problems with
diagnosing at the syndrome level. A visual aura followed by a uni-
lateral throbbing headache with nausea and vomiting is called classical
migraine. If the aura is absent it is called common migraine. If the
headache is bilateral or is not throbbing should one describe it as a
‘forme fruste’ of migraine or no longer call it migraine? There is no
clear answer to this question. The same problem applies to diagnosing
schizophrenia. This uncertainty accounts for the dominating pre-
occupation in general psychiatry with phenomenology and eliciting
so-called first-rank symptoms in the mental state examination.

Phenomenology

Phenomenology, as originally applied to psychology by the German

psychologist Jaspers, is concerned with the objective description of
abnormal states of mind ( Jaspers 1967 ). The phenomenological
approach aims to be objective and scientific in describing subjective
experiences in psychosis, through defining and classifying psychic
phenomena as the first step. Thus a delusion might be defined as a
false belief held in the face of contrary evidence and not amenable to
reason or logic acceptable to someone of a similar cultural background.

20
The medical model

A sudden appearance of a firmly held delusion in the absence of an

organic illness may be strongly suggestive of a schizophrenic illness.
In Jasperian terms, if a voice is experienced as coming from outside
one’s head this is termed an auditory hallucination and would be
regarded as pathological. If it is felt to be coming from inside the
head, it would phenomenologically speaking be termed a pseudo-
hallucination and be viewed as non-pathological. Eliciting psycho-
pathology indicative of schizophrenia is seen from the medical
position as the preliminary task in interviewing all patients. Only
then can the elicited symptoms be grouped together to form a recog-
nised syndrome.
In this exercise, theoretical views of causation have no place; indeed
they would be felt to interfere with the aim of achieving an objective
description of the patient’s subjective experiences. The advantage of
the phenomenological approach is to build up descriptions of psy-
chopathology where there is a clear and agreed understanding of the
terminology being used.
Nevertheless, the question remains how to make optimal use of
the phenomenological approach in defining schizophrenia. Schneider
(1959) tried to make the diagnosis more reliable by viewing certain
symptoms as carrying more weight, the so called ‘Schneiderian first-
rank symptoms’. These include hearing your thoughts spoken out
loud, voices talking about you, believing that you are being made to
feel things or having thoughts inserted into your mind, or having
thoughts withdrawn and broadcast, as well as delusional perceptions.
However, some 25 per cent of patients with manic depressive states
show first-rank symptoms, while some 25 per cent of patients with
established schizophrenia do not. While standardised interview tech-
niques have arisen from this dilemma for research purposes, such as
the present state examination (Wing et al. 1974), in everyday clinical
practice the diagnostic difficulties remain.

The mental state examination

Junior psychiatrists in training spend a great deal of time on the

mental state examination, developing their ability to elicit first-rank
symptoms using the phenomenological approach. The first part of
the mental state examination concentrates on this area, describing
appearance, speech, mood, thought disorder and abnormal beliefs

21
A psychoanalytic perspective on psychosis

and perceptions. The second part turns to the cognitive state,

looking for organic pathology such as evidence of disorientation and
memory impairment. After evaluating the patient’s insight into his
or her condition, a diagnostic formulation is made with a differential
diagnosis, based in the UK on the ICD-10 classification system
(WHO 1994).
While the aetiology of schizophrenia continues to be investigated,
primarily through neurological studies of the brain, and through the
psychopharmacological action of drugs and neurotransmitters, gen-
eral psychiatry recognises that emotional factors have a part to play
in relapses.
It is recognised that as well as defaulting from medication, living
in an emotionally over-pressurising environment, described as an
environment where there is high expressed emotion (EE), can lead
to relapses. Educating the family to lower their expectations of the
patient can alter this pattern (Leff 1994). However, though the poten-
tial of emotional stresses to precipitate relapse is recognised, the general
psychiatric approach to schizophrenia is firmly focused at the phe-
nomenological and psychopharmacological level. Once the diagnosis
has been made through the phenomenological approach, the focus
is treatment through medication.
This approach seems to leave little room for a psychoanalytic contri-
bution. Indeed patients diagnosed with schizophrenia are felt to be
too unwell for any psychotherapeutic intervention other than a gen-
eral supportive approach or a cognitive-behavioural approach that
reinforces reality.
The mental state examination is a snapshot taken at a particular
moment in time and as such it lacks a dynamic element. A patient
with a schizo-affective disorder may present a picture that resembles
schizophrenia one day, and a few days later looks more like depression.
Also, when taken in isolation, a purely phenomenological approach is
not necessarily reliable diagnostically in distinguishing schizophrenia
from hypomanic states.

Clinical implications

The importance of the formal mental state examination is over-

emphasised in psychiatric training. This may encourage junior doctors
to develop a somewhat one-sided, rigid, organically based approach

22
The medical model

to psychosis, lacking a dynamic touch. The following serves as an

illustrative example.

A young man in his twenties already had a protracted history of severe

chronic schizophrenia. As well as failing to take his medication, he would
also drink, and when he ran out of money would go round to his mother
and demand money from her in a threatening manner. His mother could
not stand up to him. His father, who worked as a long-distance lorry driver
and was away much of the time, was the only one who stood up to him.
The patient was in such a disturbed state on his latest admission that he
required initial containment on the secure ward. After spending a lengthy
period on the secure ward and receiving a large dose of depot medication
to calm down his aggressive paranoid state, which had been accompanied
by persecutory voices, it was felt that he might finally be ready for transfer
to our open ward. My junior doctor saw him and said that the persecutory
voices had all gone apart from one: he was still troubled by hearing his
father’s critical voice. The doctor asked whether he should increase the
patient’s medication further prior to his return to an open ward, as it seemed
that his psychosis had not yet quite resolved.
I replied in the negative, pointing out that his father’s voice represented
his sanity, the only part in his mind standing up to his disruptive lifestyle.
When I saw him the patient also complained about hearing his father’s
voice and said that he wanted it removed. However, when I pointed out its
positive significance as a representative of the only person who stood up to
him, he smiled in a way that seemed to acknowledge that a meaningful
exchange was taking place, rather than an approach centred solely on
phenomenology and concern with the appropriate level of medication to
the exclusion of all other considerations.

Incorporating an analytic perspective

Organic psychiatrists draw attention to the difference between patho-

genesis and pathoplasty. In other words, conditions have their under-
lying organic causation, although the presenting clinical picture may
be influenced by the individual’s culture and social circumstances.
The danger with this approach is the development of a false degree
of confidence in relation to psychotic states. The clinical procedure
becomes straightforward and predictable. One simply diagnoses the
type of psychosis through the mental state examination and establishes

23
A psychoanalytic perspective on psychosis

the appropriate drug regime, while reviewing any concurrent social

stresses and rehabilitation needs. Tom Freeman, a psychoanalyst who
also spent his career in general psychiatry, once said to me at a meeting
that ‘The difference between us and the organically orientated psy-
chiatrists is that they know what is going on. We haven’t the faintest
idea so we have to listen to our patients to see if they can teach us!’
(see Chapter 7 for his contributions).
I have found that incorporating an analytic perspective when lis-
tening to the patient’s history opens up a whole new way of relating
to the patient. In the following chapters I will show how this approach
can deepen our understanding of our patients. It offers a way to move
on from the necessary preliminary phenomenologically based diag-
nostic approach, into an affectively more relevant and meaningful
way of relating to our patients.

Summary

The medical model has both positive aspects and limitations. Through
a phenomenological approach, the medical model takes an objective
stance towards subjective symptoms in order to arrive at a diagnostic
and classificatory system for psychotic disorders. This is valuable for
cross-cultural research and for legal purposes, when a medical diagnosis
is required. However, the model is limited by its lack of accommoda-
tion of a dynamic perspective. It is this aspect that will be explored in
the chapters that follow.

24
3
Controver sial issues in psychosis

Introduction

This chapter will consider some ongoing controversies in psychosis.

These include the questions of whether the differentiation of psych-
osis is stigmatising, what psychoanalysis has to offer if the roots of
schizophrenia are biological, the role of the inpatient ward and how
medical, CBT and psychoanalytic perspectives differ.

Should we differentiate psychosis?

In 2003 Richard Bentall, who was then Professor of Clinical Psych-

ology at Liverpool University, wrote a book entitled Madness
Explained, in which he expressed the view that there was no clear
dividing line between what he termed sanity and madness, and that
the use of diagnostic labels was therefore stigmatising (Bentall 2003).
In his preface he wrote:

Scientists, like ordinary folk and psychiatric patients, are flawed,

emotional and excitable human beings who are sometimes wise
and sometimes stupid, sometimes lovable and sometimes bloody
irritating. By talking about my own experiences, both positive and
negative, I have attempted to highlight an important theme of this
book, which is the vanishingly small difference between them the
‘us’ who are sane and the ‘them’ who are not.
(Bentall 2003, p. xiv)

He later cited his own experience of distress following the break-up

25
A psychoanalytic perspective on psychosis

of his first marriage, as anecdotal evidence in support of this

assertion.
Bentall (2003) argued that experiences such as delusional beliefs
and hearing voices are exaggerations of mental foibles to which we
were all vulnerable, and which in some cultures were not seen as
abnormal at all. He continued:

In these pages, I have tried to demonstrate that the difference

between those that are diagnosed as suffering from a psychiatric
disorder and those who are not amounts to not very much. This is
an important insight because of its application for psychiatric care.
As I hope to demonstrate in a later publication, the dreadful state of
psychiatric services is not only a consequence of muddled thinking
about the nature of psychiatric disorders, but also a consequence of
the way in which psychiatric patients have been denied a voice by
being treated as irrational and dangerous, like wild animals in a zoo.
(Bentall 2003, p. xiv)

Bentall emphasised that he approached psychosis from the position

of an experimental psychologist. For example, he described how
he investigated the relationship between mania and depression and
the concept of the manic defence by exploring patients’ attitudes
to words presented to them in these two states. This was regarded as
a scientific and measurable approach, in contrast to the analytic
approach. Bentall entitled a chapter on mania ‘A colourful malady’, in
support of which he quoted Virginia Woolf saying: ‘As an experience
madness is terrific’ (Bentall 2003, p. 271).
From a CBT perspective, Kingdon and Turkington (1994) pro-
posed a general framework for working with psychotic patients,
which they described as a normalising strategy. Bentall observed:

The idea behind this approach is to demystify psychotic experi-

ences and make them seem less frightening, for example by point-
ing out the similarities between hallucinations or paranoia and
more mundane mental states, or by explaining to patients that these
experiences are much more common than is often realised.
(Bentall 2003, p. 508)

Bentall concluded with the view: ‘Why not help some psychotic
patients just to accept that they are different from the rest of us? Fear

26
Controversial issues in psychosis

of madness may be a much bigger problem than madness itself ’

(Bentall 2003, p. 511).
Bentall’s views are representative of an important attitude to psy-
chosis from a predominantly non-medical cognitive psychological
perspective.
In his foreword to the book, Aaron T. Beck, the father of cognitive
therapy for delusions, observed that Bentall ‘has endeavoured to slay
the monster – mental illness – and in this volume he has shown that
he has trapped it, if not finished it off’, giving his support to the view
that the idea of mental illness as a diagnostic entity can be discarded
(Bentall 2003, p. xii).
Despite the title of Bentall’s book, he does not define madness or
specify whether it is to be distinguished from psychosis. The Oxford
Dictionary (1990) does make this distinction. It gives several different
ways we use the term madness, from insane to wildly foolish, excited,
angry or light-hearted, while in contrast psychosis is described as a
severe mental derangement, especially when resulting in delusions
and loss of contact with external reality.
Bentall’s refusal to differentiate the major psychotic disorders from
moments of temporary aberration enables him to argue that the
approach of differentiation taken by mental health care services
dehumanises their patients and denies them a voice.
Bentall (2003) emphasised the limitations of the solely medical
model of psychosis, with its preoccupation with classification, phe-
nomenology and the biological approach, without considering its
positive aspects with respect to diagnosis and classification.
For example, the manic states that characterise bipolar disorders are
linked with a denial of the underlying severe depression with poten-
tial self-harm, with associated statistics of a 15 per cent risk of suicide.
Thus Virginia Woolf’s manic states would alert the clinician to her
possible underlying vulnerability to suicide, as tragically occurred.
Here diagnostic labels matter because of the associated prognostic
concerns that they can raise.
The view that fear of madness may be a much bigger problem than
madness itself is an interesting proposition. If it is correct, then we
have to consider it from all angles. First, madness, or here I would
prefer to use the term psychotic disorders, leads to frightening states of
mind for all those involved with them. We cannot easily grasp and
understand these states of mind, which challenge all our belief systems.
The challenge is for us to learn to accept these conditions, however

27
A psychoanalytic perspective on psychosis

ignorant we may be about their aetiology, and try to study them on

their own terms. If we cannot meet this challenge, we will fall back on
imposing views and theories with which we are already familiar.
Many non-psychiatrists try to minimise the condition of schizo-
phrenia, pointing out that each person is different and unique and that
a diagnosis of schizophrenia is stigmatising. When this view is adopted,
the psychiatrists and nursing staff who have primary responsibility for
containment and management of very difficult states may come in for
particularly harsh criticism.
However, it is unlikely that strategies such as changing the name
of schizophrenia to ‘integration disorder’, or even abolishing the
concept, would affect the root cause of the stigma – the public’s
ignorance and fear of people with mental illness. Renaming might
even have the unintended consequence that the individual, rather
than their illness, would be blamed for their symptoms.
As Lieberman and First (2007) have written:

Ultimately, we must gain a more complete understanding of the

causes and pathophysiological mechanisms underlying schizophre-
nia. Only then can we replace the way we characterise schizophrenia
with a diagnosis that more closely conforms to a specific brain
disease. In the meantime, we can be confident and grateful that the
benefits conferred by the concept of schizophrenia far outweigh
any perceived disadvantages.
(Lieberman and First 2007, p. 108)

Is psychoanalysis relevant to schizophrenia?

When the International Journal of Psychoanalysis decided to run a

series of articles on current psychoanalytic controversies, they chose
to begin with the relationship between psychoanalysis and schizo-
phrenia (Lucas 2003a). I was invited to put the case for analysis, while
Robert Michels, an analyst from New York, put the counterview.
Michels began by referring to the work of Martin S. Willick as an
example of the prevailing and in Michels’ view appropriate attitude
among North American analysts to the question of the relation
between psychoanalysis and schizophrenia.
In an article entitled ‘Psychoanalysis and schizophrenia: A caution-
ary tale’, Willick (2001), an American analyst, had cited the history of

28
Controversial issues in psychosis

psychoanalysis and schizophrenia as an example of psychoanalytic

theories that have not stood the test of time.
Analysts had imposed their theoretical views of aetiology, attrib-
uting schizophrenia to early trauma linked with an emotionally
unresponsive mother, rather than accepting an underlying biological
causation. This was supported by the outcome figures from Chestnut
Lodge (see Chapter 8), where a purely analytic approach had been
taken to borderline states and schizophrenia. While outcome figures
were favourable for an analytic approach to borderline states, they
were not for schizophrenia (McGlashan 1984b).
In a review of British object relations theorists, with the except-
ion of Rosenfeld, Willick held that he was unable to find a single
well-documented case of schizophrenia in the work of Klein,
Winnicott, Fairbairn, Guntrip, and Bion. Without any clinical sup-
portive evidence, they had all lumped together schizophrenia, schiz-
oid personalities and the more severe character disorders as examples
of failures adequately to overcome the paranoid-schizoid position.
In response to my argument that psychoanalysis still has a unique
contribution to make in relating to psychosis, Michels (2003) wrote:

The history of the relationship between psychoanalysis and schizo-

phrenia is complex. So-called psychoanalytic theories of aetiology
have not only been of little scientific value, their application to
the psychotherapy of schizophrenic patients or in discussion with
their families has often been demoralising and counterproductive.
In the empiric arena of evidence and science, they have largely lost
out to biologic and psychosocial models. Most North American
psychoanalysts, exemplified by Willick, see the important aspect of
the story of psychoanalysis and schizophrenia to be an example of
how analysis can go so far astray, with the hope of preventing
misadventures in the future.
(Michels 2003, p. 9)

In my article I gave several vignettes in support of the psycho-

analytic framework that I have developed in relating to schizophrenia,
which this book will elaborate. I take the view that in working with
patients with schizophrenia, as Bion suggested, we always need to
think in terms of two separate parts, the psychotic and the non-
psychotic, not one person (Bion 1957a; Lucas 1992). The psychotic
part is intolerant of frustration and attacks the thinking arrived at by

29
A psychoanalytic perspective on psychosis

the work of the non-psychotic part. Hence the need to tune into the
psychotic wavelength: whenever we are dealing with a patient with a
major psychiatric disorder, we need to ask ourselves whether we are
receiving a communication from a non-psychotic part or a psychotic
part masquerading as normal (Bion 1957a). As discussed in Chapter 1,
the commonest symptoms of schizophrenia are not auditory hallucin-
ations or paranoid delusions, encountered in some 60 per cent of
cases, but denial and rationalisation, found in over 95 per cent of cases
(Lucas 1993). One vignette was the example of a young woman who
had jumped out of a window (see Chapter 11, Case 4 for full details). I
suggested to this woman that she had not jumped out but rather had
been pushed out by an intolerant (psychotic) part of her; this led to a
dramatic change in her mental state. Michels thought this interven-
tion was ‘highly theoretical, confusing and potentially misleading –
not the kind of thing I would say to a schizophrenic patient who
might have difficulty interpreting metaphor or thinking abstractly’
(Michels 2003, p. 12). He also felt that a model incorporating issues of
conflict was inappropriate for a condition with an organic aetiology.
Michels was very critical of the lack of any evidence-based material
to support the belief that psychoanalytic treatment was relevant to
schizophrenia, for without applying this standard: ‘examples of how
psychoanalytic concepts can enhance our understanding of experi-
ences with patients with schizophrenia won’t simply be unconvincing,
they will be seen as irrelevant to the dialogue concerning the treatment
of schizophrenia’ (Michels 2003, p. 12).
Michels recognised that psychoanalysis helped people to cope with
stress and so helped caretakers to experience the humanity of their
patients or clients, but however valuable this was: ‘psychoanalysis had
no more special relevance to schizophrenia than it does to multiple
sclerosis or cancer or homelessness’ (Michels 2003, p. 10). Michels
went on to question the claim that psychoanalysis has a unique rele-
vance in the area of schizophrenia, arguing that ‘most psychoanalytic
claims in this area have been based on professional narcissism rather
than clinical evidence’ (Michels 2003, p. 11).
He concluded:

I suspect that psychoanalytic treatment has little relevance to schizo-

phrenia, or to its so-called ‘primary’ psychopathological features.
Psychoanalytic treatment is most helpful for individuals whose core
problems are largely related to mental conflicts and experiences that

30
Controversial issues in psychosis

can be understood psychoanalytically, and who have the capacity to

participate in the process of enquiry and treatment. Unfortu-
nately, neither is true of most schizophrenic patients [. . .] In
brief, schizophrenia is a relative contraindication to psychoanalytic
treatment.
(Michels 2003, p. 11)

Michels’ critique highlights some central controversial issues in a clear

way that requires responses. First, it is crucial to distinguish between
psychoanalysis as a curative treatment, a method of study of the mind
and a theoretical framework that can inform our work with patients
in general psychiatry.
Given our current ignorance of the aetiology of schizophrenia, the
criticism that the relationship history of psychoanalysis and schizo-
phrenia is complex applies to all approaches to schizophrenia, not just
psychoanalysis.
Michels highlights the risk for all practitioners of becoming over-
enthusiastic about their particular line of approach. He argued that
thinking about the behaviour and communications of schizophrenic
patients from a psychoanalytic perspective was comparable to the use
of applied analysis in interpretation of a work of art, and suspected
that while taking this approach might make the practitioner feel more
comfortable and engaged in his difficult work, other equally plausible
explanations could equally well be proffered.
It is certainly true that a consideration of the symbolic meaning
behind communications can make practitioners feel more comfort-
able and humanise their work, since it helps them to see the patient as
an individual with his or her own particular way of responding to a
crisis, rather than viewing the patient in a cut-off way as purely a
representative of a diagnostic category.
Many years ago, I heard Professor Roger Higgs, a Professor for
General Practice at London University talking about the training
of general practitioners (GPs) and the feelings related to their work. I
was struck by his descriptions, which resonated with my own feelings
working as a psychoanalyst in general psychiatry.
When he sent trainees to his practice, he did not expect them to see
all the patients in a busy clinic, but rather take one patient and see
them for as long as they liked in order to come to understand them.
He felt this experience could later be transposed into running the
busy clinics. Similarly, the experience I gained from analytic training

31
A psychoanalytic perspective on psychosis

where I had time to learn from seeing patients individually, informed

my work in busy outpatient clinics and ward reviews, which at times
can involve seeing over twenty patients at a time, including several new
admissions.
Higgs highlighted GPs’ worries about coping and fears of burnout
if they had to fit an emergency into an already busy clinic; feelings
one could readily identify with in the role of general psychiatrist.
Higgs then made the interesting point that GPs often regarded
their work as trivial in comparison to specialists. A similar attitude
can prevail in psychoanalysis, where applied analysis can be devalued
compared to individual analysis. However, Higgs drew attention to
the Latin root of the word trivial, meaning where three roads met and
where people would stop to gossip.
In subsequent chapters, clinical examples will be given to show that
incorporating an analytic perspective can enrich the psychiatrist’s
work and help to bring clarity and direction, as for example when
helping the judge arrive at a decision in ‘A tale of a wig’ (Chapter 11,
Case 2). Incorporating an analytic perspective can also bring interest
and humour into very demanding work, thereby reducing the risk of
burnout and indifference.
If we now consider the lifelong management of patients with
chronically disabling psychotic disorders, then one could take issue
with Michels’ view over the relevance of psychoanalysis in this area.
While recognising that psychoanalysis provides overall frameworks
for helping people cope with stresses, Michels suggests that psycho-
analysis has ‘no more special relevance to schizophrenia than it does
to multiple sclerosis or cancer or homelessness’ (Michels 2003, p. 10).
However, individuals with the latter conditions do not require
continual risk assessment. Their communications do not require us
to ask ourselves whether they are straightforward communications
from a non-psychotic part of the personality or denials and rational-
isation from the psychotic part, which may be harbouring dangerous
intentions (see Chapters 11, 18 and 19).
Michels questions the technique of interpreting in a confronta-
tional way to the patient about the functioning of their psychotic
part, due to the cognitive difficulties present in schizophrenia and the
lack of capacity for symbolic thinking. However, in the case of the
patient who jumped out of the window, my interpretation produced a
dramatic response, and a shift in emphasis, after months of stasis. It
brought the patient’s murderousness into the open. I believe that her

32
Controversial issues in psychosis

frightened non-psychotic part felt supported and was grateful for my

intervention. This was also true for her involved and caring mother
(Chapter 11, Case 4).
With regard to technique, if one thinks in terms of the psychotic
and non-psychotic parts of the personality, one has to deal with the
problem of the behaviour of the psychotic part first. Inevitably, this
may at times take the form of a confrontational style.

An example would be the case of a patient with a thirty-year history of

chronic schizophrenia, who was placed in a group home when his previous
asylum, Claybury Hospital, closed. In the home he became aggressive, hit
other patients and stubbed cigarettes on the carpet until he was readmitted,
now to the district hospital. In hospital, he repeatedly claimed in a tirade
that he was not Mr X, but Mr Y, born six years before Mr X. He said that he
owned Claybury Hospital, was owed £80 million pounds and that Dr Lucas
had stolen his Ford Granada!
In the end I found a way of speaking to him. I told him that I was not
talking to Mr Y but Mr X. We had a big problem with Mr Y. He was infantile,
did what he wanted and if he couldn’t get his way all the time he would
do things like stubbing cigarettes on the carpet and hitting other residents in
the group home; and he lived in a grandiose world of his own making,
believing that he owned Claybury Hospital and that I had stolen his Ford
Granada.
This intervention took the wind out of his sails. When I saw him later in the
hospital corridor, he said to me in a rather sulky voice, ‘All right, Dr Lucas,
there are two of me!’ He was transferred in time to the rehabilitation ward. I
always knew when he had been misbehaving, as on such occasions if we
bumped into each other in the corridor, he would say, ‘I’m Mr Y not Mr X!’
Invariably the rehab staff would subsequently confirm my suspicions.

While it is important at times to stand up to the psychotic part of

the patient, there are many other situations where a consideration of
the delusions they describe together with one’s countertransference
can help one to become empathic to the patient’s current predicament.
Michels (2003) questions the ability of the patient with schizophrenia
to understand metaphors. The challenge is rather for us to get onto
the patient’s wavelength and find a way to understand the meaning
conveyed within their delusional communications.
Michels referred to psychoanalysis as providing a framework for
conversations about human experiences, but only one among many

33
A psychoanalytic perspective on psychosis

others. He is correct that there are other approaches, such as cognitive

behavioural or narrative styles. However, psychoanalysis differs fun-
damentally from other psychological disciplines in its recognition of
an unconscious internal world and its influence on the individual’s
life and behaviour.
Finally, Michels emphasises the importance of controlled outcome
studies and the fact that while they have shown the efficacy of psy-
choanalysis as a treatment for borderline states, this has not been the
case for schizophrenia. However, by focusing solely on the research
outcome of controlled trials, one is in danger of moving away from
seminal insights gained through individual case studies, and throwing
the baby out with the bathwater.
Moreover, within the context of audit, there are in fact operational
research outcome data to support the effectiveness of applied analysis
as part of an overall integrated approach to schizophrenia.

The role for hospital-based services within an

integrated approach

Robbins advocated an integrated approach to schizophrenia, thinking

in terms of interlocking hierarchical systems – intrapsychic, inter-
personal, family, social and cultural and neurobiological – to remedy a
reductionistic approach in the United States, which some decades
ago was dominated by a psychoanalytic approach (Jackson 2001a;
Robbins 1993).
Based on forty years of psychotherapeutic involvement with
patients with schizophrenia in Finland, Alanen (1997) advocated
the development of what he termed a ‘need-adapted’ approach
to treatment. While all approaches to treatment were recognised,
including biomedical, individual, familial, therapeutic community
and rehabilitation, Alanen held that decisions about which approaches
are most appropriate should be made on a case-specific basis. For this
to happen, Alanen argued for the central importance of an overall
psychoanalytically informed assessment.
Input from a consultant supervisor with analytic experience is
required to make the need-adapted evaluation. As Alanen (1997)
described, the consultant should promote a non-authoritarian atti-
tude, in which each team member is encouraged to develop his/her
own skills in a creative way. Caring family members also have a crucial

34
Controversial issues in psychosis

role to play in the initial assessments and ongoing treatment. This

approach led to shorter admissions, lower levels of medication and
improved rehabilitation figures compared to other districts in Finland.
When I moved out from the asylum to a district setting, the intro-
duction of a sector team afforded the opportunity to make this sort of
integrated approach available to a local area. The community workers,
the day hospital and the inpatient unit were now able to function
together as parts of one cohesive service. The sector ward was designed
by the ward manager to maximise the size of a centrally supervised
area for day activities, while allowing for separate-sex sleeping quarters.
Regular ward reviews three times a week, availability of access
to move out easily to the day hospital and other community sup-
port were vital ingredients. However, a psychoanalytically informed
framework of approach to assessments was at the core of the approach.
This framework of approach encompassed a basic philosophy of
accepting psychosis, tuning into the psychotic wavelength, differen-
tiating the psychotic from the non-psychotic personality, exploring
the meanings of hallucinations and delusions, utilising the team’s
countertransference experiences and an appreciation of the import-
ance of the function of the ward admission for containment and
assessment.
The adoption of this approach led to annual bed occupancy figures
of 100 per cent compared to 150 per cent levels for the other acute
wards, with associated lower drug expenditure figures and shorter
length of stay in hospital (Lucas 2004).
Unfortunately, a policy was subsequently introduced to make each
ward single sex, leading to the loss of the integrated model and six
consultants sharing beds on one ward. This led to bed occupancy
running at 150–170 per cent, with sleeping out in the private sector.
The response has been the creation of crisis resolution home treat-
ment teams and early intervention services to reduce the stress on the
ward and contain patients in the community wherever possible away
from hospital based services ( Johannessen et al. 2006).
Brian Martindale (2007) described setting up such an early inter-
vention service in North England, based on Cullberg’s Swedish
‘stress-vulnerability model’ (Cullberg 2001; Martindale 2007). He
noted that ‘In the UK, perhaps because of the separation of specialist
training for psychotherapy from adult and community psychiatry,
psychodynamics is rarely integrated into the psychiatry of psychosis’
(Martindale 2007, p. 34).

35
A psychoanalytic perspective on psychosis

Nowadays, there is less emphasis on developing a seamless service

that incorporates inpatients, day hospital outpatients and community
services, and admission to hospital is often viewed in negative terms.
The closure of the asylums resulted in a drastic reduction of inpatient
beds and the acute wards became overburdened, leaving the nurses
little time to relate therapeutically to their patients. The wards became
depressing, unsafe places, with easy access to drugs (Fagin 2001, 2007;
Mind 2000). This problem remains, though attempts are being made
to address the crisis (Firth 2004; Holmes 2004; Kennard et al. 2007).
However, the important role played by the acute ward in contain-
ment and assessment needs recognition. Within this context, nurses
need support and training to gain confidence in what is most
demanding work (Evans 2006).
There is also controversy about the role of day hospitals. Some
of us would argue strongly that having a professionally run day hos-
pital at one’s disposal is a real asset. It can be used to prevent admis-
sions and facilitate early discharge. It can help people to work through
adjustment reactions. It can also help young patients facing the early
stages of a schizophrenic illness to combat social isolation. It provides
individual therapy, groups and occupational therapy.
Apart from the economic cost of running a professionally staffed
day hospital, there is a view in some quarters that the name alone of
day hospital carries the stigma of institutionalisation and that like the
inpatient ward, it is a place best avoided. The aim, after early onset
psychotic breakdowns, would be to ‘normalise’ the situation by getting
people back in the community as soon as possible and receiving their
support away from hospital settings. Our day hospital recently only just
survived a threat of closure within a climate of economic austerity,
thanks to powerful representations to management from the users.
Nevertheless many such day hospitals have been closed in recent years.

Contrasting approaches to delusions

The medical model

Classical psychiatric teaching, based on phenomenology, the eliciting

of symptoms for purposes of diagnostic classification, does not look
for dynamic explanations for delusions. This approach distinguishes
between obsessional symptoms, overvalued ideas and delusions.

36
Controversial issues in psychosis

Obsessional or compulsive symptoms are characterised by a sub-

jective sense of compulsion overriding an internal resistance from the
healthy part of the patient. If the whole of the patient identifies itself
with the idea (e.g. of contamination), then we are dealing with a
delusional idea rather than a compulsive one. Overvalued ideas fall in
between these two forms of symptoms; they are accepted by the
patient but not without doubts.
In relation to delusions the idea of ‘incomprehensibility’ is not an
absolute one. For example, a markedly sensitive premorbid personality
who develops delusional jealousy could partly be understood in terms
of their previous background (Slater and Roth 1969).
In modern day psychiatry,

A delusion is a belief that is firmly held on inadequate grounds, is

not affected by rational argument or evidence to the contrary, and
is not a conventional belief that the person might be expected to
hold given their educational, cultural and religious background.
(Gelder et al. 2006, p. 9)

Partial delusions are those that are held with some degree of doubt.
The phenomenological approach also classifies delusions in relation
to onset, distinguishes primary and secondary delusions, and considers
them according to theme, discriminating between paranoid (persecu-
tory) delusions, delusions of reference, grandiose delusions, delusions
of guilt, nihilistic, hypochondriacal, religious, jealous, sexual or amor-
ous, delusions of control, delusions concerning possession of thought,
thought insertion, thought withdrawal and thought broadcasting.
There are also shared delusions (Gelder et al. 2006, p. 10).

The cognitive-behavioural approach to delusions

From a CBT perspective, Turkington et al. (1996) recommended that

the definition of delusion be revised as follows:

A delusion is a false belief at the extreme end of the continuum of

consensual agreement. It is not categorically different to overvalued
ideas and normal beliefs. It is held in spite of evidence to the
contrary but it may be amenable to change when that evidence is
collaboratively explored. In that case, the belief may come to

37
A psychoanalytic perspective on psychosis

approximate closely to ideas in keeping with the patient’s social,

educational, cultural and religious background.
(Turkington et al. 1996)

CBT treatment involves assessment of delusional beliefs in terms of

pre-existing beliefs, and linked emotional reactions. First and fore-
most, a therapeutic alliance is established through sensitivity. The
clinician avoids being drawn by the patient into a confrontational
stance by using responses such as ‘Well, that is a possible explanation,
but could it be something else?’ or ‘Let’s explore the evidence and see
if your ideas are right’ (Turkington and Siddle 1998).
There appear to be two differing approaches to working with
delusions. The first uses normalisation strategies including peripheral
questioning and Socratic questioning to encourage the patient to
relinquish his or her delusion. The second recognises when there is a
defensive nature to delusions, linked to strong affects (‘hot cognition’),
protective of underlying low self-esteem, where a different approach
is advocated using ‘inference chaining’ and ‘schema focused’ work.
Techniques include ‘peripheral questioning’ about how the delu-
sion might work. ‘Socratic questioning’ involves using a line of ques-
tioning to lead the deluded patient to an entirely different conclusion.
For example, if a patient said that she was the Queen of Spain, one
might respond by saying, ‘Let’s presume for a moment that this belief
is completely true. In that case you must have had a coronation, speak
good Spanish and you must have made many state visits.’
Socratic discussion is regarded as a penetrating and challenging
form of questioning only to be attempted later in cognitive therapy
when the patient is beginning to be doubtful of their beliefs.
The second scenario recognises where the delusion serves as pro-
tection for underlying low self-esteem, the clue being its link to
strong affects (‘hot cognition’). Here a different approach is advocated
using ‘inference chaining’ and ‘schema focused’ work.
‘Inference chaining’ is a method of working beneath the delu-
sion, in particular with grandiose or systematised delusions, which
are often resistant to other techniques because of their protective
function in relation to self-esteem.
If a patient said that she was the Queen of Spain, but on being
questioned about why she held on to this belief, said it meant that
she was admired by everyone, and then became tearful, this would
be explored further. The patient might disclose that she no longer

38
Controversial issues in psychosis

wished to take abuse from anyone and just wanted to be her normal
self, without criticism. The tears are indicative of a ‘hot cognition’, a
cognition which carries with it a powerful affective charge that indi-
cates an important arena for further investigation, through ‘schema
focused’ work.
Work at the schema level would focus on issues of approval
demands and underlying low self-esteem. Schemas include core mal-
adaptive beliefs, for example ‘I am unlovable’, and compensatory
beliefs such as ‘I must be approved at all costs’. Techniques involve
articulating the evidence, positive and negative, logging of approvals,
acting against the belief in imagery and in real-life situations, and
direct disputation. CBT does not contraindicate concurrent use of
medication.
Turkington and Siddle (1998) concluded that all available evidence
points towards the fact that delusions, at least in certain of their
parameters, can be expected to shift along the spectrum towards
normality when a cognitive therapy approach is used.
I was fortunate on 10 July 2006 to share a session on ‘Psychosis
– Dreams and Delusions’ with Douglas Turkington, a leading author-
ity on the application of CBT to delusions. The session was part
of a day event in celebration of Freud’s 150th birthday held at
the Royal College of Psychiatrists’ annual meeting. Turkington took
the Schreber case to illustrate common ground between Freud’s
analytic approach and Beck’s CBT approach to delusions, show-
ing that both agreed that the emergence of delusions is linked to
stress and that symptom formation and content was replete with
meaning.
Turkington outlined the CBT treatment that he would have insti-
gated for Schreber. This included ten sessions each of the following:

1 Scaffolding
This involves ‘containing’, affect reduction, scheduling activities and
healthy living exercises. This input can by provided by other involved
staff as well as the CBT therapist, who would typically visit a patient
with a persistent severe psychotic disorder at home, or group home.
Scaffolding plays a very important role in patients lacking in motiv-
ation and without it nothing else is possible, although in Schreber’s
case, Turkington thought that the aim would be to engage his keen
intellect.

39
A psychoanalytic perspective on psychosis

2 Systematised delusional level work

3 Schema level work

In Schreber’s case this would involve noting his background history:
his abusive father and the fact that he was a second son whose elder
brother had committed suicide, which probably resulted in laying
down early schemas of core weakness and inferiority, expressing
views that ‘I am not man enough’. His desperation for achievement
and approval then led to the progression of his illness. He developed
severe hypochondriasis from overwork but, as his anxiety levels rose,
this led to a delusional mood and the emergence of grandiose delu-
sions of being mankind’s redeemer and the passive recipient of God’s
attentions. This protected him against his schema vulnerability.

4 Consolidation

5 Relapse prevention
In the same presentation, Turkington described being asked to visit
and treat a man with chronic paranoid schizophrenia, at his residential
home. This man had never lived independently, abused cannabis and
had a forensic history of assaulting people. He harboured chronic
delusions.
Following CBT he became initially a lot less preoccupied with his
delusional system, reduced his cannabis intake, was compliant with his
medication and started living for the first time in his life in a sup-
ported flat. The professionals involved in his treatment paid a lot of
attention to the scaffolding work on befriending and challenging his
schema of low self-esteem.
Midway through the interventions, however, the patient became
panicky and his conviction rate increased again. On review, the ‘con-
taining’ scaffolding work was felt to have played a very important role
and without it nothing else would have been possible, but his chronic
delusional beliefs remained essentially unaltered.

CBT and psychoanalytic approaches: similarities and differences

Commenting on the CBT approach, Martindale (1998) wrote:

40
Controversial issues in psychosis

It is a very welcome development that cognitive therapists are now

finding effective techniques to work with people with problems
relating to psychosis. It is clear that their approaches involve a
very special attention to the therapeutic relationship. Though there
are radical differences, it is also striking that their approaches are
leading to a rediscovery of some important features long familiar to
those with a psychodynamic perspective who have worked with
such patients.
(Martindale 1998, p. 242)

Murray Jackson went further in his comment: ‘I think that the long-
term future of cognitive behavioural work with psychotic patients
without a psychoanalytic input is uncertain’ ( Jackson 2001b, p. 51).
Certainly the rediscovery and incorporation of psychoanalytic
concepts within CBT, including an appreciation of defence mechan-
isms and the complexity of the therapeutic relationship, is evident in
the work of CBT therapists. One example of this would be the devel-
opment of Anthony Ryle’s cognitive analytic therapy (CAT). The
Royal College of Psychiatrists in the UK requires its psychotherapy
trainees to have experience of three approaches, psychoanalytic, CBT
and CAT. CAT is an integrative model of psychotherapy (Ryle and
Kerr 2002). It is a brief time-limited procedure, expanded from an
initial range of neurotic disorders to more difficult groups of patients.
CAT understands abnormal development as due to the internalisation
of dysfunctional reciprocal role procedures (RRPs). The aim is to
create with the patient both narrative and diagrammatic reformula-
tions of their difficulties. Advocates of the procedure feel that CAT
could be helpful in extending the repertoire of individual approaches
to psychosis (Kerr et al. 2006).

An analytic understanding of the cognitive approach

Cognitive techniques have an advantage over the analytic approach in

that changes in attitudes are easily measurable, but the patient’s
responses may be more complex than might at first appear to be the
case. Britton (2009) suggests that believing is something that we do
from birth, like breathing. He distinguishes between beliefs that have
merely been surmounted and those that have been worked through
and relinquished. The relinquishment that is necessary for psychic

41
A psychoanalytic perspective on psychosis

change takes time and contrasts with CBT strategies of generation of

alternative explanations, normalisation and behaviour reattribution
(Morrison 2004).
Britton (2009) writes:

A belief that has been surmounted is simply overlaid by another

belief and its quiescence remains dependent on the prevailing
context of rationality and the authority of a parental transference
figure; the surmounted belief meanwhile bides its time. It is like
believing one thing when in company in daylight and another
when alone in the dark. It is those lurking beliefs of the night
that most interest us as analysts, those ghosts that vanish when we
subject ourselves to the sharply focussed light of educated reason.
In contrast to the attempt to overcome beliefs that I take to charac-
terise CBT, the aim of analysis is to find the hidden beliefs of our
patients and to help to relinquish them.
(Britton 2009)

The suggestion here is that CBT works through identification in the

transference with a desired authoritarian parental figure. Patients are
guided in how to think and do task-related exercises. Of course at a
time of crisis some patients may find it a relief to be directed how to
think and may prefer to be offered such an approach.
Those who wish to identify with a parental authority figure might
prefer a CBT approach, while those wishing to free themselves from
parental values and develop a mind of their own might favour an
analytic approach. Of course both attitudes can be present in the
patient at the same time, adding to the complexity.
Patients tend to nudge their therapists to act out their unconscious
wishes, something an analyst has to consider prior to their formula-
tion of an interpretation ( Joseph 1985). Perhaps in response to the
patient’s ambivalence about whether to be interested in or dismissive
of their delusional experiences, CBT practitioners have formulated
two approaches that seem otherwise to be contradictory. The first
approach is ‘normalisation’, trying to remove the delusion through
logical argument, while in the second approach patients convey
through their affect (‘hot cognition’) that their delusion has a meaning
that needs to be understood.
In psychiatry, it is interesting to observe how many psychoses
resolve through a flight into health by identification with an idealised

42
Controversial issues in psychosis

parental figure. This is particularly apparent with the resolution of

episodes of psychotic depression. Up to one-third of cases of puer-
peral psychoses seem to spontaneously click back into place, often
after the patient has been in a severely dysfunctional state for a long
period. If one studies the process, as in the first case reported in
Chapter 15, it becomes apparent that it is through forming identifica-
tion with an idealised parental figure that the psychosis is resolved. To
others this patient may have seemed to undergo a spontaneous cure,
but she herself knew better, remaining aware of what Britton might
refer to as her former beliefs lurking in the night, with her recogni-
tion of her vulnerability to a further psychotic episode with her next
pregnancy.
Psychoanalysts recognise the effects that transference and counter-
transference phenomena can have on the nature of the therapeutic
alliance. In psychotic states, the patient may initially attribute special
therapeutic powers to the therapist, which later becomes unsustainable,
leading to relapse, as perhaps was the case in Turkington’s description
of the case of the man with a severe chronic psychosis.
This underlines the need to differentiate between relating to delu-
sions as acute stress reactions and relating to an underlying long-
standing psychosis. The latter condition will not go away, whatever
therapeutic approach is used. It will fluctuate in intensity depending
on whether the degree of support being provided is commensurate
with the patient’s needs.
Not all cases are receptive to treatment. I could imagine that
whatever intervention strategy might have been employed with
Schreber, in his case there would have been a strong probability of an
underlying psychotic state with its own autonomy.
If we provide appropriate environments in the community for
patients with persisting psychoses, whether this is described in CBT
terms as scaffolding or in my terms as building an exoskeleton (see
Chapter 17), the patients are less likely to act out in alarming ways.
This may appear self-evident, but its importance is by no means
always appreciated (see Chapter 17).

Summary

In this chapter I have reviewed some controversial issues in the treat-

ment of psychosis, including the question of whether considering a

43
A psychoanalytic perspective on psychosis

diagnostic label is necessarily stigmatising, whether psychoanalysis

has anything to contribute to schizophrenia if its origins are biologic-
ally determined, and whether hospital admission should always be
regarded as a negative outcome. I have also considered similarities
and differences between the cognitive and analytic approaches to
psychosis.
Despite views expressed to the contrary by both psychoanalysts
and some cognitive psychologists, I have argued that psychoanalytic
perspectives have a central role to play within the world of psy-
chosis. In Part Three, on tuning into the psychotic wavelength, I
will develop this argument, showing how a consideration of counter-
transference phenomena is of crucial importance, and how explor-
ation of meaning and developing dialogues with patients can replace
normalisation strategies as the way forward. From an analytic perspec-
tive, one also needs to differentiate psychotic processes from major
psychotic disorders.
Part Two will set the scene for this development with a review of
psychoanalytic perspectives on psychosis.

44
PA RT T W O

Psychoanalytic Theor ies

about Psychosis
A Selective Review
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4
Freud’s contr ibutions to psychosis

Introduction

Any review of psychoanalytic thinking about psychosis must begin

with Freud’s contribution. He produced many seminal ideas, inviting
their further elaboration by succeeding analysts. Here I will consider
the relevance of some of his ideas.

The Schreber case

Freud inaugurated our psychoanalytic thinking on psychosis in 1911,

with his analysis of the memoirs of Daniel Paul Schreber. Schreber
was a judge who had a psychotic breakdown. He wrote a memoir of
his experiences on recovery before succumbing to a further and final
hospitalisation. In a very rich paper, Freud (1911a) introduced three
major concepts in relation to psychosis – projection, narcissism and
delusional formation as pathological attempts at recovery.
After a breakdown associated with multiple hypochondriacal symp-
toms, Schreber perceived the world as being in a state of primitive
catastrophe. He believed that his mission was to restore the world to
its former state of bliss. This was to occur through his delusional
experience whereby God transformed him into a woman, and then
as a result of direct impregnation from God, Schreber produced
miraculous rays that restored the world.
Freud’s approach to Schreber’s memoirs draws attention to many
aspects to be explored in psychosis, beyond the conventional psychi-
atric question of clarification of diagnosis. Although Freud spent
much time in his paper explaining analytically how he arrived at

47
Psychoanalytic theories about psychosis

his own formulation for Schreber’s delusions, his approach encour-

ages the development of a whole new way of viewing psychotic
experiences.
Implicit in Freud’s description is the notion that Schreber has
an unconscious internal world, with its own rich content. This world
has its own specific characteristics, and functions according to its own
rules, separate from external reality but with links to real life experi-
ences. Although this internal world may be largely unconscious,
external manifestations periodically present themselves.
Freud described processes of displacement and symbolisation,
splitting and condensation in Schreber’s delusions (processes first
described in relation to dreams). For example, Freud suggested
that Schreber’s primary conflict with his father was displaced onto a
God figure, which was then split into anterior and posterior realms.
At the time of writing this paper, Freud emphasised the importance
of unconscious homosexual conflicts with a perceived powerful
father figure in the genesis of Schreber’s paranoid states. In fact,
Schreber’s father was a well-known doctor and a powerfully influen-
tial figure, the founder of Schreber health clinics throughout Germany,
who had his own strong ideas about mental illness. He designed
models of penile clamps with spikes for babies to wear to stop them
from masturbating, since he regarded masturbation as the cause of
insanity (Niederland 1974).
Freud did not claim that his understanding of Schreber’s delusions
was the only possible explanation, but the strength of his paper lies in
the invitation to the reader to consider different possible explanations.
Indeed at the end of his paper Freud wrote:

It remains for the future to decide whether there is more delusion

in my theory than I would like to admit, or whether there is more
truth in Schreber’s delusion than other people as yet are prepared
to believe.
(Freud 1911a, p. 79)

On recovery from his psychotic episode, Schreber was aware of the

separateness of his psychic experiences from the real world and was
even able to convince a tribunal that he was fit for release from
hospital and competent to resume his former work as a judge. It was at
this point that he wrote his memoirs.
Freud’s central point, namely that we should listen with care to the

48
Freud’s contributions to psychosis

content of psychotic experiences rather than dismissing them merely

as manifestations of underlying organic pathology, remains equally
pertinent today. As such, this paper remains the inspiration and start-
ing point for all further analytic explorations in the field of psychosis.

Projection

Freud viewed Schreber’s unconscious homosexual conflict with his

powerful father as central to his psychopathology. The conflict was
transferred first on to his eminent psychiatrist Flechsig and then on
to God, whom he would openly taunt for having sexual needs to
be satisfied through turning Schreber into a woman.
Schreber’s delusions of persecution were seen as arising through
projection of his disowned homosexual feelings. Love is denied by
turning the feelings into hatred – ‘I love him’ becomes ‘I hate him’.
The hatred is then projected, taking the final form – ‘I do not love
him, I hate him because he hates me’ (Freud 1911a, p. 63).
Here Freud gives an explanation of the mechanism underlying
the creation of paranoid delusions, that is the denial of unconscious
anxieties through reversal into the opposite followed by projection
into an external object.

Delusions as attempts at recovery

Freud invites us to consider delusions as attempts at recovery, albeit

pathological ones. Freud understood Schreber’s idea that the world
was at an end as a projection of a catastrophic internal mental state.
His subsequent delusional formation, the belief that he was being
turned by God into a woman, was seen as ‘an attempt at recovery,
a process of restoration’ (Freud 1911a, p. 71).
Freud later described the restorative function of delusional forma-
tion as ‘like a patch where originally a rent had appeared in the
ego’s relation to the external world’ (Freud 1924, p. 151).
Analytic understanding of delusions has not remained static since
Freud’s time. The contribution of Wilfred Bion (1957a), who intro-
duced a new way of approaching delusions, has been particularly
striking. Bion’s contribution on psychosis will be the subject of
Chapter 6.

49
Psychoanalytic theories about psychosis

Narcissism

Freud regarded narcissism as a central concept to be considered in

all cases of major psychotic disorders. In the Schreber case, Freud
had postulated theoretical stages of the development in object rela-
tionships, from a stage of primary narcissism, in which one takes
one’s own body as one’s love object, to a homosexual relationship,
and finally a heterosexual object relationship. Freud viewed Schreber,
in his paranoid psychosis, as regressing from a homosexual object
relationship to a primitive state of primary narcissism.
The concept of primary narcissism remains controversial and has
engendered much debate among different schools of thought. For
classically orientated analysts primary narcissism describes a primary
oceanic feeling, before object relationships start. By contrast, analysts
in the Kleinian tradition (see Chapter 5), see all our phantasies
as object-related from the start, and this implies that all states of
narcissism involve a denial of the presence of another, a two-person
object relationship. For classical analysts this would be termed second-
ary narcissism. Leaving aside the academic argument, from a clinical
perspective the problem in psychosis is how powerfully the narcissistic
forces are operating at any given moment in time in terms of denial
of the need for help from others.
In his paper ‘On narcissism: an introduction’, Freud (1914) con-
trasted two fundamentally different types of object choice:

1. The anaclitic (attachment) type, where object choice is deter-

mined by early experiences of satisfaction with the infant’s
caregivers and their later substitutes, such as teachers.
2. The narcissistic type – individuals whose model for later love
objects is their own selves. Such individuals may love what they
themselves are, were, would like to be, or someone who was
once part of themselves.
(Freud 1914, p. 90)

Freud noted a predominance of the narcissistic mode of relating in

psychotic disorders, especially schizophrenia. As a result, at this junc-
ture, Freud referred to the psychoses as the narcissistic neuroses,
in contrast to the transference neuroses (anxiety hysteria, conversion
hysteria and obsessional neurosis). Freud held that psychoses were
not amenable to treatment by classical analytic technique, since the

50
Freud’s contributions to psychosis

narcissistic self-centredness of these patients meant that transference

phenomena were generally lacking.
In his metapsychological paper on the unconscious, Freud was to
write:

In the case of schizophrenia, on the other hand, we have been

driven to the assumption that after the process of repression the
libido that has been withdrawn does not seek a new object, but
retreats into the ego; that is to say, that here the object-cathexes
are given up and a primitive objectless condition of narcissism is
re-established. The incapacity of these patients for transference
(so far as the pathological process extends), their consequent
inaccessibility to therapeutic efforts, their characteristic repudiation
of the external world, the appearance of signs of hypercathexis
of their own ego, the final complete apathy – all these clinical
features seem to agree excellently with the assumption that their
object-cathexes have been given up.
(Freud 1915, pp. 196–197)

David Rosenfeld, an analyst from Argentina, pointed out that

Freud did not entirely dismiss the concept of transference in psych-
osis: at a later date, Freud wrote, ‘Transference is often not so com-
pletely absent but it can be used to a certain extent’ (Freud 1925, p. 60;
D. Rosenfeld 1992, p. 5). Nevertheless, the prevailing view among
most classically trained analysts remained that transference was rela-
tively absent so that analytic technique had to be modified with
psychosis. The American analysts at Chestnut Lodge who became
involved with schizophrenia consequently described their approach
as ‘intensive psychotherapy’ rather than psychoanalysis, as reviewed
in Chapter 8 (Fromm-Reichmann 1950).
It was many decades after Freud that Herbert Rosenfeld, a Kleinian
analyst, was to refute the notion of an absence of transference phe-
nomena in psychosis (H. A. Rosenfeld 1954). Rather, in patients with
psychoses, there was a particularly concrete nature to the transfer-
ences, which lacked the usual ‘as if’ quality; for example, Schreber
concretely viewed his psychiatrist as a persecutory father figure.
Rosenfeld, therefore, thought that the analytic technique of interpret-
ing the transference did not require modification for patients with
diagnoses of schizophrenia.
Segal and Bell (1991) have argued that Freud’s notion of narcissism

51
Psychoanalytic theories about psychosis

implies the idea of an innate destructiveness, an idealisation of

death and a hatred of life. In their review of the concept of narcissism,
they bring this out by returning to the original Narcissus myth:

Narcissus is trapped gazing at something that he subjectively

believes is a lost object but it is the idealised aspect of his own
self. He believes himself to be in love. He dies of starvation,
however, because he cannot turn away towards a real object from
whom he might have been able to get what he really needed.
(Segal and Bell 1991, p. 172)

It is not difficult to relate this to patients with chronic schizophrenia

who have turned their backs on life to live in a world of their own
making in an asylum. Freud was later explicitly to develop the idea of
an innate destructiveness when he introduced the concept of the
death instinct.

Melancholia (psychotic depression)

In ‘Mourning and melancholia’, Freud (1917) emphasised the pre-

dominance of the narcissistic type of object choice as the key to
understanding melancholia. Freud’s brilliant paper, in conjunction
with Abraham’s (1924) paper, cannot be bettered as a description of
what is nowadays called major depressive illness. Freud related depres-
sion to a disease of an internal critical agency or conscience, as he had
not yet introduced the term superego. The need for an appreciation
of the hidden psychosis underlying what is now termed major
depressive illness will be addressed in later chapters (see Part Four).

The structural model and psychosis

Freud’s earlier model of the mind was called the ‘topographical

model’, the word topography coming from the Greek, meaning
theory of places (Laplanche and Pontalis 1973, p. 449). In that model,
Freud differentiated the psychical apparatus into a number of sub-
systems, namely the conscious, preconscious and unconscious. Con-
flict occurred between the system unconscious, which was dominated
by the pleasure principle and the conscious, which was dominated by

52
Freud’s contributions to psychosis

the reality principle. Censorship occurred between one subsystem

and another, through the operation of repression, with return of
the repressed in disguised forms as evidenced in hysterical states and
in dreams.
From 1920 onwards, Freud introduced a new framework, the
id, the ego and the superego, to describe the personality and its
mode of functioning. This has sometimes been referred to as ‘the
second topography’, but more commonly as ‘the structural model’
(Laplanche and Pontalis 1973, p. 452). The id represents the store-
house of primitive instinctual feelings demanding gratification. The
ego, viewed as partly operating unconsciously, has to cope with
demands from the id, but also from the superego and external reality
(Freud 1923).
The introduction of the structural model did not entail a rejection
of the earlier notions described under the topographical model,
but the new structure allowed for more precise descriptions. For
example, the earlier concept of the ego being faced with a conflict
due to the incompatible demands of the pleasure principle and the
reality principle could now be reconsidered in terms of the demands
placed on the ego by the id, superego and external reality.
Similarly, many previous concepts were brought together in the
role of the superego. The functions of the superego include the
sense of a conscience, a self-observer and also the representative
of ego ideals. The superego was also seen as the heir to the Oedipus
complex. The child gives up its wish to take the place of one of
the parental couple with the other and instead incorporates their
values in the superego. Freud thought that this internalisation
occurred, with the resolution of the Oedipus complex, at around
3 years old. Melanie Klein (1945) was later to introduce the idea
of an earlier, more primitive and severe superego that came into
existence within the first year of life, as a forerunner to the later more
mature superego.
Following the introduction of the structural model, Freud amended
his theoretical formulations on the psychoses. Transference neuroses
(anxiety, hysterical and obsessional states) now corresponded to a
conflict between the ego and the id. Narcissistic neuroses, by which
Freud now meant melancholia, corresponded to a conflict between
the ego and superego; while the psychoses, i.e. schizophrenia, related
to a conflict between the ego, under the dominance of the id, and
the external world (Freud 1923).

53
Psychoanalytic theories about psychosis

Defence mechanisms

The introduction of the structural model invited further consider-

ation of how the ego develops defence mechanisms against psychic
stress (A. Freud 1936). A defence mechanism is an automatic uncon-
scious mental operation, taking place in the ego, which has the
function of helping the individual to retain a state of psychic equi-
librium (Milton et al. 2005). The aim of the ego is to maintain psychic
equilibrium under conflicting pressures from the id, the superego and
external reality.
Repression lies at the centre of the defence mechanisms. If
repression fails, there are many other defence mechanisms includ-
ing projection, denial, negation, identification with the aggressor,
reversal into the opposite, rationalisation and intellectualisation.
The following vignette illustrates the power of repression and
the consequences when the patient is no longer able to maintain it.

Years ago, while I was in training, I was working in a psychiatric rehabilita-

tion day unit. The unit consisted of a detached house on several floors. This
arrangement made it hard to cope with a patient who was in a disturbed
state. A patient was admitted with a diagnosis of paranoid schizophrenia.
He had been referred from an inpatient unit where he had required over
a thousand milligrams of chlorpromazine, a large dose of antipsychotic
medication, to settle him sufficiently for his discharge. In the day hospital,
he would fall asleep in groups. However, the staff were afraid to lower
his medication dose in case he relapsed into a paranoid aggressive state.
On the other hand, it was felt that he needed to be in a less soporific state
in order to benefit from the rehabilitation programme.
However, after the groups, he played badminton without showing any
of the tiredness or stiffness that would be the expected side-effects of his
medication. It was then noticed that in therapy groups, the patient would
fall asleep whenever the psychologist raised any emotional topic. Here we
can see the effects of massive repression, mimicking the physical side-effects
of medication. Unfortunately, this repression was not sustainable, leading
to an aggressive eruption with the need for a further admission.

Historically the introduction of the structural model was of

enormous importance for the subsequent development of the
ego-psychology that became the prevailing school of thought parti-
cularly in the United States (Hinshelwood 1989, pp. 286–295).

54
Freud’s contributions to psychosis

Differences of analytic approach to psychosis emerged between the

ego psychology school in the States, with its emphasis on
encouraging the development of more mature defence mechanisms
than projection and denial, and the Kleinian school in London,
where the focus centred on interpretation of the transference (H. A.
Rosenfeld 1969).

The death instinct

In Beyond the Pleasure Principle, Freud (1920) introduced the concept

of the death instinct or drive. In a detailed review of the death instinct,
Laplanche and Pontalis (1973) summarised Freud’s view as follows:

[T]he death instincts, which are opposed to the life instincts,

strive towards the reduction of tensions to zero-point. In other
words, their goal is to bring the living being back to the organic
state.
The death instincts are to begin with directed inwards and tend
towards self destruction, but they are subsequently turned towards
the outside world in the form of the aggressive or destructive
instinct. The notion of a death instinct [. . .] has not managed to
gain the acceptance of [Freud’s] disciples and successors in the
way that the majority of his conceptual contributions have done –
and it is still one of the most controversial of psycho-analytic
concepts.
(Laplanche and Pontalis 1973, p. 97)

A problem is that the concept embraces more than one idea. For
example, at an intellectual level many have questioned the notion that
human beings have an inbuilt drive to return to an organic, lifeless
state.
While the concept of the death instinct somewhat belatedly
introduced aggressive drives into Freud’s conceptualisations, thereby
enriching them, many would argue that aggressiveness is an under-
standable reaction to frustration and does not require the hypothesis
of a death instinct. The human wish to live makes it difficult to accept
the concept of an innate self-destructive drive.
Laplanche and Pontalis (1973) point out that a dualistic tendency
is fundamental to Freudian thought, and the introduction of the death

55
Psychoanalytic theories about psychosis

instinct, in opposition to the life instinct, added another dimension

in thinking about the ambivalent nature of communications from
people in very disturbed states of mind.
Classical analysts argue that Freud conceptualised the death instinct
at a purely theoretical (metapsychological) level, putting it forward as
a speculative idea that had no basis in clinical practice. In reviewing
the concept, Black (2001, p. 195) wrote: ‘the death drive, as such,
probably merits no future in psychoanalytic thinking’. Schwartz
(2001, p. 199) endorsed this view: ‘We should stop thinking of a death
drive but directly in terms of destructiveness’, forcefully adding, ‘We
should stop teaching the death drive in our training’.
In contrast, Klein viewed envy directed towards the breast as
the earliest direct externalisation of the death instinct, since it attacked
the source of life (Klein 1957; Segal 1973a).
However, Britton (2003), as a post-Kleinian, has also questioned
Freud’s concept. He observes that Freud was much more diffident
about his thoughts on the ‘destructive instinct’ than about his
thoughts on the libido (i.e. the life instinct), and writes:

It seems to me to make more sense to see the original destructive-

ness directed outwards and in the course of development internal-
ised, rather than the other way round. For this reason I prefer to call
this a destructive instinct, and not the death instinct as it is more
usually referred to.
I believe that both the desire for a love object and hostility
to objects outside the self is primary. It is the sort of thing that
experience in the consulting room cannot settle, and for that reason
will remain debatable. Some of my colleagues who are convinced
of the action of the ‘death instinct’ will differ from me on this
and point out the effects on some individuals’ own mental appar-
atus of a deadly internal force. I think that can be accounted for
by supposing that the anti-object relational force acts on any
attachment to an object.
(Britton 2003, pp. 3–4)

In The Ego and the Id, Freud described how the superego can
come to be committed to the death of the ego, with a part of
the ego that is opposed to another part becoming entrenched in the
superego: ‘the destructive component has entrenched itself in the
super-ego and turned against the ego. What is now holding sway in

56
Freud’s contributions to psychosis

the super-ego is, as it were, a pure culture of the death instinct’

(Freud 1923, p. 53).
Klein also refers to the conflict in the ego between the two
instincts, with splitting of the ego and location of the bad object
within the superego, leading to the formation of an early harsh
superego. Britton notes how:

Melanie Klein repeatedly stresses that this original hostile internal

object is only modified and mitigated by love. In her model,
therefore, the introjection of a loving mother and father is abso-
lutely necessary in order to modify the potentially ego-destructive
super-ego. . . .
If the actual parent is hostile and envious, it becomes the
external location for the projection of this malignant internal
object and this becomes its incarceration.
(Britton 2003, pp. 119, 128).

We are left with the question of why, in the face of sustained criticism,
Freud ended up so strongly endorsing the concept of the death
instinct, given its original speculative foundations. To quote:

To begin with, it was only tentatively that I put forward the views
that I have developed here, but in the course of time they have
gained such a hold upon me that I can no longer think in any
other way.
(Freud 1930, p. 119)

In my view, differences in opinion over the usefulness of the concept

of the death instinct can be resolved only at the clinical level. Those
analysts who are critical of the concept of the death instinct are
relating to their experience in the consulting room with neurotic
and borderline states, where Freud’s concept does not seem to
consider aggression as an understandable expression of the frustrat-
ion of not being understood within the parent–child relationship
(Winnicott 1960).
I see Freud’s conceptualisation of an innate destructive force
directed towards the self as aimed at addressing the area of psychosis.
It may have been the suicide of his psychoanalytic colleague Victor
Tausk in 1919 that first alerted him to consider the concept in
relation to depression (Roazen 1973).

57
Psychoanalytic theories about psychosis

In relating to patients with major psychotic disorders, namely

schizophrenia and affective disorders, we need to develop a quite
different psychoanalytic framework from that applied to neuroses
or borderline states. For the framework to be clinically meaningful,
it will have to incorporate recognition of a separate psychotic part of
the personality and deadly internal forces.
How are we to relate to incidents where patients kill themselves
out of the blue in spite of all the love and support being given to
them by their relatives and staff? Awareness here of the operation of
the death instinct, acting in envious rivalry to the life instinct,
can help relatives, professional staff and management to understand
the dynamics behind such events and to grasp why blame should not
be apportioned when unavoidable tragedies occur (see Chapter 18).
While debate over the death instinct will no doubt continue at an
academic level, the need remains to assess the extent of powerful
anti-life forces in all cases of major psychotic disorders. Years of daily
involvement with psychotic states of mind leads one to an appreci-
ation of the power and autonomy of destructive forces and of
why Freud should have said, once he had discovered the death
instinct, that he could no longer think in any other way.

Psychoanalysis and psychiatry

Freud was aware of the tensions between the two disciplines and
wished to bridge the gap:

Psychiatry does not employ the technical methods of psycho-

analysis; it omits to make any inferences from the content of
the delusion, and, in pointing to heredity, it gives us a very general
and remote aetiology instead of indicating first the more special
and proximate causes. But, is there a contradiction, an opposition
in this? Is it not rather a case of one supplementing the other?
Does the hereditary factor contradict the importance of experi-
ence? Do not the two things rather combine in the most effective
manner? You will grant that there is nothing in the nature of
psychiatric work which could be opposed to psycho-analytic
research. What is opposed to psycho-analysis is not psychiatry,
but psychiatrists. Psycho-analysis is related to psychiatry approxi-
mately as histology is to anatomy: the one studies the external form

58
Freud’s contributions to psychosis

of organs, the other studies their construction out of tissues and

cells. It is not easy to imagine a contradiction between these two
pieces of study, of which one is a continuation of the other. Today,
as you know, anatomy is regarded by us as the foundation of
scientific medicine. But there was a time when it was forbidden
to dissect the human cadaver in order to discover the internal
structure of the body as it now seems to practise psycho-analysis
in order to learn about the internal structure of the mind. It is
to be expected that in the not too distant future it will be realised
that a scientifically based psychiatry is not possible without a
sound knowledge of the deeper-lying unconscious processes in
mental life.
(Freud 1916–1917a, p. 254)

Freud was also aware of the lack of a psychoanalytic presence

in general psychiatry and the need for such a presence to make an
impact and further our means of relating to patients with psychotic
disorders:

There are difficulties in addition that hold up our advance. The

narcissistic disorders and the psychoses related to them can only
be deciphered by observers who have been trained through the
analytic study of the transference neuroses. But our psychiatrists
are not students of psycho-analysis and we psycho-analysts see too
few psychiatric cases. A race of psychiatrists must first grow who
have passed through the school of psycho-analysis as a preparatory
science. A start in that direction is now being made in America.
(Freud 1916–1917b, p. 423)

Summary

In this chapter, I have reviewed some of the basic analytic concepts

described by Freud that are relevant to psychosis, commencing
with his exploration of Schreber’s memoirs. These concepts include
an appreciation of the power of the unconscious inner world, the
meaning of delusions, narcissism and defence mechanisms and the
introduction of the structural model of the mind. Particular attention
has been paid to the notion of the death instinct, with its clinical
implications.

59
Psychoanalytic theories about psychosis

While Freud did not personally analyse psychotic patients, he

provided many seminal insights and issued a challenge to future gen-
erations of analysts to work with patients in such states in order to
further our clinical understanding of them.

60
5
The Kleinian contr ibution to psychosis

Introduction

Melanie Klein introduced many basic concepts that have proved cru-
cial to the psychoanalytic understanding of psychosis. This chapter
will highlight some of these concepts in order to illustrate their
relevance within the sphere of general psychiatry. I will also draw
attention to some relevant post-Kleinian contributions. This will
not constitute a résumé of the works of Klein and her followers. The
interested reader is referred to Hanna Segal’s (1973a) Introduction to
the Work of Melanie Klein and Robert Hinshelwood’s (1989) Dictionary
of Kleinian Thought for a fuller exposition.

The internal world

In her work with little children, Klein was impressed by the richness
of their unconscious phantasy life. Her observations of babies and
small children led her to argue that from earliest infancy all of us have
an internal world as well as an external world. This internal world
arises as

the result of the operation of unconscious phantasy, in which

objects are introjected and a complex internal world is built up
within the ego, in which the internal objects are felt to be in
dynamic relationship to one another and the ego.
(Segal 1973a, p. 127)

Patients with schizophrenia may renounce the external world in

61
Psychoanalytic theories about psychosis

favour of an internal world of their own making, dominated by their

unconscious phantasies. In all cases of psychoses, part of our task is to
come to grasp the underlying dynamics operating within the patient’s
internal world.

The paranoid-schizoid position

Klein went on to describe, theoretically speaking, two basic constella-

tions of anxieties, defences and characteristic object relations, which
she called positions: the paranoid-schizoid position and the depres-
sive position. Throughout life we shift back and forth between these
positions, although the paranoid-schizoid position appears before
the depressive position in infantile development. In describing the
paranoid-schizoid position, Klein chose the word schizoid to evoke
splitting, rather than the more common meaning of social with-
drawal, while paranoid referred to the fact that the leading affect
or mood was a persecutory one. In the paranoid-schizoid position
the internal world was characterised by part-object relationships,
predominantly to the breast, with another important part-object
being the penis. At the stage of infantile development where the
paranoid-schizoid position dominates, because of the immaturity
of the ego, in order to maintain a relationship with a good object
the infant is forced to use the primitive defences of splitting and
projection of the bad object, along with idealisation to preserve the
good object. In the older child and adult idealisation may be seen as
part of a manic defence against underlying depressive anxieties (see
below).
Klein was struck by the similarity between the internal world of
children in the paranoid-schizoid position and patients with psych-
otic disorders. In schizophrenia, the patient may be living in an
internal world of part-objects dominated by paranoid ideation. For
example, in the case of a patient who carries a knife for protection
against imaginary assailants, the knife, symbolically speaking, might
stand concretely for a penis that is protecting an identification with an
idealised breast from attack.
When we come across patients in a psychotic breakdown, it is
useful to ask ourselves whether they are functioning in their internal
world at a part-object level dominated by a persecutory affect, with
little or no insight at the time.

62
The Kleinian contribution to psychosis

Envy and gratitude

A particularly important internal factor affecting the infant’s experi-

ence of the paranoid-schizoid position is envy. Envy is a destruc-
tive projective process, operating in the paranoid-schizoid position,
through which the good qualities of the external object are denied
and destroyed in phantasy. Envy aims to spoil the object’s goodness.
Since it attacks the source of life (the breast), Klein saw envy as the
earliest externalisation of the death instinct. If envy is particularly
strong and predominating, as is the case in major psychotic disorders,
this may seriously hamper emotional development since the individual
is unable to preserve a good object. The hostility of the projective
attack on the good object leads to persecutory anxiety of a retaliatory
nature. The gratitude towards the good object that arises as a result
of good experiences can reduce the negative effects of envy.

The depressive position

At the time of weaning, the baby comes to recognise the mother as a

whole person. The bad breast and the good breast experiences come
together and the baby feels guilty and frightened that his or her aggres-
sive phantasies may have damaged the mother. If the guilt becomes
unbearable, then defences come into play, such as manic defences or
regression to the splitting associated with the paranoid-schizoid pos-
ition. The depressive position is never fully worked through and is
linked to our varying capacities to stay with psychic pain.

Regression to the paranoid-schizoid position

As noted above, Klein described the paranoid-schizoid and depressive

states of mind as positions rather than stages. Although they can be
thought of as descriptions of stages of development, Klein thought
that throughout life we continue to oscillate between these two posi-
tions, at times operating in a more integrated, reflective way and at
other times functioning in a paranoid way.
For example, I used to work in a situation where the hospital beds
were divided between two sites. When we were not under pressure it
was possible to reflect on the way the sites functioned together as a

63
Psychoanalytic theories about psychosis

service. However, if we felt overworked and our beds were full to over-
flowing, then we would complain that the other site was not doing its
fair share of the work. When the pressure of external demands makes
it very difficult to maintain the more reflective state of mind associ-
ated with the depressive position, one way to gain relief is to regress to
a paranoid-schizoid mode of functioning, blaming the other site and
turning it into the bad object.
While we can see such psychotic processes at work in everyone
at times of stress, a more persistent paranoid-schizoid mode of func-
tioning predominates in patients with underlying major psychotic
disorders.

The superego

Reaching the depressive position involves a painful realisation of

having damaged one’s love object. At this stage the ambivalently loved
parental objects are introjected to form the core of the superego. Freud
originally linked the formation of the superego with the resolution
of the Oedipus complex, aged 3 to 5, when the child incorporates
parental values to form his or her conscience. Freud (1917) later
understood melancholia or psychotic depression as a disease of the
‘critical agency’ or superego.
Melanie Klein (1945) introduced the concept of an earlier, more
primitive and persecutory superego operating at a part-object level in
the paranoid-schizoid position. This persecutory superego emerges
in consequence of attacks on the good object and is particularly harsh
and severe. It can dominate the mind of patients in a psychotic break-
down. For example, on admission in a psychotic state, patients in their
confusion may feel that the staff are criticising them and may respond
violently (M. Klein 1945).

Persecutory, depressive and castration anxiety

Segal (1973a) summarised the different forms of anxiety that arise

when the death instinct is deflected outwards. In the paranoid anxiety
that is characteristic of the paranoid-schizoid position, the projection
results in an experience of objects as persecutors that are trying
to annihilate the ego and the ideal object. Depressive anxiety is the

64
The Kleinian contribution to psychosis

concern that one’s own aggression has annihilated one’s own good
object. Castration anxiety is a paranoid anxiety linked to a fear that
one has lost one’s penis as the organ of reparation.
Freud highlighted the intimate relationship between the mind and
body with his statement that ‘The ego is first and foremost a bodily
ego’ (Freud 1923, p. 26). This means that the organs of the body
are intimately connected to the acting out of unconscious phantasies.
Young children in their play will speak freely in terms of bodily
functions, and Klein would relate to children in those terms in her
interpretations. We are less likely to interpret in bodily terms with
adults unless patients are expressing themselves in this way. However,
psychoanalysts familiar with the inner world of unconscious phantasy
may be at ease in thinking in these ways, even if they might not speak
to their adult patients in such terms.
Schizophrenic patients may be particularly concrete in their pro-
jection of their aggressive phantasies into bodily organs, and may well
present their problems and the solutions that they find for them in
these terms.
For example, a patient with his first breakdown, which subsequently
developed into a chronic schizophrenic illness, changed his name to ‘Johnny
Nothing’ and came along to see me in outpatients, asking to be castrated,
as he felt that his penis was a dangerous organ with which he would attack
women.

Projective and introjective identification

Projective identification is a key Kleinian concept. It is the process by

which parts of the self are projected into an object. Klein originally
saw projective identification as a means for the infant to communicate
with the mother, who by taking in the projection would become
aware of the child’s needs. Since then the concept has been thought
about and expanded in many other ways, becoming an umbrella term
for many different processes ranging from normal modes of com-
munication to violent types of fragmentation in psychotic states
(Sodre 2004; Steiner 2008).
Klein (1959) wrote:

By projecting oneself or part of one’s impulses and feelings into

another person, an identification with that person is achieved. . . .

65
Psychoanalytic theories about psychosis

On the other hand, in putting part of oneself into the other person
(projecting), the identification is based on attributing to the other
person some of one’s own qualities. Projection has many repercus-
sions. We are inclined to attribute to other people – in a sense, to
put into them – some of our own emotions and thoughts; and it is
obvious that it will depend on how balanced or persecuted we are
whether this projection is of a friendly or a hostile nature. By attrib-
uting part of our feelings to the other person, we understand their
feelings, needs, and satisfactions; in other words, we are putting our-
selves into the other person’s shoes. There are people who go so
far in this direction that they lose themselves entirely in others and
become incapable of objective judgement. At the same time exces-
sive introjection endangers the strength of the ego because it
becomes completely dominated by the introjected object.
(M. Klein 1959, pp. 252–253)

If the aim of projective identification is to rid oneself of troublesome

feelings, the object may be perceived as having acquired the character-
istics of the projected part, or the self may become identified with the
object of its projections. If both good and bad feelings are projected
into the same object, this will result in ambivalent feelings towards the
object.
In introjective identification the object is introjected into the ego,
which then identifies with it. Throughout development there is a
constant to and fro of projective and introjective processes in the
building up of internal objects in one’s inner world.
Projective identification as a means of communication is particu-
larly striking in patients with borderline states.

I was once asked to see such a patient who, after being physically treated
for taking an overdose, was referred on to the psychiatric emergency clinic.
In the emergency clinic, the patient told me his whole life history. He then
became extremely anxious when I went to leave the room. He had felt that
he had concretely projected the whole of himself into me, and was then
worried about where I was going with him.

O’Shaughnessy (1992) emphasised that Klein approached psychosis

via anxiety and that the baby’s earliest anxieties are psychotic in ori-
gin, that is a dread of primitive projected terrifying figures. If the
infant is unable to bind, work through and modify his or her primitive

66
The Kleinian contribution to psychosis

anxieties about these terrifying figures that threaten to dominate the

psyche, then the ego is driven to excessive use of the otherwise normal
defence of splitting and projective identification.
In other words, Klein understood psychoses in terms of an excessive
use of normal projective processes in relation to persecutory anxieties,
and located the pathology in the paranoid-schizoid position.

Pathological projective identification

This is the term used by Segal for the process that Bion later described
as operating in schizophrenia. Pathological projective identification is
characterised by fragmenting and disintegration of the self, which is
projected into external objects to create what Bion called ‘bizarre
objects’ (Segal 1973a, p. 127). Bion’s contribution will be examined
in Chapter 6, but it is important to note here that Bion disagreed
with Klein’s view that schizophrenia arose out of an excessive use of
normal projective processes in the paranoid-schizoid position. Bion
(1957a) thought that those individuals who would subsequently
develop schizophrenia negotiated the paranoid-schizoid position in a
markedly different way from others, due to a fragmentation of the
psyche, resulting in the formation of a psychotic part of the personal-
ity that was left functioning quite differently from the non-psychotic
parts.

Manic defences

This is a concept of fundamental clinical importance. In Segal’s

account of Klein’s work manic defences are described as arising to
protect the individual from the experience of depressive anxiety, guilt
and loss. In manic defences psychic reality and object relations are
omnipotently denied. Manic defences are characterised by feelings of
triumph, control and contempt (Segal 1973a, p. 127).
Clinical practice reveals manic defences as a universal phenomenon
that can arise to protect the individual from experiencing any severe
underlying anxiety or psychic pain, whether predominantly per-
secutory or depressive in nature. Manic states can be encountered in
patients with schizophrenia as well as in manic depressive states.
Wherever one encounters manic states, it is important to consider

67
Psychoanalytic theories about psychosis

what underlying unbearable states of mind are being warded off.

Sometimes the answer is readily apparent, as in the following vignette.

A 49-year-old woman was admitted in a manic state. She was cheerful and
infected those around her with her jollity when she was seen for review. She
felt persecuted when I did not join in the laughter. Her manic defence broke
down and she became tearful. Underneath her apparent cheerfulness was
a feeling that everything important in her life had been lost. She had
recently been made redundant, a long-term relationship had broken down,
and she was now menopausal, too old to have children. Her manic defence
was an attempt to avoid facing up to her underlying depression about the
bleakness in her life.

Short-lived manic defensive states need to be distinguished from pro-

tracted manic states in recurrent manic depressive disorders, which
will be considered later in the book.

Reparation and manic reparation

In working through the depressive position, the ego is preoccupied

with restoring the loved and injured object, through an active repara-
tive drive. This means facing up to underlying depressive anxieties
and guilt, not denying them. Klein drew attention to unconscious
reparative drives as a basic human trait. We can appreciate how repara-
tive drives contribute to the choice of work within the caring profes-
sions, at the same time as obliging us to face the fact that we cannot
always cure but must sometimes make the best of a bad job in our
therapeutic efforts to help others.
If one’s internal objects are felt to be unforgiving, then persecutory
or depressive anxieties can be so overwhelming that guilt cannot be
faced and no working through can occur. Instead, manic reparation
occurs, characterised by feelings of triumph, control and contempt
linked to a denial of dependency. The object is magically restored to
its previous state, prior to the breakdown, without the patient having
to face up to and work through their underlying feelings of guilt.
Time and time again, one can observe patients with severe psych-
otic disorders, whether of a schizophrenic or depressive nature, recover
from relapses through manic reparation, by means of which they
appear to magically get better, suddenly recovering and leaving

68
The Kleinian contribution to psychosis

hospital none the wiser about the reasons for their admission. The
following example taken from everyday general psychiatry is a gross
example of manic reparative mechanisms in operation.

A patient with a diagnosis of recurrent manic depression was admitted in a

severely disinhibited state. He kept taking baths on the ward with all his
clothes on. Every time he was confronted with his behaviour, he promised
not to do it again, but did. His action could be seen as a very concrete
attempt to wash away feelings of persecutory guilt. He then threw his wed-
ding ring in the bin in occupational therapy. His wife was very angry, so he
tried to repair the damage by leaving the hospital to put a deposit on a car
for her, regardless of the fact that she did not drive.
He then took to picking up elderly ladies walking in the asylum corridors
and frog-marching them to the hospital church. It was as if the old women
represented the attacked and denigrated internal mother figures that God
was to magically restore to their former state of health. This example illus-
trates the characteristic triad of feelings of triumph, control and contempt
towards the needed object, acted out here initially towards his wife and
then the elderly patients.

This patient was living entirely in an internal phantasy world of his

own making. As with so many severe cases in general psychiatry, while
it may not be possible to influence the behaviour patterns of such indi-
viduals, working with them offers the opportunity to gain first-hand
experience of the operation of some fundamental mechanisms of the
mind, which can help the practitioner to understand similar and less
severe cases. If one can understand the way the mind deals with psy-
chic pain in psychosis, one can share this experience with the nurses,
stimulating a more involved and human response among the staff
to the patient’s suffering. This would help to address Hinshelwood’s
concern that nursing staff are nowadays becoming overwhelmed by
the projection of deadening forces from patients with psychosis, and
need an ‘external consultant’ to help revive the reflective function of
the ‘internal consultant’ within them (Hinshelwood 2004).

Post-Kleinian contributions

Following on from Klein’s seminal work, Kleinian analysts have con-

tinued to contribute to our understanding of psychosis, through their

69
Psychoanalytic theories about psychosis

own detailed analytic work with borderline and psychotic patients.

This section of the chapter offers an overview of some key concepts
emanating from their work.

Hanna Segal

Symbolism and symbolic equation

The capacity for symbolism, projecting phantasies into objects and
using them to convey our deepest feelings, is a basic feature of the
human mind and is intimately linked to all artistic expression. Segal
distinguished between symbolism proper and what she termed the
‘symbolic equations’ that operate in psychosis. Symbolism proper
depends on the capacity to differentiate psychic reality and external
reality:

If psychic reality is experienced and differentiated from external

reality, the symbol is differentiated from the object; it is felt to be
created by the self and can be freely used by the self.
(Segal 1973a, p. 76)

Segal contrasted symbolism proper with ‘symbolic equation’ in

which the symbol is equated with the original object, giving rise to
concrete thinking. Segal gives two contrasting examples to illustrate
the distinction. In the first one, a young man dreams of playing a
violin duet with a young girl and has associations to fiddling and
masturbation, conveying his recognition of the symbolic meanings
in this dream. In the second case, a concert violinist has a psychotic
breakdown during which he says that he will never play the violin
again as that would be masturbating in public. Here the violin is
concretely equated with the genitals, so that touching it in public
becomes impossible (Segal 1981a, p. 49).
The following example from my work in general psychiatry serves
as a striking illustration of concrete thinking and symbolic equation.
A patient was admitted for the first time to hospital. He told me that the Devil
was good and God was bad and that he was going to Africa to preach
about it. I felt that I had better inform his father that his son was suffering
from a severe schizophrenic illness with all its long-term management
implications. However, the father endorsed his son’s view and I realised that

70
The Kleinian contribution to psychosis
they were both psychotic. Some time later a situation arose where the son
took to banging all the doors in the house. His father, lacking the ability for
symbolic thinking, dealt with the situation by removing all the doors, includ-
ing the front and back doors. One was left feeling sympathy for his wife
having to cope with it all.

Herbert Rosenfeld

The psychotic transference

Rosenfeld refuted Freud’s suggestion that no transference could
occur in psychotic disorders, since such patients had withdrawn into a
narcissistic world of their own making where they remained unavail-
able for transference interpretations. Rosenfeld (1954) maintained
that transference indeed occurred but that, as with symbolic equations,
it was of a concrete nature. Rosenfeld argued that since transference
did occur, patients with psychotic disorders were open to an analytic
interpretive approach. Psychotic transference phenomena of a con-
crete nature occur all the time in the psychiatric wards. For example, a
patient who hits a nurse for no apparent reason may do so because he
is concretely experiencing her through projection as a persecutory
parental figure. In a similar vein, a patient who smashes up the ward’s
television may do so because he feels persecuted by the newsreader on
the screen due to a hostile projection of his own perceptual apparatus
onto the newsreader.
Rosenfeld’s insight into the nature of the psychotic transference
opened the door to further development of psychoanalytic approaches
to the mind in psychosis.

Confusional states
In schizophrenia, Rosenfeld emphasised that instead of the normal
clear splitting of good and bad experiences that occurs in the
paranoid-schizoid position, hostility towards the good object leads to
confusion about the nature of what is being reintrojected. This in
turn leads to further hostile projective splitting and still more confu-
sion about the nature of the object. The patient ends up not being
able to distinguish self from object or good from bad, and as a result
stays stuck in a confusional state within the paranoid-schizoid position
(H. A. Rosenfeld 1950).

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Psychoanalytic theories about psychosis

Destructive narcissism
Freud posited an instinctual dualism between positive libidinal forces
emanating from the life instinct and destructive forces associated with
the death instinct. Rosenfeld described how in certain character
structures, the libidinal forces can come to be subjugated to the more
powerful destructive narcissistic forces. The result is that pleasure is
obtained from destructive behaviour: Rosenfeld termed this destruc-
tive narcissism. In their internal world, such patients often look to
similarly minded others to support their destructive internal organisa-
tion, and typically the mafia or similar types of gangs may feature in
their dreams (H. A. Rosenfeld 1971).
In this state destructiveness is idealised, with propaganda that it is
macho to drink or take drugs rather than face emotional needs with
help from others. The destructive narcissistic part of the personality
perversely distorts and feeds off any positive intercourse. If a patient
with this underlying character structure were to overdose on alcohol
or drugs and require hospital admission, we would then try to find
ways of helping them to change their behaviour, but the dominating
destructive narcissistic organisation in the patient may have a different
intention, namely, simply to recover as quickly as possible in order to
return to their former state of denial of their problems. Any concerns
that such patients feel are projected into the carers, who are then left
feeling guilty that they should have done more. Those working in
addiction centres are only too well aware of having to face up to such
difficult dynamics.
If the destructive organisation breaks down as a defence, then
the patient may temporarily feel extremely vulnerable, experiencing
something akin to the feelings undergone during a drug withdrawal
state, and may experience paranoid psychotic states. Temporary para-
noid states, including hearing voices, can occur in patients with so-
called personality disorders, especially when the picture is complicated
by drug abuse, and such symptoms do not necessarily mean that one
should revise the patient’s diagnosis to one of schizophrenia.

Betty Joseph

I have had the privilege of attending Betty Joseph’s clinical workshops

for some twenty years, where leading analysts have presented clinical

72
The Kleinian contribution to psychosis

material for discussion (Hargreaves and Varchevker 2004). Her con-

tributions have related primarily to psychoanalytic technique, espe-
cially the need to be aware of the nudge from the patient for the
analyst to act out to relieve the patient’s anxieties, rather than stay
with the problem. Among her contributions has been the notion of
the ‘total transference situation’ where everything occurring in the
session needs to be taken into account in arriving at the picture before
formulating an interpretation (Joseph 1985). She has also described
patients who remain ‘addicted to near death’ in their psycho-
pathology, refusing to allow movement to occur (Joseph 1982). The
title of her book Psychic Equilibrium and Psychic Change points to her
exploration of the question of when a patient’s response is defensive
against anxiety linked to change, or when it may be more perverse in
its intention (Joseph 1989).

Leslie Sohn

I was very fortunate to have Leslie Sohn as my training analyst. Sohn

has taken a lifelong interest in the application of analytic thinking
to the world of psychosis as encountered in NHS settings. Following
the days of Cooper and Laing, he took over Villa 21 at Shenley
Hospital. During his time there he offered his inpatient beds for
patients in analysis, provided the analyst came to see the patients for
their sessions.
Sohn had a unique ability to provide understanding in the area of
psychosis. My first experience of his clinical acumen came while I was
still in analysis.

For a year as a senior registrar, I was delegated to work in liaison psych-

iatry at a general hospital. I vividly recall visiting one woman on a dialysis
machine in the renal unit who was mute. She had a past history of manic
depression, but was not on lithium due to the dialysis. She was uncoopera-
tive and when she went home for the weekend, her husband had difficulty in
bringing her back.
Sohn’s response was that she was obviously in envious rivalry with the
dialysis machine. In my early naivety, I saw no evidence for this. However,
the next time I went round the dialysis unit, I approached the mute patient,
and asked her what she thought of the dialysis machine. It was as if I had
pushed the magic button.

73
Psychoanalytic theories about psychosis
She responded: ‘What machine, the machine does nothing’, and pointed
to the clips on the blood lines as proof of this.
Clearly her envious rivalry with her mother as a person who was able to
detoxify her feelings had been concretely projected on to the machine.
Unfortunately, in the end her lack of cooperation led to her death. Now-
adays I would see a situation like this as raising the challenge of how to start
a meaningful dialogue with such a patient.

Sohn’s work has illuminated many areas linked to psychotic thinking

over the years, and these analytic insights can then be taken and
applied within the world of general psychiatry.

The narcissistic identificate

Sohn described a particular highly organised quality to destructive
narcissistic processes in schizophrenia. Rather than speaking of iden-
tifications in such cases, Sohn preferred the term ‘identificate’ to high-
light the relative permanence of the narcissistic organisation in the
ego brought about by projective identification in psychosis. Parental
qualities were taken over in a controlling and triumphant manner.
The identification had a callow, cynical and plastic quality. Thus Sohn
extended Rosenfeld’s concept of destructive narcissism into the
world of psychosis (Sohn 1985b).

A patient who I once had in analysis would immobilise the analytic work by
maintaining a sitting-on-the-fence state of mind. He used his own awareness
of this to openly mock me. He pointed out that the analysis was all a charade
and that he was merely going through the motions in the session.

Clearly, with such a patient one is asked to contain an enormous

amount, reaching the very limits of endurance, until the patient
can allow himself to be in a more reflective state. Awareness of
these highly organised and enduring narcissistic organisations can
be taken into general psychiatry where an appreciation of the under-
lying dynamics can help the nursing staff to tolerate periods of
unbearable behaviour by patients, which may often be protracted in
duration.

74
The Kleinian contribution to psychosis

Anorexic and bulimic states of mind

Sohn described a peculiar appetite-less disinterested facade encoun-
tered in the analysis of anorexic patients, which conceals secret greedy
demands on their objects that can never be satisfied. He described a
patient who exhibited these states of mind to an extreme degree.

She would throw all the food she was given on the floor. When a ward sister
gave her a magazine to read, she only became interested in it when she
had torn it into pieces and urinated on the bits. She then ate the bits of paper
with relish. This obliteration of difference was also manifest in the way she
treated interpretations in her analytic sessions (Sohn 1985a).

The attack on difference in anorexia nervosa was forcibly brought

home to me by an anorexic patient whom I saw for a number of years
for analytic therapy in the NHS.

She wore grey, nondescript clothes and always wore trousers. She was
delighted when she took her motorbike for petrol, and the petrol pump
attendant was unable to tell if she was male or female. This did not stop her
having a boyfriend and being insanely jealous if there happened to be a
blonde-haired girl in the pub.
She reported a dream, where she had stuffed herself with cream buns so
that when I made an interpretation there was no room left for her to take
it in and she vomited. Perhaps the most striking lesson I learned from her
was regarding the anorexic part of the personality’s hatred of appetite. This
was an intelligent young woman attending university. Yet she reacted quite
bizarrely when a friend accompanied by her 3-year-old daughter came to
tea at the patient’s mother’s house. The patient’s mother offered the 3-year-
old girl a bar of chocolate. When the child accepted it, the patient swore at
the child and stormed out of the room.

Sohn followed Bion’s distinction between the separate psychotic and

non-psychotic parts of the mind, and emphasised the need to be mind-
ful of which part of the mind is receiving one’s interpretation and
responding. Analogously, it is helpful to think about the anorexic
and non-anorexic parts of the mind in approaching anorexia nervosa,
and study the anorexic part in its own right. This concept is applied to
the second case described in the discussion of the psychosis workshop
in Chapter 20.

75
Psychoanalytic theories about psychosis

Murderous assaults on strangers

In his later work with patients in the maximum security hospital
prison at Broadmoor, Sohn (1997) explored the psychotic processes
underlying murderous assaults on strangers. I recall him describing
what was going through the mind of a patient, suffering from chronic
schizophrenia, who pushed a stranger on to a railway line.

The patient needed money, but when he had gone to the benefit office the
previous day he was confronted with a notice saying that it was closed and
instructing visitors to come back tomorrow. When he arrived the next day,
the office was closing and he was left with no money. He then saw a woman
standing on the station platform, seemingly on holiday and carefree. He
projected all his wishes to be free from problems, and his murderous hatred
of experiencing himself in a needy helpless state into her and then felt that
she was mocking him, so he pushed her on to the railway line.

Sohn’s insights help to make sense of similar events as they occur in

the general psychiatric setting.

During a relapse, a patient with a diagnosis of paranoid schizophrenia

threw bleach in the face of a stranger, a young woman, who had come to
collect her young child from a school opposite to where he lived. Fortunately
no lasting damage was done, but afterwards in hospital he said that his
intention had been to scar her.

To the patient, this woman seems to have represented part of a hated

couple of a mother giving all her love and undivided attention to her
child. This forced the non-psychotic part of the patient to be aware
of his own similar needs and wishes. The psychotic part wished to
disown any awareness of this. His murderous state of mind towards
this self-awareness led, through projection into the mother, into the
wish to scar her as if to make sure the disownment was complete.

Henri Rey

When training in psychiatry, I had the privilege of working under

Henri Rey in the psychotherapy department at the Maudsley Hospital.
Rey described many seminal ideas, especially in relation to borderline

76
The Kleinian contribution to psychosis

psychopathology. Borderline psychopathology will be given detailed

consideration in Chapter 10.
Rey was fond of emphasising the centrality of object relations in
our inner world and their re-enactments in the transference. He
summarised the information needed to characterise the analytic inter-
change with a patient in one sentence by asking ‘What part of the
subject is in what state, situated where in space and time, with what
consequences for the object and subject?’ (Rey 1994a, p. 7).
Rey graphically described the inner world of the borderline
patient. The only safe position for such patients was sitting on the fence
avoiding unbearable affect from the depressive position on one side
and the paranoid-schizoid position on the other, hence the term
borderline states. Borderline patients can teach the clinician a great
deal about the use of psychotic mechanisms. At the same time, it is
important to be aware that they pose different psychotherapeutic and
management problems from patients presenting with schizophrenia
(see Chapter 10). Rey saw the differences as being due to the fact that
in schizophrenia the container has been destroyed and schizophrenics
are living in a delusional world entirely of their own making; schizo-
phrenics do not concern themselves with external reality but delu-
sionally believe whatever they wish. In contrast borderline patients
remain very concerned over the functioning of the container.

The claustrophobic-agoraphobic dilemma

Rey described the claustrophobic-agoraphobic dilemma as a basic
universal organisation of the personality. This organisation is especially
prominent in borderline states and schizophrenia. Patients seek space
to breathe by projecting internal excessive demands into the outer
world. They then feel the effects of their projected unbearable feelings
coming back at them. This leads them to oscillate between reclusive
states and attempts to escape from this restricted state of mind. Due to
the concrete thinking that characterises both borderline states and
schizophrenia, this may lead such individuals to make constant adjust-
ments to their environment in order to avoid projected persecutory
feelings. This can be especially marked in schizophrenia, as illustrated
by the following example.

A patient had managed to avoid facing up to her paranoid psychotic

experiences by constantly keeping on the move in her life. Every few months

77
Psychoanalytic theories about psychosis
she would feel that she had to move accommodation. After some twenty
years of this, the council gave her permanent accommodation. Con-
sequently, she began to experience a persecutory delusion that she could
hear a couple having non-stop intercourse in the flat above. In reality,
there was no flat above. Finally she went round to an elderly male neigh-
bour, attributing the cause of the persecution to him, and attempted to
stab him with her kitchen scissors. As long as she had kept on the move,
the problem of facing her concretely projected delusional world was
avoided. Interestingly, she later attempted to rationalise away her disturbed
behaviour, drawing on knowledge originating from a nursing background
to claim that she had developed a steroid psychosis through using ointment
for eczema.

Repair versus reparation

Rey distinguished between repair and reparation. With concrete
thinking, true reparation in Kleinian terms cannot occur, only a con-
crete repair. The original object is restored in such a way that no
acknowledgement and working through of conflicts is possible. Repair
without working through of conflict can occur in borderline states
and schizophrenia and it also accounts for the repetitive cycle in
recurrent manic depressive states, as illustrated in Chapter 14.
Rey added a new dimension to our understanding of manic
depressive states. In depression, the maternal breast, as a part object,
represents the destroyed mother. In contrast, in mania the penis is
identified with as the means of reparation, imagined as able to recreate
the mother’s attacked babies and breasts, through a phantasy of mak-
ing her pregnant and refilling her empty breasts with milk. However,
in the manic state, Rey argued that ‘we have a pseudo-penis which
repairs nothing.’ It denies the reality of the destroyed objects and
presents itself as the universal substitute, while the aggressive impulses
continue to destroy the object. Since no reparation proper takes place
in the manic phase, the subject returns to their depression without
any progress in maturation having occurred. Rey cites a dream related
by a very schizoid patient to illustrate the immeasurably grandiose
quality of the manic penis. In the dream, the patient was balancing a
baby on the tip of an enormous penis. He found that he was saying to
himself: ‘this fucking penis is good for nothing, it’s so big that it’s
useless’ (Rey 1994b, p. 18).

78
The Kleinian contribution to psychosis

John Steiner

Psychic retreats and pathological organisations: the retreat to a

delusional world in psychotic organisations of the personality
Steiner’s concept of psychic retreats describes pathological organisa-
tions of the personality that offer protection from anxiety and pain.
These organisations are conceptualised both as a grouping of defences
and as a highly structured, close-knit system of object relationships.
They can occur in psychotic, neurotic and borderline patients. In
psychosis such organisations represent the most extreme end of the
experiences with which the psychotic patient has to contend, a retreat
to a delusional world in defiance of reality:

Psychotic organisations are rarely completely successful or stable,

and the anxieties which threaten the individual as the organisation
begins to break down are usually conspicuous. The catastrophic
nature of such anxiety underlies the desperate dependence on the
organisation, the loss of which implies the return of uncontrolled
panic associated with experiences of fragmentation and disintegra-
tion of the patient’s self and his world.
(Steiner 1993a, p. 64)

Even though the patient may recognise that the retreat he has
created is mad, he idealises his delusional world because of the pro-
tection it affords against psychotic ordeals of disintegration and
annihilation. ‘True integration and security are felt to be impossible
and, despite its delusional foundation, the retreat offers a measure
of stability as long as the psychotic organisation is not challenged’
(Steiner 1993a, p. 65). Within this context delusions have a restorative
function.
In a review of the Schreber case, Steiner emphasised a depressive
core, and saw Schreber’s delusional system as a form of psychic retreat,
with Schreber’s subsequent projection of omnipotence in search of
further relief leading to his descent into paranoia and humiliation
(Steiner 2005).
Steiner also considers the complexity of the relationship between
the psychotic and non-psychotic parts of the personality, as described
by Bion, within the functioning of the psychotic organisation. The
non-psychotic part can learn to face mental pain and guilt and

79
Psychoanalytic theories about psychosis

introduce reparative drives in defiance of the psychotic part, disturb-

ing the status quo:

The patient’s sanity and his respect for the analytic work may survive
the psychotic attacks and become sufficiently strong that they can-
not simply be overwhelmed by brute force. It is then that perverse
mechanisms are likely to become operative and the sane parts of
the patient have to be seduced, threatened, and invited to collude
with the psychotic organisation.
(Steiner 1993a, p. 68)

A patient I saw for analysis with a diagnosis of schizophrenia would

become intimidating and turn to alcohol when threatened by insight.
The complexity of his psychotic organisation was summarised in
correspondence from his long-suffering father:

It is a half-and-half thing, a battle, no side has the ultimate grip. Both sides
have their victories and defeats. With my son, somehow, it’s like the life
force has joined up with the dead force and the life is in service of the dead.
That is why there is triumph about. It’s like Mother Theresa making a pact with
the devil to provide him with the nourishment to continue his ambitions.

Steiner questioned how much progress can be made through analy-

sis with such powerful psychotic organisations of the personality, but
took the view that where the psychotic process had not totally des-
troyed the patient’s capacity to feel depression, some useful analytic
work still seems feasible. Nevertheless, there may be limits to the
progress that can be made, with the patient having to face the psychic
reality of his state.
Steiner’s description of the usefulness of what he calls analyst-
centred rather than patient-centred interpretations was an important
technical contribution to work with the acute sensitivity of border-
line patients (Steiner 1993b). His approach is considered in some
detail in Chapter 10 on borderline states.

Edna O’Shaughnessy

Edna O’Shaughnessy has made her own original observations on the

functioning of the pathological ego-destructive superego in psychotic

80
The Kleinian contribution to psychosis

depression and the problem it poses for treatment, as well as providing

a clear review of the contribution of Klein and Bion to psychosis. Her
contribution is considered further in Chapter 16 (O’Shaughnessy
1992, 1999).

Ron Britton

Ron Britton’s wide-ranging writings have deepened our appreci-

ation of preceding psychoanalytic contributions from Freud, Bion,
Winnicott and others. Britton has also provided insights into the
minds of famous creative writers, poets and scientists. To appreciate
the depth of his work one has to turn to his writings (Britton 1989,
1998 2003). Here I will briefly review some aspects of his work that
are relevant to our thinking on psychosis.

Belief and psychic reality

Phantasies are generated and persist unconsciously from infancy
onwards. Britton drew attention to the way that some of our uncon-
scious phantasies can be favoured over others, becoming beliefs; our
favourite beliefs can then be treated as if they were facts.
Giving up favoured beliefs can be a disturbing and painful process,
and counter-beliefs may usurp the place of disturbing beliefs, as in
mania. The function of belief may be suspended as in the ‘as-if ’ syn-
drome; or the apparatus for belief may be destroyed or dismantled,
as may occur in some psychotic states (Britton 1998).

Oedipal illusions
Britton invites a different emphasis in approaching beliefs that are
held to a delusional intensity in hysteria and borderline states, com-
pared with schizophrenia.
While we all have oedipal illusions, some may live their entire life
in such a world, as in the case of Anna O (Bertha Pappenheim), where
an erotised transference dominated her treatment with Breuer (Britton
2003). As well as our individual relationships with each parent, Britton
underlines the importance of being able to allow the parental couple
to have their own privacy in order to establish the triangular space
that is necessary for thinking. The parental relationship comes to

81
Psychoanalytic theories about psychosis

represent the third position, one for reflection. If this third position
has not developed, as in borderline states where there are unresolved
issues with the maternal object, the dominating feeling can be that
one is constantly being misunderstood (Britton 1989).
Erotised transference relationships can occur in psychoses as well
as in hysteria and borderline states, making it difficult at times diag-
nostically to differentiate between the onset of a major psychotic
disorder and borderline states. This area will be considered further in
Chapter 10.

The ego’s relation to the superego, and the ego-destructive superego

In relation to the superego, Britton concludes: ‘self-observation is an
ego-function and not a superego function’ (Britton 2003, p. 72). The
ego observes itself in a realistic light, the superego in a moral light. He
sees the position of self-observation as vulnerable to being usurped by
the superego with self-depreciation and reproach, the language of
morality, taking over from non-judgemental self-observation.
Thus, the emancipation of the ego from the superego becomes
a task for analysis. Britton’s description of the internal struggles of
Job, as a believer, when challenging the calamities imposed on him
by God, provides a very vivid background for the theme (Britton
2003). Britton also considers further the characteristics of the ego-
destructive superego, as noted first by Freud in the case of melan-
cholia, and enlarged on by Bion. Here the superego is committed
to the death of the ego. Britton highlights its envious qualities, and
links this to Klein’s comment ‘creativeness becomes the deepest cause
of envy’ (Britton 2003, p. 120; M. Klein 1958, p. 202).
The nature of the ego-destructive superego and its attempt to
usurp the place of a more benign superego in psychotic depres-
sion will be explored in some detail in later chapters relating to
depression.

Summary

Klein provided many basic analytic concepts that are relevant to

understanding psychosis. In this chapter, I have described and illus-
trated some of them. I have highlighted some of the leading theor-
etical contributions from members of the Kleinian school, following

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The Kleinian contribution to psychosis

on from Klein, including the work of Segal, Rosenfeld, Joseph, Sohn,

Rey, Steiner, O’Shaughnessy and Britton. Bion, a follower of Klein,
introduced a new theoretical approach to psychosis, and this is the
subject of Chapter 6.

83
6
Bion and psychosis

Introduction

Edna O’Shaughnessy has written of Bion’s ideas: ‘For me they are

that truly rare thing – new scientific ideas. They have thrown light on
the obscure territory of psychosis, and they will. I feel sure, illuminate
it still further in the future’ (O’Shaughnessy 1992, p. 101).
While many articles and books have reviewed Bion’s overall ideas,
fewer have focused specifically on his contribution to psychosis
(Meltzer 1978; O’Shaughnessy 1992; Segal 1979), and none has con-
sidered their application within general psychiatry.
In his book Second Thoughts, arising from his analytic involvement
with patients in psychotic states, Bion (1967) introduced a new
approach to understanding the functioning of the mind in schizo-
phrenia, which has profound implications for clinical practice. This
new approach is outlined in the chapters: ‘Differentiation of the
psychotic from the non-psychotic personalities’, ‘On hallucination’
and ‘A theory of thinking’.
These chapters are densely written, with much theoretical analytic
content. Although they are not always easy to follow, they amply
repay detailed attention. In this chapter I have endeavoured to extract
some of the essential concepts and demonstrate how they relate to
the world of everyday psychiatry. I will refer to each of the chapters
in turn.

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Bion and psychosis

Differentiation of the psychotic from the

non-psychotic personalities

Most therapists, whether of an analytic or a cognitive persuasion, do

not think in terms of the functioning of a separate psychotic part in
major psychotic disorders, but prefer to view each person on a con-
tinuum basis, locating their functioning on a spectrum from projecting
mental pain in psychotic states of mind to taking ownership of feelings
in more neurotic states.
In his chapter on differentiating the psychotic from the non-
psychotic personalities, Bion invites us to consider a different
approach in schizophrenia and schizophrenia-like states of mind in
those who may not be diagnosed as schizophrenic, where in his view
the individual is dominated by a separate psychotic part that needs to
be studied in its own right. In my view fruitful opportunities for such
study can present themselves within everyday general psychiatry, as
well as within an analytic setting. In later chapters I will argue that
the notion of the separate psychotic part has profound implications
for work in everyday psychiatry and that it is just as important to
think in these terms in approaching affective disorders as it is with
schizophrenia.
Bion characterised the difference between the psychotic and
non-psychotic personalities as follows:

The theme of this paper is that the differentiation of the psychotic

from the non-psychotic personalities depends on a minute splitting
of all that part of the personality that is concerned with awareness
of internal and external reality, and the expulsion of these fragments
so that they enter or engulf their objects.
(Bion 1957a, p. 43)

From early on in life, Bion suggests that there exists a separate psych-
otic part that attacks all the aspects of the mind that have to do with
registration of awareness of internal and external reality. In con-
sequence of this attack, the individual’s developing awareness of sense
impressions, attention, memory, judgement and thought are frag-
mented and projected into objects outside of the self. The projected
fragments engulf the objects so that they take on the characteristics of
the projections. Bion called these creations ‘bizarre objects’, and saw
them as developmentally early examples of delusional formations.

85
Psychoanalytic theories about psychosis

The psychotic part of the personality lacks the ability for balanced
assessment that is available to the non-psychotic part, and is unable
to evaluate emotional issues. Instead, it functions as a muscular organ
to fragment and evacuate troublesome feelings.

Intrinsic features linked to the development of schizophrenia

Bion lists four characteristic features of an individual who is likely to

develop schizophrenia, in whom the psychotic part of the personality
will be the dominating force. The four features are:

1 A preponderance of destructive impulses so great that even the

impulse to love is suffused by them and turned to sadism.
2 A hatred of reality, both internal and external, which is extended
to all that makes for awareness of it.
3 A dread of imminent annihilation.
4 A premature and precipitate formation of object relations.

This premature, precipitate formation of object relations is marked

in the transferences made by such individuals. Bion writes of these
transferences that

[their] thinness is in marked contrast with the tenacity with which

they are maintained. The prematurity, thinness and tenacity are
pathognomonic and have an important derivation, in the conflict,
never decided in the schizophrenic, between the life and death
instincts.
(Bion 1957a, p. 44)

The attack by the psychotic part of the personality on the indi-

vidual’s capacity for reflective thinking leaves individuals very
dependent on others for answers to all their emotional problems:
hence the precipitateness, prematurity, thinness and tenacity of the
transferences they make. It can be a bewildering experience for junior
doctors starting life in psychiatry and finding themselves in the emer-
gency clinic on their own at night for the first time to be confronted
with a patient with a chronic psychotic disorder, who arrives from
nowhere in a dependent state demanding all manner of decisions
and answers.

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Bion and psychosis

Bion’s description of ‘the conflict, never decided in the schizo-

phrenic, between the life and death instincts’ refers to an internal
conflict between the non-psychotic part of the patient, which seeks
help, and the psychotic part, which tries to negate this need. In
practical terms this irresolvable conflict explains why, in psychiatry,
lifelong monitoring of patients with chronic schizophrenia is neces-
sary in order to combat social withdrawal.
The need for constant monitoring of schizophrenic patients was
vividly illustrated in a classical rehabilitation study on patients with
chronic schizophrenia who were residing in mental hospitals. It was
observed in occupational therapy that patients with learning difficul-
ties, or with organic brain damage recovering from strokes, retained
the new skills they were taught. In contrast, as soon as patients with
schizophrenia were no longer being supervised they rusted up, did
not retain the new skill and returned to their former state of inertia
(Wing and Brown 1961).

The nature of bizarre objects

As already described, the psychotic part of the personality attacks,

minutely fragments and projects all the aspects of the mind needed for
emotional assessments. This pathological splitting and projective iden-
tification differs from normal splitting and projective identification
where the projected parts remain relatively unaltered by the project-
ive process and can subsequently be reintegrated into the ego. In
pathological splitting and projective identification the splitting that
takes place is a splintering and disintegration into minute fragments
which are then violently projected in such a way that containment,
reintegration and reintrojection become extremely difficult. In the
psychotic individual’s phantasy, once they have been expelled, these
fragments encyst the objects into which they are projected, which
swell up in angry reaction to the projection into them to form
‘bizarre objects’ that then suffuse and control the projected piece of
personality (Bion 1957a, p. 48).
Bizarre objects are characterised by the part of the mental apparatus
that has been projected into them. If a part of the mind concerned
with sight was projected into a gramophone to form a bizarre object,
then the gramophone would be experienced as spying; if related to
hearing then the gramophone when played would be experienced as

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Psychoanalytic theories about psychosis

listening to the patient. If the projection contained a fragment to do

with judgement, then the experience would be one of being judged.
Bion therefore recommends paying careful attention to determine
the sensory modality that has been projected and has given rise to a
delusional experience.

The non-psychotic part

The psychotic part of the personality attempts to impose a total with-

drawal from reality by fragmenting and projecting the sense impres-
sions that are the precursors to the development of thinking, and
attacking the links between different thoughts. However, contact with
reality is never entirely lost, due to the existence of a non-psychotic
part of the personality that functions in parallel with the psychotic
part, though it is often obscured by it.
Therefore, the psychotic part can never succeed in totally negating
reality and completely cutting itself off from psychic pain. Importantly,
this means that there is always a part of the patient that we can try to
talk to about the way that their psychotic part is operating, even if at
times it feels as though all the sanity has been projected into the carers
and professionals, so that the capacity for thinking has to reside in
them until the patient has settled into a more receptive state.
While total withdrawal from reality remains for the patient an illu-
sion not a fact, this may not stop the psychotic part from trying to
actualise total withdrawal from reality. Religion is often used for this
purpose.

For example, one patient on admission to hospital complained bitterly that

when baptised as a child one of his feet had not been submerged in the
holy water. If he had been totally submerged, then by identification with
God he would have been immune to all problems, without this Achillean
vulnerability.

Thinking: putting thoughts into words

According to Freud, thinking was originally an unconscious process

that became ‘perceptible to consciousness only through its connec-
tion with memory traces of words’. Freud argues that a thing becomes

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Bion and psychosis

preconscious ‘by coming into connection with verbal images that

correspond to it’ (Freud 1923, p. 20).
Putting thoughts into words puts us in touch with our underlying
feelings. In psychosis, through the functioning of the psychotic part,
the link with words may be attacked in order to annihilate the possi-
bility of a connection to underlying thoughts and feelings.

I recall a patient with schizophrenia who was completely silent when he first
came into hospital, just twitching his extended arms. As he settled down he
started to speak. At first his utterances were an incomprehensible word
salad, but later he began to speak comprehensibly. The psychotic part
had attacked links between thinking and words, first evacuating his feelings
non-verbally through twitching, then later in a mutilated form of speech,
word salad.
An NHS patient whom I unsuccessfully tried to engage in analytic treat-
ment illustrated how persecutory linking thoughts to words could feel
because the result of this was to make his thoughts more conscious. He
spent all his time criticising the notices on the ward or articles in the news-
paper, pointing out that they were unreliable as every word had a double
meaning. He argued that you could not therefore rely on words. I realised
that this was his way of attacking the links that would have enabled him
to be in touch with thoughts and feelings that would threaten his current
state of mind.
When I put this to him, he initially became quite paranoid and defensive.
He then said that if I was right then he was in a terrible state and really
needed twenty years of analysis. However, he said that he did not have time
for this and instead cajoled his mother to finance him to go on a trip to the
United States to learn to be a film director. Relieved at the prospect of a
temporary respite, his mother agreed, but he later returned to London and
was readmitted after trying to baptise her in the bath. He had experienced
the voice of an old man persecuting him from across the road, making one
think of the absence of an effective father figure in his case. He then turned
to the neighbours for help, but experienced sexually taunting voices coming
through their walls, so he daubed ‘Christian?’ on their walls, as if questioning
their response. He then went to church to request an exorcist to remove the
evil spirit from next door. He said that this was like going to one side for help
and being told to join the enemy, as they told him that what he needed was
not a spiritualist but a psychiatrist! On admission, he apologised for his
behaviour, saying that there had been a voice in his anus controlling him.
However, when he was ready to leave hospital, he refused all offers of

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Psychoanalytic theories about psychosis
involvement in therapeutic activities, adding that his intention now was to
become a professional comedian.

While many aspects of the working of this patient’s mind are fascinat-
ing, his case aptly illustrates how attaching thoughts to words makes for
much more conscious awareness, which leads to paranoid reactions
as Freud suggested.

Ideographs and origins of thinking

Bion regarded the linking of thoughts to words as an advanced

stage of development that was preceded by an earlier pre-verbal stage.
He wrote:

My experience has led me to suppose some kind of thought,

related to what we should call ideographs and sight rather than to
words and hearing, exists at the outset. This thought depends on a
capacity for balanced introjection and projection of objects and,
a fortiori, on awareness of them. This is within the capacity of the
non-psychotic part of the personality.
(Bion 1957a, p. 49)

Therefore, according to Bion, the earliest development of thought is

visual rather than verbal in nature. In my view, the psychotic part col-
lects visual memories, or ideographs, which are accumulated through
the working of the non-psychotic part. These memories are stored
and retrieved when required. They are then used for the purpose of
communication through what we commonly refer to as delusions.
Bion (1957a, p. 56) gave the example of a patient who said, ‘My
head is splitting; maybe my dark glasses’, without giving any associ-
ations. This statement was a response to Bion’s interpretation that he
had got rid of his capacity to see in order to avoid the pain that
seeing can cause. In interpreting this statement, Bion recalled that he
himself had worn such glasses many months previously. Although
the patient had made no comment on this at the time, Bion thought
that this had provided him with an ideograph which he had stored up
for possible use in communication if needed later.2 For the patient,
Bion in the dark glasses had been a bizarre object formed as a result of
the patient’s projection of his capacity to see. His reference to ‘my

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Bion and psychosis

dark glasses’ was an attempt to take back his ability to see. He made
use of the ideograph of the dark glasses as part of an attempt to repair
the damage to his ego caused by his excessive projections so that he
would be able to cope with the coming weekend break. In schizo-
phrenia the priority is to address the needs of the psychotic part to
repair the ego before turning to any other concerns.

The functioning of the psychotic part

From the outset, the psychotic part of the personality has attacked
all the mental functions that lead to consciousness of external and
internal reality, the development of ideographs and the linking of
ideographs in developing new thoughts. The capacity to bring objects
together while leaving their intrinsic qualities unimpaired, symbolic
thinking, is not available to the psychotic part.
The psychotic part cannot think; it can only fragment and expel. If
the expelled parts come back, individuals experience this as an assault
by actual objects. The more they aggressively fragment the particles
coming back at them, the more they experience them as being increa-
singly hostile as they try to take them back in an attempt at restitution.
The following clinical vignette serves as a marked example of this:

The wife of a patient in a severely psychotic state left him, resulting in his
experiencing, through hallucinatory projection, a witch in his bedroom. He
dealt with this by setting his room on fire. He then massively fragmented
the persecutory experience coming back at him from the witch, creating
hostile particles to be evacuated as far away as possible. By the time he
came into hospital, he felt that rays coming from the outer planets were
causing painful pin-pricks on his skin. He dealt with this by covering his skin
with Vaseline and sleeping under the bed. He said that he did not need to
see a psychiatrist but an astrologer! It took some nine months in hospital
before this state subsided.

According to Bion, since the psychotic part lacks the capacity for
symbolic thinking, the patient is apt to confuse primitive mental func-
tioning with the laws of natural science. In other words, the psychotic
part has no resources other than logical thinking by means of which
to comprehend matters that belong to the emotional sphere. The
following vignette vividly illustrates this point:

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Psychoanalytic theories about psychosis
A patient with a diagnosis of chronic schizophrenia decided that he wanted
to leave hospital in order to have sex, so he wrote to the head of the YWCA
(a women’s youth hostel association) asking for a place there. He signed
the letter ‘Mr X, educated to “A” level standard, the world’s best logician’. I
received an irate phone call from the head of the YWCA asking me to speak
with the patient and telling me that she was not amused by the letter. When
I spoke to the patient, he replied with no trace of emotion, ‘I can’t see the
problem; if I went there it would be a mixed hostel!’ Clearly the patient’s
logic was impeccable, but he demonstrated a complete incapacity to
consider emotions and their effects on others.

The divergence between the psychotic and non-psychotic parts of

the personality

The fragmentation of the ego and its expulsion into objects by the
psychotic part of the personality takes place at the onset of the
patient’s life.

The sadistic attacks on the ego and on the matrix of thought,

together with projective identification of the fragments, make it
certain that from this point on there is an ever-widening divergence
between the psychotic and non-psychotic parts of the personality
until at last the gulf between them is felt to be unbridgeable.
(Bion 1957a, p. 51)

Bion thought that

real progress with psychotic patients is [not] likely to take place

until due weight is given to the nature of the divergence between
the psychotic and non-psychotic personality [. . .] The patient’s
destructive attacks on his ego and the substitution of projective
identification for repression and introjection must be worked
through. Further, I consider that this holds true for the severe neur-
otic, in whom I believe there is a psychotic personality concealed
by neurosis as the neurotic personality is screened by psychosis in
the psychotic, that has to be laid bare and dealt with.
(Bion 1957a, p. 63)

Bion’s conclusion is that, in major psychotic disorders in particular,

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Bion and psychosis

we have always to think in terms of two separate parts of the personal-

ity and identify the needs of the psychotic part as the priority. Later
chapters will illustrate the profound implications of this insight for
work in everyday psychiatry.

On hallucination

Genesis of hallucinations

In this chapter, Bion writes about his detailed observations of hal-

lucinatory processes and the theory that follows from these. The
chapter centres round clinical material from a patient in analysis.
In the patient described, over a period of time, Bion had discerned
a pattern whereby as a result of an envious reaction by the psychotic
part, a good session was inevitably followed by a bad session. Following
one such good session, the patient came in and the way that he then
lay down on the couch made Bion feel that the two of them had
become parts of a clockwork toy denuded of life. Before lying down,
the patient glanced at Bion, stared into the far corner of the room,
gave a shudder and then when he lay down continued to look at the
corner of the room as though he saw something hostile there. He
then said ‘I feel quite empty. Although I have eaten hardly anything,
it can’t be that. No, it’s no use; I shan’t be able to do any more today’,
and lapsed into silence (Bion 1958, p. 66).
Bion was able to arrive at a quite remarkable formulation of the
patient’s behaviour, which he derived from the patient’s subsequent
comment that ‘I seem to hear things all wrong’. Bion thought that
this statement indicated that the patient had taken in Bion’s interpret-
ations in a way that he felt ‘all wrong’, that is cruelly and destructively.
The patient had taken in Bion’s helpful interpretations through his
ears, experienced his ears as chewing them up and consequently
expelled them out through his eyes to distance himself as far as pos-
sible from them, thereby creating the frightening figure in the corner
of the room. Here we can clearly see the psychotic part of the mind
at work. It takes in Bion, linked with his interpretations, through his
ears, chews him up, and then acts as a muscular organ in projecting
the attacked Bion through his eyes, resulting in a frightening visual
hallucination.

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Psychoanalytic theories about psychosis

Psychotic and hysterical hallucinations

Bion distinguished between two types of hallucinations, psychotic

and hysterical. Psychotic hallucinations are the result of a violent
fragmentary projective process. They show no respect for the natural
lines of demarcation between objects. Consequently, if you are with a
patient in a florid psychotic state, trying to make any sense of a situ-
ation is liable to leave you with a headache, the aftermath of feeling that
your head is being pulled apart while you try to keep your bearings.
Bion contrasts this violent hallucinatory process that arises through
the operation of the psychotic part of the personality, with a more
benign process that creates hallucinations that are understandable,
which he called hysterical hallucinations. Hysterical hallucinations
arise through dissociation, a process that does respect the natural lines
of demarcation between objects. Hysterical hallucinations relate to
whole organs or the body in general and are linked to the work of
the non-psychotic part of the personality. Understanding the content
of hysterical hallucinations can help treatment to progress.
As Bion’s patient progressed in treatment, his fragmentary psychotic
hallucinations began to give way to more hysterical hallucinations.
Bion thought that this was because the patient’s capacity to tolerate
depression had increased. He observed that the onset of depressive
feelings is particularly intense in schizophrenia and when such feel-
ings emerge the danger arises of either suicide or of a secondary
fragmentation of such severity that it could reach a point where
recovery of the ego is no longer possible (Bion 1958, p. 80).
Bion summarises: ‘The hysterical hallucination contains whole
objects and is associated with depression; the psychotic hallucination
contains elements analogous to part-objects. Both types are to be
found in the psychotic patient’ (Bion 1958, p. 82).

Dreams in the context of psychosis

Bion observed that ‘much work is needed before a psychotic patient

reported a dream at all, and that when he did so he seemed to feel
that he had said all that was necessary in reporting the fact that he
had dreamt’ (Bion 1958, pp. 77–78). Bion viewed dreams at night as
sharing many characteristics of hallucinations occurring in the day in
the consulting room: to the psychotic ‘a dream is an evacuation from

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Bion and psychosis

the mind strictly analogous to an evacuation from his bowels’ (Bion

1958, p. 78).
The patient described in ‘On hallucination’ said that he had had a
‘peculiar dream’, and added ‘you were in it’. For Bion, the ‘peculiarity’
of the dream to the psychotic is not its fragmentation, but the appear-
ance of whole objects in it, resulting in powerful feelings of guilt and
depression, associated with the onset of the depressive position.
In summary, the psychotic part fragments and projects sense impres-
sions into objects in the outer world, creating bizarre objects that obey
the laws of natural science rather than emotions, and the patient moves
‘not in a world of dreams, but in a world of objects which are ordinarily
the furniture of dreams’ (Bion 1957a, p. 51). As he progresses he may
start to report dreams, as he begins to introject meaning from the
analytic encounter, but early on in treatment his dreams serve a purely
evacuatory purpose of discharging fragmented part-objects, as in
psychotic hallucinations when awake. Later, the patient’s report of
‘peculiar dreams’ indicates the presence of whole objects that matter
to him, as he approaches the threshold of the depressive position.
Such dreams are similar to hysterical hallucinations.
Bion’s patient was afraid that he had taken in, attacked and evacu-
ated a real person when he produced his hallucination of the man in
the corner of the room. This led to his subsequent report of a linked
dream as ‘peculiar’ as it contained a whole person, namely Bion, in it.
Freud suggested that delusions may be the ‘equivalents of the con-
structions that we build up in the course of an analytic treatment –
attempts at explanation and cure’, though he pointed out that under
the conditions of a psychosis they are bound to be ineffectual (Freud
1937, p. 268). Bion thought that during the period of work with his
patient described in ‘On hallucination’, ‘some of his delusions were
attempts to employ bizarre objects in the service of therapeutic intu-
ition’ (Bion 1958, p. 82). The patient could be seen as attempting to
use his delusions for constructive purposes.

Hallucinations as evacuations

Psychotic projective hallucinatory activity (as distinct from hysterical

hallucinations) should not be seen as an attempt to test out the
environment or alter it to understand its way of functioning better.
Rather, Bion views such hallucinations as a muscular activity aimed at

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Psychoanalytic theories about psychosis

unburdening the psychic apparatus of accretions of mental stimuli

linked to an inability to tolerate frustration.
The expulsion of fragments of the mind into the external world
can result in a state of megalomania, where the patient feels that as
he has created the world surrounding him and that he is the only one
who understands it.
Any patient coming into a ward review conveying an ‘all-knowing’
affect, like ‘the cat that has got the cream’, should alert one to the
possibility that they are living in an internal megalomaniac world of
their own creation.

Frequency of hallucinations
Bion writes of ‘the analyst’s need to appreciate that the presence of
hallucinations is much more frequent than is realised’ (Bion 1958,
p. 85).
Certainly in general psychiatry the genesis of hallucinations at
interviews is far more frequent than realised. One can see hallucina-
tions being generated whenever one asks a recently admitted patient
in an acute psychotic state an emotional question. If patients are asked
factual questions they may reply appropriately, but when one turns
to emotional issues, patients are liable to roll their eyes around the
room or stare out of the window. Like Bion’s patient, they may be
evacuating the emotional sense that one has put into them and gener-
ating hallucinations. The patient might then turn to the person sitting
next to them with a look that seems to say, ‘Who is that funny person
asking the silly questions?’
Psychiatrists in training are used to asking patients if they hear
voices, but they are not used to thinking in terms of voices arising as
a projective process from the patient. Neither are psychiatrists
accustomed to try to understand the genesis of their patients’ visual
hallucinations. Bion’s insights into hallucinations open the door for
further detailed observational studies of this whole area.

A theory of thinking
In this very original theoretical chapter, Bion (1962) suggests that
thinking depends on the successful outcome of two main develop-
ments. The first is the development of thoughts and the second is the

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Bion and psychosis

development of an apparatus for ‘thinking’. Bion contends that we do

not develop thoughts through the operation of a thinking apparatus,
but rather have to develop a thinking apparatus to cope if we have
thoughts (Bion 1962).
Psychopathology can arise in the developments of thoughts or in
the thinking apparatus brought into play to deal with thoughts, or in
both. I will briefly consider the contribution of Bion’s original ideas
in this area to our understanding of psychotic processes.

Development of thoughts

‘Thoughts’ can be classified according to their developmental history

as preconceptions, conceptions or thoughts, and finally concepts,
which are named and therefore fixed conceptions or thoughts. As an
example, Bion suggests that the infant is born with a preconception
(inborn expectation) of a breast. If the preconception meets with a
realisation, then it develops into a conception of the breast, with an
attendant sense of emotional satisfaction.

Intolerance of frustration

Bion then considers what happens if a preconception meets with a

frustration, the ‘no-breast’ or absent breast. The outcome of this
inevitable experience will depend on the infant’s capacity to tolerate
frustration.

If the capacity for toleration of frustration is sufficient the ‘no-

breast’ inside becomes a thought and an apparatus for thinking
it develops. This initiates the state, described by Freud in his
‘Formulations on the Two Principles of Mental Functioning’
(S. Freud 1911b), in which dominance by the reality principle is
synchronous with the development of an ability to think and so
bridge the gulf between the moment when a want is felt and the
moment when an action appropriate to satisfying the want culmin-
ates in its satisfaction. A capacity for tolerating frustration thus
enables the psyche to develop thoughts as a means by which the
frustration that is tolerated is itself made more tolerable.
(Bion 1962, p. 112)

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Psychoanalytic theories about psychosis

If the infant’s capacity to tolerate frustration is inadequate, then the

development of an apparatus for thinking is disturbed and ‘instead
there is a hypertrophic development of the apparatus for projective
identification’ where ‘evacuation of the bad breast is [felt to be]
synonymous with obtaining sustenance from the good breast’ (Bion
1962, p. 112).
The end result in psychosis is that rather than developing an appar-
atus for thinking, the individual develops an apparatus for ridding
the psyche of bad internal objects. Anything indicative of the exist-
ence of an object separate from the subject is also to be obliterated.
In this context space and time are perceived by the psychotic part of
the personality as identical to a bad object, to be repeatedly annihi-
lated. Bion graphically illustrated this with the description in Alice’s
Adventures in Wonderland of the Hatter’s mad tea party, where it is
always four o’clock. In a more familiar setting we can appreciate
this dynamic in the case of patients whose aim seems to be to destroy
time by wasting it; such as in patients with severe chronic schizo-
phrenia where intrinsically powerful forces keep them in a state of
inertia.

Learning from experience

If frustration can be tolerated then one can learn from experience.

If, as in the case of the operation of the psychotic part, frustration
cannot be tolerated then no learning from experience can occur, only
projection and paranoia.
If intolerance of frustration is not so great to activate mechanisms
of evasion through projection, and yet is too great for the dominance
of the reality principle to be bearable, then Bion points out that a
sense of omniscience may develop, an all-knowing state based on
morality, as a substitute to thinking and learning from experience.
Being able to distinguish between true and false lies within the cap-
acity and structure of the non-psychotic part, and ‘omniscience
substitutes for the discrimination between true and false a dictatorial
assumption that one thing is morally right and the other wrong’
(Bion 1962, p. 114).

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Bion and psychosis

The role of maternal reverie: alpha-function, alpha- and beta-elements

So far, Bion has focused his theories on the working of the patient’s
mind. He now turns to the effect of the environment, in the first place
the mother’s mind. The infant projects out whatever feels unbearable,
like his fears of dying, into the mother. Bion calls these unbearable
states of mind beta-elements. It is like projecting bits of undigested
food. A well-balanced mother can accept these fears and make them
more tolerable. By entering into a reverie state she converts the baby’s
intolerable beta-elements into a tolerable sense of himself, which
Bion calls alpha-elements. The mother’s alpha-function thus enables
the infant to become conscious of himself.
If the mother cannot tolerate the infant’s projections, for example
of his fears that he is dying, the infant must resort to continued pro-
jective identification carried out with increasing force to denude his
projections of their penumbra of meaning. In the consulting room
the patient will convey an internal object that has the characteristics
of ‘a greedy vagina-like breast’ that strips away all goodness and
starves the infant of a development of understanding. The develop-
ment of a capacity for thinking is then seriously impaired with a
precocious development of consciousness (Bion 1962, p. 115).

Nameless dread

Normal development follows if the relationship between infant

and breast permits the infant to project a feeling, say, that it is dying
into the mother and to reintroject it after its sojourn in the breast
has made it tolerable to the infant psyche. If the projection is not
accepted by the mother the infant feels that its feeling that it is
dying is stripped of such meaning as it has. It therefore reintrojects,
not a fear of dying made tolerable, but a nameless dread.
(Bion 1962, p. 116)

The object’s failure to contain projections is key to understanding

borderline states and will be described in Chapter 10, where it is
linked to another of Bion’s papers, ‘On arrogance’ (Bion 1957b).
However, to my mind, Bion’s concept of nameless dread can also be
linked to the agitation that is the overriding symptom in psychotic
depression: persistent insecurity in relation to an internal object that is

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Psychoanalytic theories about psychosis

not supportive to the subject’s feelings. I will return to expand on this

area in the chapters addressing depression.

Communication

Bion thought that a sense of truth is experienced ‘if the view of an

object that is hated can be conjoined to a view of the same object
when it is loved and the conjunction confirms that the object experi-
enced by different emotions is the same object’ (Bion 1962, p. 119). A
commonsense view can then be established for sharing with others.
A sense of truth is crucial to any shared communication. As it is
acquired, it builds up the strength of the non-psychotic part, reducing
its need to employ splitting and dissociation. Our task with all
our patients is to work towards achieving such moments of shared
communication through honest and meaningful interactions.

Summary

In this chapter I have attempted to review some of the key concepts

relating to psychosis described by Bion in his three seminal papers.
I had two supervisions with Bion late in his life. When I told him
how helpful I had found his ideas, he replied that the fun starts when
you go and do your own thing! I feel a deep gratitude that his ideas
have helped this to happen. I hope to show in later chapters how the
ideas presented here can be further developed and usefully applied
within the general psychiatric setting.

100
7
A contemporar y Freudian per spective
on psychosis

This chapter briefly reviews the contemporary Freudian perspective

on psychosis presented in the work of Tom Freeman (e.g. Freeman
1988, 1998). Freeman had a long and distinguished career as both a
psychoanalyst and general psychiatrist, first in Glasgow and later in
Northern Ireland. He also worked closely with Anna Freud at the
Hampstead Child Therapy Clinic in London. He wrote many books
and over a hundred papers related to the study of psychosis. The
purpose of this selective review is to clarify and discuss some differ-
ences between the perspective on psychosis represented by Freeman’s
work and the one presented in this book.3

Introduction

Freeman was concerned at the widening divide in approach to neur-

osis and psychosis within general psychiatry. While a psychothera-
peutic approach of talking to the patient was regarded as appropriate
for neurosis, it was seen as unsuitable for the treatment of psychosis
where increasingly the prescribing of medication was becoming
predominant.
Freeman held that psychotherapy was an integral part of psychi-
atric practice, as a means of participating in, as well as observing the
patient’s subjective experience. He was concerned that psychotherapy
was being gradually divorced from general psychiatry, resulting in the
loss of a clinical tradition in psychiatry that would equip psychiatrists
in training with the ability to relate to their patients. In his book, The

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Psychoanalytic theories about psychosis

Psychoanalyst in Psychiatry (Freeman 1988), he provided a detailed

exposition of his individual approach based on thirty-five years of
experience in psychiatry and psychoanalysis.
Freeman viewed psychosis from a developmental perspective. He
worked closely with Anna Freud, sharing her developmental theor-
etical approach, and constructed a psychoanalytic schema for examin-
ation of psychotic patients which was adapted from the one she
developed for use with neurotic patients. He understood schizo-
phrenia and organic psychoses in terms of a dissolution of the person-
ality and consequent regression to earlier stages of development in
which the mind works in less sophisticated ways. He drew attention
to the similarities between psychotic children and certain adult cases
of schizophrenia. In children there was a failure to reach the libidinal
cathexes of objects, while in the schizophrenic there was a failure
to maintain them. The loss of developmental achievements, as a result
of the illness, account for the negative symptoms in schizophrenia.
With the dissolution of the adult personality, less developed forms
of mental life come to the fore, and these account for the positive
symptoms of schizophrenia. Freeman emphasised the importance of
sharing in the patient’s experience while they were going through it
and relating to them according to their state of mind.
The dissolution of the personality led to the emergence of symp-
toms reflecting the loss of the capacity to discriminate between
mental representations of the self and others. Freeman adopted terms
used by Bleuler (1911) and Wernicke (1906) – transivitism, parts of
the self externalised on to the external object, and appersonation,
features of the object remaining in the self, to describe this state. He
regarded the phenomena of transivitism and appersonation as at the
heart of differing psychoanalytic theories of psychoses.
Freeman’s account of the origins of psychosis is very different from
Bion’s understanding in terms of a never-ending conflict between the
life and death instincts with a psychotic part of the personality devel-
oping separately from the non-psychotic part (Bion 1967). To make
sense of these differences, we must consider some of Freeman’s basic
analytic beliefs in more detail.

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Contemporary Freudian perspective on psychosis

Freeman’s basic analytic beliefs

Freeman saw Freud’s pleasure principle as the key to understanding

the clinical material of both neurotic and psychotic patients. He noted
similarities in the contents of dreams and in the thought disorder
of non-remitting schizophrenias, for both contained a plethora of
substitutions with the aim of satisfying a wish fulfilment.
In schizophrenia, as a result of the dissolution of the cognitive
organisation that underwrites logical thought, the patient expresses
his psychically fulfilled wishes in the manner available to the healthy
dreamer. Freeman gave the example of a patient with the delusion
that he was Christ thrice martyred and restored, and brought back
to life and reunited with his girlfriend.
The partial or complete dissolution of the secondary process, with
a backward course (topographical regression) leads to the character-
istics of the presentation in schizophrenia. Freeman describes a
35-year-old woman with non-remitting schizophrenia, whose hus-
band had left her, who said ‘They are all dirty, Persian Oil and Glas-
gow Royal. Oil is mental’. Her statement was a condensation of
memories of an unhappy life in Persia with her husband, when he had
worked in an oil company. He had been unfaithful to her and now
she was a prisoner in a mental hospital. ‘Oil is mental’ gave expression
to her conviction that it was her husband who was ill and not herself.
In Bion’s terms, I would understand this patient’s resistance to
accepting her illness, by attributing it to her husband, as an instance
of the power of denial of the psychotic part of the personality, fuelled
by the death instinct.
Freeman felt that Freud’s topographical model and his concept of
the pleasure principle was the theoretical framework that enabled him
to be most in touch with his patients’ clinical material. To quote, ‘The
theory of the pleasure principle demonstrates that Freud judged the
value of his theoretical formulations in accordance with their proxim-
ity to clinical observations’. Freeman felt that Freud’s reformulation
of his theory of the mind, starting with Beyond the Pleasure Principle,
took one further away from the clinical material.
In Freud’s (1920) reformulation, a new principle emerged, the
Nirvana Principle, whose action was to convert ‘The restlessness
of Life . . . into the stability of the inorganic state’. The Nirvana
Principle was put on the same footing as the pleasure principle. By
attributing the movement to reduce unpleasure to the death instinct,

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Psychoanalytic theories about psychosis

wish-fulfilment, real and psychical, were now seen as being under the
governance of the Nirvana Principle.
Freeman proposed an alternative to acceptance of Freud’s concept
of the death instinct. Prior to introducing the death instinct, Freud
had envisaged hatred as a reaction of the self-preservative aspects of
the ego-instincts to unpleasure. He reasoned that in schizophrenia,
hatred and physical attacks on others are the result of ego instincts
striving to reduce the unpleasure stimulated by contact with real per-
sons. Destructive attacks on the body are, paradoxically, a desperate
attempt by the ego instincts to preserve the mental self. Only by
destroying the body can the unpleasure caused by bodily needs (sexu-
ality), affects, and violent urges be removed.
Freeman’s reluctance to accept the notion of the death instinct was
not only because it seemed to be based on theoretical speculation
rather than on a clinical foundation, but also because he felt that it
undermined Freud’s earlier analytic thinking, and the beauty of its
application in his case histories, which all preceded the introduction
of the structural model.
However, I would argue that there might be a need to use different
theoretical frameworks of understanding depending on the present-
ing clinical case. For example, young adolescents may attack their
body by cutting or taking overdoses. This could be appreciated in
terms of an attempt to preserve the mental self while undergoing an
adolescent crisis, along the lines Freeman describes.

A different framework of understanding may be required to comprehend the

action of a patient with a depressive illness who killed himself by cutting his
throat, body, arms and legs with a kitchen knife, for his brother to find on
returning from work. His family had continually offered this man their loving
support and after his suicide they asked for help to understand the event;
they did not wish to blame anybody. I saw his behaviour in terms of a
destructive independent narcissistic part that had never allowed the patient
to develop in life, keeping him dependent on his relatives’ support. When
approaching mid-life, and confronted by his negative behaviour, the narcis-
sistic part of the patient’s personality silenced the healthy part. His relatives
needed to know that the tragedy was no one’s fault and that the love they
had given him was for another, non-murderous, part so that they were not
left feeling that all they had given had been without meaning.

Here one might say that the line I have taken, derived from another

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Contemporary Freudian perspective on psychosis

part of Freud’s thinking, originates from his 1914 paper ‘On narcis-
sism’. In this paper Freud described two modes of functioning, the
anaclitic and narcissistic. In the anaclitic mode the individual was able
to develop by taking in nourishment from parents and teachers. In the
narcissistic mode the individual took himself as the object and no
development was possible, like the chronic hospitalised schizophrenic
who had renounced real life for his own world. Freud’s distinction
between the anaclitic and narcisstic modes of functioning foreshadows
Bion’s theory of the separate psychotic and non-psychotic parts of the
personality. Freud’s introduction of the concept of the death instinct,
with Klein’s addition of envy as its external manifestation, underlines
the powerfulness of the innate destructive forces linked to the narcis-
sistic mode. While the pleasure/unpleasure principle was central to
Freudian theory, one might say that relatively early on in his writings
Freud was also beginning to elaborate his thoughts in other directions.
Because of his strong adherence to the topographical model, and
his theory of the dissolution of the personality in schizophrenia,
Freeman does not see the superego as capable of becoming a patho-
logical entity in its own right. He views it as arising from the ego and
then experienced outside it, in terms of the ego ideal, but vulnerable
again to dissolution. He was critical of Fairbairn and Klein’s contribu-
tions on splitting, seeing them as a reinterpretation of clinical facts,
with splitting replacing dissolution. He also did not see Klein’s con-
cept of the manic defence as a universal unconscious dynamic, but
rather saw it as applying only to the small group of patients where a
manic attack follows real object loss.
He shares Katan’s view that a change to pathological (secondary)
narcissism takes place when there is extensive psychical dissolution.
This results in the exposing of an ‘undifferentiated state’ (Katan 1979).
This raises the question of whether neurosis and psychosis can be
thought of as differing only in terms of the degree of psychic dis-
solution. Freeman recognised this dilemma in commenting, ‘The
theories described here to account for narcissistic object relations
reflect a long-standing controversy on the nature of non-psychotic
and psychotic illness. Are they or are they not quantitatively different
clinical entities?’ (Freeman 1998, p. 113). This is the most crucial and
controversial question of all the psychoanalytic debates on schizo-
phrenia. The reluctance of analysts to recognise the special nature of
chronic schizophrenia is manifest in the belief that, like neurosis, it can
be cured, either by physical or psychological approaches.

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Psychoanalytic theories about psychosis

Belief in the possibility of an analytic cure exposes us to inevitable

disillusionment. Tom Freeman and I came to share the view that our
priority as psychiatrists is to listen to and live with our patients rather
than be concerned about cure. As I’ve already mentioned, I will
always remember Dr Freeman once saying to me that the difference
between us and the organically based psychiatrists was that they knew
what was going on. We hadn’t the faintest idea, so we had to listen to
our patients to see if they could help us!
Those who approached patients with schizophrenia in the hope
that their presence, their sympathetic understanding and their interest
would strengthen what remained of healthy life did so because they
adhered to the decathexis-recathexis theory. In other words, many
non-analytically trained people may be understood as operating
within an approach advocated by Freeman.
Freeman summarised the aim of psychoanalytic treatment in
schizophrenia as to enable the patient to recover their lost
independence.

This aim will best be furthered if the analyst’s contributions are

limited to sweeping away the obstacles (transference, ego and
superego resistances) that prevent the patient from giving expres-
sion to his wishes, fears, phantasies and memories. This restores the
continuity between the patient’s present and past mental life –
continuity that has been lost.
(Freeman 1998, p. 148)

Freeman ended his last published book with a trenchant restatement

of his beliefs:

The purpose of the book has been to show that Freud’s introduc-
tion of the theory of the death instinct and the ‘structural’ formula-
tions laid the foundations for the theories of contemporary
psycho-analysis. The concept of the death instinct marked a change
in Freud’s thinking. He no longer found it necessary to anchor this
concept in clinical observations, as had been his practice in the past.
He used the new concept to reinterpret clinical facts. The effect
was to cause his original ideas to slip into the background.
(Freeman 1998, p. 149)

106
8
The psychoanalytic treatment
of schizophrenia
Lessons from Chestnut Lodge

Introduction

This chapter considers the important lessons to be drawn from the his-
tory of Chestnut Lodge, a famous psychiatric sanatorium in Rockville,
Maryland, near Washington DC. Chestnut Lodge was opened by its
first director Ernest Bullard in 1910 and closed in 2001. For a full
summary of its history, contributions and references, the reader is
referred to the writings of Ann-Louise Silver (1997). The purpose of
this chapter is to highlight some lessons to be drawn from a unique
establishment that focused on the management of severe and chronic
psychotic disorders, particularly schizophrenia, as well as affective
and borderline states, and which for a long time used an exclusively
analytic approach. While important contributions to psychoanalytic
thinking about psychosis were made by the eminent analysts work-
ing at Chestnut Lodge, the story illustrates the need to introduce a
more flexible attitude, including incorporation of medication where
indicated, when approaching psychosis.

Background history

The initial aim of Chestnut Lodge was to provide a rest cure and work
therapy. Ernest Bullard is reported to have said that it was better for
people to grow real roses than to make artificial ones, foreshadowing

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Psychoanalytic theories about psychosis

Joanne Greenberg’s (1964) autobiographical novel based on her

experiences at the Lodge, I Never Promised You a Rose Garden.
In 1931, Ernest Bullard died and his son Dexter Bullard took
over. He was in psychoanalytic training and noticed the similarities
between dreams and psychosis. This led him to look for an analyst to
run the sanatorium. Frieda Fromm-Reichmann, a training analyst
with the Berlin Psychoanalytic Institute, came over to the United
States in 1935, looking for work. She had previously run her own
sanatorium in Heidelberg, and was appointed to give Chestnut Lodge
a uniquely analytic focus. Her approach was described in her book
Principles of Intensive Psychotherapy, which was widely read by psychi-
atrists (Fromm-Reichmann 1950).
Fromm-Reichmann had a classical analytical training and a very
strong personality. In line with Freud’s view that no transference
occurred in psychosis, she held that the classical analytic technique
could not be applied to schizophrenia. Nevertheless, all the patients at
Chestnut Lodge received individual fifty-minute sessions, termed
‘intensive psychotherapy’ in order to maintain the sense of a dis-
tinction from psychoanalysis. These sessions took place only four
times a week, and incorporated a long-term dedicated supportive
element.
Harry Stack Sullivan was never formally on the staff of Chestnut
Lodge, but strongly influenced Lodge styles and attitudes (Sullivan
1962). In contrast, Harold Searles, an eminent psychoanalyst, was on
the staff and his own analytic contributions on schizophrenia were
based on his work within that setting (Searles 1963a).
Fromm-Reichmann died in 1957, but the power of her personality
influenced the approach at the Lodge long after her death. I visited
in 1988, and was told the following story.

A junior analyst in training was on night duty. He was required to visit all
the wards at night at a stipulated time with the matron. He asked if they
could do their rounds slightly earlier, so that he would be in time to watch an
important sporting event. He was told that Dr Fromm-Reichmann would not
have liked it. She had in fact died fifteen years previously!

At the same time I met a young analyst working at the Lodge, who
took great exception to using the word psychoanalysis to describe his
work with patients, whom he was seeing four times a week. Despite
this inflexible adherence to Fromm-Reichmann’s definitions, he

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The psychoanalytic treatment of schizophrenia

described a problem that was preoccupying him, namely that a patient

who had just been allocated to him for intensive individual therapy
had assaulted his previous therapist. He was uncomfortable with the
prevailing institutional attitude, which seemed to be that he should
continue seeing the patient regardless.

Chestnut Lodge’s theoretical framework

Following on from Fromm-Reichmann, Ping-Nie Pao, who was then

Director of Psychotherapy at Chestnut Lodge and a graduate of
the Washington Psychoanalytic Institute, wrote a book describing
Chestnut Lodge’s development of an integrated theory and approach
to schizophrenia by incorporating analytic contributions from Freud
onwards (Pao 1979). The theoretical premise underpinning the
approach was that a certain combination of nature and nurture in the
first weeks of life results in a deficient capacity for adaptation, which
becomes increasingly impaired resulting in schizophrenic illness. The
birth of psychoanalysis at the beginning of the twentieth century was
held to have revolutionised our conception of schizophrenia, enabling
a shift from the previous view of a hereditary-constitutional-
degenerative disease of the brain to considering it in terms of human
development.
While each person with schizophrenia was held to be unique,
such individuals were thought to have early traumatic interpersonal
experiences in common. The degree of difficulty in early relation-
ships determined the severity of the illness. Sullivan’s interpersonal
theory is mentioned within this context, with its assumption that the
mother of the future schizophrenic is more anxiety-ridden than the
average mother (Sullivan 1962).
Pao (1979) divided schizophrenia into four categories depending
on the severity of the early trauma, and also distinguished acute, sub-
acute and chronic phases. He held that ‘intensive psychotherapy’ was
a must in the sub-acute phase in order to head off a self-perpetuating
regression, with a move into a chronic state.
Delusions were seen as extensions of pre-existing fantasies. For the
patient they contributed immensely to the re-establishment of a
badly needed sense of self-continuity. In the chronic phase a reso-
lution or correction of delusions in patients was not expected; rather,
the aim was to increase the patient’s capacity to tolerate instinct-affect

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Psychoanalytic theories about psychosis

tensions to enable them to arrive at the best solutions without resort-

ing to extremely distorted views about the object world.
Hallucinations were seen as the patient’s attempts to ward off pain-
ful affects, as illustrated by an example of a woman with schizophrenia
who developed breast cancer. She came from a background of social
isolation and for her the voice she heard was a comfort. Fromm-
Reichmann was said to have often told her patients that ‘you may
keep your voice as long as you feel you need it’ or ‘you will give it up
when you are ready’ (Pao 1979, p. 264). For Pao, the background
dynamic was that, while acknowledging patients’ desire to rid them-
selves of something unpleasant, one was also reassuring them that an
end to the unwanted experience was conceivable.
Pao (1979) wrote that his aim in treating schizophrenic patients was
to improve their self- and object-representational world. A decision
would be needed as to whether the patient could be treated in his
office or would require admission. While antipsychotic medication
removed florid symptoms (e.g. terror, confusion, hallucinations), this
would only result in a temporary remission. Without provision of
adequate intensive psychotherapy the symptoms would come back,
accounting for the development of the ‘revolving door’ phenomenon.
Fromm-Reichmann introduced the term ‘psychoanalytically
orientated intensive psychotherapy’ for the treatment at Chestnut
Lodge (Fromm-Reichmann 1950). Intensive psychotherapy was to
be distinguished from psychoanalysis by allowing patients not to
use the couch and not requiring them to free associate, and refraining
from transference interpretations in the early stages. The aim was
to enable patients to study and resolve their conflicts within a devel-
opmental perspective and subsequently change their self- and/or
object-representational world. It was a ‘modified psychoanalytic
treatment’, which also gave support but was more than just supportive
therapy. Pao remained very cautious about prescribing psychotropic
drugs, despite the efficacy of some of them in removing symptoms.
He felt:

Prescribing antipsychotic drugs to such a patient whenever symp-

toms arise may temporarily give him some relief but may inadvert-
ently distract him from the goal of resolving his conflicts and
make subsequent modification of his personality that much more
difficult.
(Pao 1979, p. 319)

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The psychoanalytic treatment of schizophrenia

The lawsuit

In 1982, a patient initiated a lawsuit against Chestnut Lodge. He was

regarded as having a depressive illness with psychotic features. He
claimed that as a result of staff negligence in not administering medi-
cation, which would have quickly restored him to normal functioning,
in the course of a year he had lost a lucrative medical practice, his
standing in the community, and custody of two of his children. An
arbitration panel found for the plaintiff, in that the psychiatrist has a
responsibility to provide information on alternative treatments, such
as efficacy of medication or behavioural approaches (Klerman 1990).
In summing up, Klerman wrote:

In the current situation in psychiatric practice, where there are large

areas of ignorance, it behoves individual practitioners and institu-
tions to avoid relying on single treatment approaches or theoretical
paradigms. Thus, in modern psychiatry, treatment programmes
based only on psychotherapy or only on drugs are subject to criti-
cism. Professionalism requires balancing available knowledge against
clinical experience and promoting the advancement of scientific
knowledge. In the case of treatment practices, such knowledge best
comes from controlled trials.
(Klerman 1990, p. 417)

Outcome research

Following the lawsuit, other treatment modalities became available

beyond a purely analytic approach. However, prior to the change,
Chestnut Lodge provided a unique cohort of patients with diagnoses
of affective disorders, borderline patients, and patients with chronic
schizophrenia, who had been treated solely with intensive analytic
psychotherapy and could be studied for outcome research purposes.
McGlashan (1984a, 1984b) instigated a follow-up study whereby
446 patients (72 per cent of the total) treated at Chestnut Lodge
between 1950 and 1975 were followed up an average of fifteen years
later. They were typically chronic psychotic and borderline patients
who had been in long-term specialist residential treatment for severe
illness.
McGlashan found that roughly two-thirds of the schizophrenic

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Psychoanalytic theories about psychosis

patients were only marginally functional or worse at follow up, com-

pared to one third of the unipolar affective disorders (McGlashan
1984a, 1984b). Borderline patients were comparable with unipolar
affective patients and scored significantly better than schizophrenic
patients on most outcome indexes. Outcome also varied over time,
with borderline patients functioning best in the second decade after
discharge (McGlashan 1986a, 1986b). Better global outcome for
chronic schizophrenia was predicted by less family history of schizo-
phrenia, better premorbid instrumental functioning (interests and
skills), more affective signs and symptoms (especially depression) in
the manifest psychopathology and absence of psychotic assaultiveness
(McGlashan 1986a, 1986b).

Learning the lessons of history

There are lessons to be learned from Chestnut Lodge that should be

noted by all workers who become involved in the field of psychosis,
especially with chronic schizophrenia, whether they are psycho-
analytic or organic in orientation.
Schizophrenia is a condition that demands to be studied in its own
right, from both a psychological and organic perspective. In the full-
ness of time many differing aetiologies may emerge, some more
clearly genetically based and some in which environmental factors
may play an important contributory role. Our problem is that, in our
ignorance, instead of accepting the complexity of the condition and
the limitations of our knowledge about it, we are tempted to impose a
solution, a cure. This applies equally to one-sided attempts to impose
either a talking cure or an organic cure.
On the organic side, we have seen the harmful effects of insulin
coma and leucotomies. We have seen the drive to cure through medi-
cation, creating the revolving door syndrome. More recently we have
seen again the drive to cure in the attribution of the cause of schizo-
phrenia to institutionalisation, resulting in the closure of the asylums
with community care held to be the cure. R. D. Laing also attributed
the cause of schizophrenia to both society and the medical profes-
sion’s intolerance of eccentricity, and advocated the solution of a
laissez-faire attitude. None of these approaches cured the psychoses.
Chestnut Lodge is another example of an attempt to treat psychosis
by a single method, intensive analytic therapy, which again was

112
The psychoanalytic treatment of schizophrenia

not supported by the follow-up outcome figures. Similarly in the

UK, a Kleinian approach to psychosis, after much initial enthusiasm,
also failed to produce dramatic outcome results for patients with
schizophrenia.
This raises the question of whether all the psychoanalytic input has
been a waste of time and effort. I think that the answer to this ques-
tion is a definite no. The mind of the psychotic patient demands to be
studied and understood in its own right if we are to improve our ways
of relating to patients and handling crises. The lifetime involvements
and insights of those working at Chestnut Lodge, including eminent
analysts such as Searles, were not in vain.
We need to keep in mind Ron Britton’s warning not to get too
caught up in our favourite beliefs and see them as the only way
forward, treating our own overvalued ideas as selected facts (Britton
1998). We may not be able to synthesise the organic and psychological
approaches into a single theory, but neither should we try to aggrandise
one at the expense of the other. The different approaches to schizo-
phrenia each have something to contribute, even if we can never
be absolute, so that we need to remain open to consider all aspects. As
Britton emphasised, there is nothing so dangerous as a half-truth, and
we can see this clearly in the history of schizophrenia, where attempts
have been made to impose half-truths as the whole truth, whether
from the organic or analytic perspective, with disappointing results
(Britton 2009).
While we cannot merge the organic and psychological approaches
into one, from a psychoanalytic perspective we should be facing
towards our organic colleagues and taking an interest in their dis-
coveries, rather than turning our backs on them while pursuing our
own interest. A flexible approach to schizophrenia is required where
different perspectives are considered while making use of psycho-
analytic insights to provide an integrative framework (Alanen 1997).
The lesson from Chestnut Lodge is that no single approach to
schizophrenia can provide the answer. This does not mean that people
should not dedicate themselves to a lifelong study of their area of
expertise and interest, but in such studies it is important to keep in
mind that only one aspect of the overall picture is being examined.
Given our current state of knowledge about schizophrenia, we must
strive to remember that our object cannot be to bring about a cure of
a condition that has remained stubbornly resistant to treatment, but to
avoid harmful treatments, while learning all the time about how to

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Psychoanalytic theories about psychosis

help the patient and their relatives to live as comfortably as possible

with the condition.

Summary

Chestnut Lodge is a unique institution where for decades patients

with schizophrenia received only an analytic approach. Follow-up
studies revealed that while patients with more borderline pathology
produced positive outcome figures, those with a diagnosis of chronic
schizophrenia did not. While both the expertise and dedicated care
given over many decades by the staff at Chestnut Lodge and the
insights gained from individual work must be acknowledged, there is
a lesson to be learned. When we are dealing with severe psychotic
disorders, we need an integrated approach that is open to differing
modalities of treatment, including medication.

114
9
The divided self
Evaluating R. D. Laing’s contr ibution to
thinking about psychosis

Introduction

R. D. Laing’s most famous work, The Divided Self, was first published
in September 1960. Only 1,600 copies were sold in the first four years
but by the time of Laing’s death in 1989, over 700,000 copies had
been sold in the UK alone. This chapter will consider whether
the issues Laing raised in this seminal work are as pertinent today as
when the book was first published in 1960.

Laing’s background

After qualifying as a doctor in 1951, Laing began his medical career

at Killearn hospital neurosurgical unit, where he was taken under
the wing of Joe Schorstein. Schorstein, a neurosurgeon, had an exten-
sive knowledge of philosophy, and Jaspers, Nietzsche, Kierkegaard
and Kant were common ground between them. Schorstein, who
acted as a surrogate father to Laing, was a strong opponent of leu-
cotomies, electroconvulsive therapy (ECT) and the ‘mechanisation of
medicine’.
Laing had his first experiences in psychiatry during his national
service from 1951 to 1953, when he was stationed at the British Army
psychiatric unit at Netley. In Wisdom, Madness and Folly, Laing (1985)
wrote movingly of the nightmare of administering insulin coma,
where he would work in total darkness, apart from a torch strapped

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Psychoanalytic theories about psychosis

to his head. He had difficulty telling on intubation if the tube went

into the stomach rather than the lungs.
From the beginning of his psychiatric work Laing made efforts to
enter into his patients’ experiences. He recalled joining one patient,
John, in a padded cell, and feeling strangely at home. He took another
patient home for the weekend from the insulin ward. This patient
became the case of Peter in The Divided Self.
After he was demobbed in 1953, Laing returned to complete his
general psychiatric training at Gartnavel Hospital in Glasgow. With
two psychiatric colleagues, Drs Cameron and McGhie, he partici-
pated in a year-long experiment, where patients from a refractory
ward were provided with a room with nurses. The room was pleas-
antly equipped with material for knitting, drawing, playing records
and so on. The patients responded to the more stimulating environ-
ment. It was called the ‘Rumpus Room’, and was later written up
in the Lancet (Cameron et al. 1955). For Laing, the experiment acted
as a prototype for Kingsley Hall. In January 1956, Laing completed
his Diploma in Psychological Medicine (DPM) and was registered as
a psychiatrist. In the latter half of that year, he moved to the Tavistock
Clinic in London.
From adolescence, Laing had studied the German philosophers,
but Adrian Laing (1977) records that between October 1951 and
July 1954 his father ploughed through the works of Kafka, Camus,
Sartre, Wittgenstein, Simone Weil, Coleridge, J. S. Mill, Bleuler,
Rex Warner, Schoenberg, T. S. Eliot, Tolstoy, Freud, Schweitzer,
Rousseau, Husserl, Tillich, Dylan Thomas, Jaspers, Kierkegaard,
Heidegger, Martin Buber, Marx and Minkowski.
Out of all this reading arose an overriding ambition to write
something in the tradition of existentialism and phenomenology.
He also wanted to publish his first book before the age of 30. By 1957,
Laing had completed the manuscript of The Divided Self.

The Divided Self

Drawing on his experiences in psychiatry, in The Divided Self Laing

sought to address his fellow professionals, trying to persuade them to
think about their psychotic patients in a different way. He argued that
it is possible for the psychiatrist ‘to know in fact, just about everything
that he can know about the psychopathology of schizophrenia or of

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Laing on psychosis

schizophrenia as a disease without being able to understand one

single schizophrenic’ (R. D. Laing 1960, p. 33). Laing criticised
Kraepelin for his preoccupation with classification (Kraepelin 1905),
and argued, for example, that his demonstration of catatonia in a
patient could have been the result of the patient being placed in a
tormented and untenable position in front of students. Laing wrote,
‘in his eagerness to find signs and symptoms, the psychiatrist has
not time to simply try and understand the patient’ (R. D. Laing 1960,
pp. 29–31).
In The Divided Self the key to understanding the schizophrenic
patient lies in Laing’s differentiation between physical birth and exist-
ential birth. The physical birth of infants is fairly closely followed by
their existential birth, that is, their sense of themselves as an entity
with continuity in time and a location in space. Existential birth
is a development which is usually taken for granted. However,
whereas most people develop a sense of being an entity in infancy,
Laing argued that in schizophrenia this firm core of ‘ontological
security’ is not established. He acknowledged that this could partly
be due to genetic predisposition but argued that an individual’s family
also play a vital role in facilitating or impeding the establishment
of ontological security.
Laing thought that the psychotic patient is beset by fears of
engulfment, implosion (fear of the world crashing in on you at any
moment) and petrifaction (turning to stone). He argued that dividing
the self defended against these threats. To preserve the ‘true self ’, a
‘false self’ was offered as an ambassador and hostage to the world. Real
contact was avoided through secrecy and over-compliance. Laing
claimed that the schizophrenic’s apparently mystifying behaviour and
language could be understood by imaginatively entering into their
strange and alien world.
The clinical material for The Divided Self was derived largely
from Laing’s time in the army and at Gartnavel, and written mostly
from memory. The patient called Julie in the book was a chronic
schizophrenic at Gartnavel. Her mother would not let her live and
she was trying to become a real person. She was taken as a prime
example of ‘ontological insecurity’.
Laing held that no one has schizophrenia; rather, someone is
schizophrenic if, for example, ‘he says he is Napoleon, whereas I say
he is not, or if he says I am Napoleon whereas I say I am not . . . etc.’
He suggested that ‘sanity or psychosis is tested by the degree of

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Psychoanalytic theories about psychosis

conjunction or disjunction between two persons where the one is

sane by common consent’ (R. D. Laing 1960, p. 36).

Existentialism and psychoanalysis

At the time of writing The Divided Self, Laing was a member of

a group of intellectuals in Glasgow with a marked existentialist orien-
tation, which included Joe Schorstein, Karl Abenheimer, a Jungian
psychotherapist, John Macquarrie, Jack Rillie and Ronald Gregor
Smith. Rillie, who has written on existential theology, noted that
Smith, a theologian, was a guiding member of the group and had little
time for psychoanalysis. He also shared with Laing a strict religious
upbringing. It was with this group that Laing discussed The Divided
Self in its formative phase (Beveridge and Turnbull 1989).
Adrian Laing (1977) has traced the existential origins of some of
the terminology used in the book. The title of The Divided Self came
from the eighth chapter of The Varieties of Religious Experience by
William James (1902). The concept of the false self came from
Kierkegaard’s Sickness unto Death (1849). The state of mind Laing
deemed ‘ontological insecurity’ was based on The Opposing Self by
Lionel Trilling (1955). However, while the connection that Laing
made between the disciplines of existentialism and phenomenology
and psychosis was not entirely novel, the intense and persuasive
manner in which the ideas were expressed were Laing’s, and his alone
(A. Laing 1977, p. 68).
Laing’s psychoanalytic training did not begin until the latter half
of 1956, when he came to London. Jock Sutherland, then medical
director of the Tavistock Clinic, had introduced a scheme for promis-
ing young psychiatrists outside London to train as analysts. His hope
was that they would then return to the provinces. Sutherland decided
on Charles Rycroft as Laing’s analyst, and had him appointed part-
time consultant psychotherapist in the NHS, at the Tavistock, for
this specific purpose. Marion Milner and Donald Winnicott were
appointed his supervisors.
Rycroft’s and Laing’s backgrounds contrasted sharply. Rycroft was
upper-middle-class English and Laing lower-middle-class Glaswegian.
They had an amicable relationship, but Laing’s primary aim was to
qualify as an analyst and he saw analysis as a place to relax and put his
feet up after a long day. Rycroft acknowledged that Laing came to

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Laing on psychosis

analysis primarily to qualify. He also accepted that there was a

deep underlying depression that was never reached. He saw Laing’s
psyche as ‘an extremely effective schizoid defence mechanism against
exhibiting signs of depression’ (Clay 1997, p. 66).
Laing’s qualification was controversial because of his irregular
attendance at seminars and because of the training committee’s
concern that he was quite disturbed and ill. Nevertheless, by the age
of 33, Laing was a qualified psychoanalyst.
However, in his book, Self and Others (1961), Laing began to
distance himself from the psychoanalytic approach with his critique
of Susan Isaacs’s classical paper on ‘The nature and function of
phantasy’ (Isaacs 1952) in which he regarded ‘The unconscious’
simply as ‘what we do not communicate to ourselves and one
another’ (R. D. Laing 1961, p. 32).
Although Laing acknowledged Freud for his courage in descend-
ing into ‘the underworld’ and describing the ‘stark terrors’ he met
there, he criticised psychoanalysis, with its emphasis on object rela-
tions, for its tendency to treat people as ‘things’. Zbigniew Kotowicz
(1997), in his book R. D. Laing and the Paths of Anti-Psychiatry,
observed that while Laing’s relation to existential philosophy was
quite simple – he agreed with its basic tenets and then freely bor-
rowed from it for his purposes, which are not philosophical but
clinical – in contrast, his relation to psychoanalysis was more complex.
Laing’s commitment to existentialism did not allow him to accept
the metapsychology of psychoanalysis. He rejected the centrality
of unconscious processes and unconscious guilt. He denied the
importance of pre-oedipal disturbances or Klein’s paranoid-schizoid
position in understanding psychosis (Kotowicz 1997, p. 23). In
Laing’s view, his concept of ontological insecurity was the key
to understanding psychosis. He had no difficulty with accepting
Winnicott’s view of a facilitating environment and his emphasis
on interpersonal relations converged with the American school of
Frieda Fromm-Reichmann, Harry Stack Sullivan, Paul Federn and
Harold Searles.
Juliet Mitchell (1974) in Psychoanalysis and Feminism has com-
mented on how, for Laing, the unconscious could be understood or
rendered intelligible in exactly the same way as consciousness. In
analytic terms, psychosis can be seen as having its origins in the narcis-
sistic pre-oedipal stage, while neurosis has its nucleus in the Oedipus
complex. In contrast, Laing’s approach to psychosis attempted to

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Psychoanalytic theories about psychosis

dissolve the differences between ‘normal’, psychotic and neurotic

behaviour and Mitchell argued that this was unhelpful, although
she did feel that his work enhanced understanding of the nuclear
family.
Laing’s rejection of the operation of the unconscious may clarify
why many psychoanalysts do not read Laing. One exception was
Nina Coltart, an analyst who was deeply involved with the Arbours
Crisis Centre. Coltart (1995) expressed appreciation of Laing’s careful
and human efforts to make sense of what was happening to a mad
patient.

After The Divided Self

In 1962, Laing met Gregory Bateson, whose ‘double bind theory’

(Bateson 1972) profoundly influenced Laing’s thinking on the func-
tioning of families of schizophrenics. Sanity, Madness, and the Family
(Laing and Esterson 1964), based on Laing and Aaron Esterson’s
recorded interviews with families of patients with a diagnosis of
schizophrenia, was seen as implying that families were responsible for
causing the problems in the patient.
In 1958, Laing first met David Cooper, with his anti-psychiatry
stance and his ‘Villa 21’ experiment at Shenley, akin to Laing’s own
‘Rumpus Room’ experiment. They obtained the lease of a property
in the East End of London, Kingsley Hall, from 1965 to 1970,
to continue to implement their ideas. They aimed to provide a regres-
sive therapeutic experience for those who otherwise might have
been admitted to a mental hospital for physical treatment. Their most
famous resident, Mary Barnes, wrote a joint book with her therapist
Dr Joseph Berke (Barnes and Berke 1991) and also became the
subject of a play by David Edgar.
At its height, Kingsley Hall attracted much interest and visitors
from all over the world. However, the laissez-faire attitude prevail-
ing there led to incidents such as someone climbing on to the roof
and making noises late at night, disturbing the neighbours, and
at times the atmosphere grew ugly. Laing eventually tired of the
project and moved out of Kingsley Hall, and the lease was not
renewed.

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Laing on psychosis

Laing’s legacy

Laing was clearly right to condemn the damaging and dangerous

practices of insulin coma and leucotomies, which were widespread
in the 1940s and 1950s before the introduction of antipsychotic
medication. He was right to challenge the reductionistic view in
psychiatry that fails to comprehend patients as total human beings
rather than as an illness.
He was also right in drawing attention, with others, to the negative
effects of institutionalisation, prior to the introduction of the thera-
peutic community approach, and the excessively restrictive powers
held over patients in the days preceding the Mental Health Act 1959,
and its further amendments.
However, he was wrong on a number of fundamental issues, and
the biographies by Adrian Laing (1977), Clay (1997) and Kotowicz
(1997) allow one to appreciate the reasons for this. Laing was deter-
mined to make an impact early in his life, through his writing.
However, in his chosen field of psychosis, he was still a very young
and inexperienced psychiatrist when he wrote The Divided Self
(1960). Accumulating psychoanalytic experience, clinically speaking,
is inevitably a slow, difficult, lifelong learning process. One cannot
possibly grasp transference and countertransference experiences in an
immediate manner, other than in a superficial intellectual way.
Laing must have known this. Therefore, to support the notion of
his making an original contribution to the theory of psychosis,
he had to be dismissive of psychoanalytic theories.
Having read existential and phenomenological literature widely, he
had no problems in utilising their concepts to write in his own com-
pelling style. However, the theory he brought to bear on psychosis
came primarily not from existing existential theory, but from his own
tangled childhood experiences with a difficult mother. It centred on
the role of the parents, in particular the mother, with her double-bind
messages, resulting in the recipient being unable to express himself
openly in interpersonal communications.
While Laing was accepting of any analytic literature supporting
a general facilitating attitude, such as Winnicott or Fromm-
Reichmann’s approach to psychosis, he later showed no interest in
Bion’s seminal work on schizophrenia (Bion 1967). In marked
contrast to Laing’s view of psychosis as an expression of a healthy real
self, Bion described the psychotic part as fuelled by an envious hatred

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Psychoanalytic theories about psychosis

of psychic reality and attacking the mental apparatus for thinking.

Once I had the opportunity to raise this contrast with Laing for
debate, but his response was a maddening silence.
Material presented by a psychotic patient invites the clinician
to ignore the psychosis and accept a rationalised explanation. In his
critique of Kraepelin’s patient with catatonia, Laing made the mistake
of assuming a plausible reason for the catatonia. He assumed that the
patient was disturbed by being exhibited before students, thereby
inviting one to ignore the patient’s psychosis.
While appealing widely to a general audience, Laing’s work never
influenced mainstream psychiatry, perhaps because his theory did
not relate to the problems posed in daily management of psychotic
patients. Unlike Bion’s theory, it did not provide a framework
adaptable for utilisation in everyday psychiatry (Lucas 1993).
Nevertheless, Laing’s refreshing criticism of the reductionist atti-
tude in mainstream establishment psychiatry, with its overemphasis
on the mental state examination, remains as pertinent today as when
The Divided Self was first published. Laing’s invitation to question
any assumptions held too rigidly in the management of psychosis is
perhaps his greatest legacy to those left working in this difficult area.

122
PA RT T H R E E

Tuning into the Psychotic Wavelength

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10
Differentiating psychotic processes from
psychotic disorder s

Introduction

The aim of this chapter is to discriminate the central psychopathology

of borderline states from that found in schizophrenia and affective
disorders.
In recent times, within the NHS, there has been increasing recogni-
tion of the fact that patients with borderline personality disorders,
who have difficulty in processing their feelings and a vulnerability
to act out through self-harm, are in need of specialist, analytically
informed services. Such services include specialist psychotherapy
day hospitals that provide a combination of individual and group
therapies. This finding is the result of research work by Anthony
Bateman and Peter Fonagy, based on the application of attachment
theory and particularly Fonagy’s theory of mentalisation (Fonagy
and Bateman 2006). Staff are trained to be especially sensitive to the
patient’s difficulties in mentalisation, and progress can be made and
admissions prevented through this approach.
At the level of international classification, analytic concepts have
predominated in the diagnostic classification of narcissistic and
borderline states (Kernberg 1984). In contrast to psychosis, psycho-
analytic thinking is widely accepted as having a key role to play in
both diagnostic categorisation and treatment approaches to borderline
personality disorders.
Psychoanalysts rarely encounter cases of the major psychotic dis-
orders, schizophrenia and manic depression, in their daily practice.
However, they often encounter psychotic processes, particularly in

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Tuning into the psychotic wavelength

patients with borderline states. In contrast, psychiatrists often have

to determine whether they are dealing with a patient with a border-
line personality disorder who is having a transient psychotic episode,
possibly drug induced, or a major psychotic disorder. This distinction
is not always easy to make.
In the treatment of borderline states the primary emphasis is on
individual analytic therapy, even if in some cases groups and day
hospitals can provide valuable ancillary back-up, and patients are
typically committed to their therapy. In contrast, in cases of major
psychotic disorders, where admissions are more likely, working psy-
choanalytically requires the clinician to work closely with the
patient’s family, GP and psychiatric services for treatment to be a
viable proposition. Thus, the discrimination of borderline states
from major psychotic disorders has both theoretical and practical
importance.

Borderline states

Clinical aspects

Before considering the theoretical aspects underpinning the diagnosis

of borderline personality disorder, the following would serve as a
typical clinical example encountered in an analytic psychotherapist’s
practice.

A somewhat reclusive young woman is referred with problems in sustaining

meaningful relationships, feeling an overall sense of despair rather than
depression. She describes a relationship with a difficult mother with whom
she could never somehow have a satisfying emotional relationship, while
her account of her father portrays him as an ineffective background figure.
At the beginning, just as he would with any patient, the therapist makes a
relatively innocuous interpretation in order to open up a joint exploration of
material that the patient seemingly presented for this purpose. However, the
patient’s response to this is ‘You can talk to other patients like that but not to
me!’ There is no way that therapists can be forewarned that they will be
receiving a person with borderline characteristics. In time one appreciates
with such patients that their transference is directly to the clinician, who is
perceived as the source of all their problems, as a concrete representation
of the originally perceived unhelpful mother.

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Psychotic processes and psychotic disorders
Initially, the patient says that she could be more helpful if she wanted to,
but since she seems to experience the therapist as the unhelpful mother, her
responses often seem to be attempts to get her own back for the insensitive
way that she feels that she was treated.
Inevitably, at first the atmosphere is electric, as if the therapist is surviving
on a knife-edge. If he says the wrong thing, there is an explosion. If he is
lulled into feeling that it is safe enough to make an interpretation that he feels
is presented sensitively, nevertheless the patient seems to feel it to be the
very opposite, as a premature rejection of what she has said, leading to
another crisis in her confidence in the therapist. If the therapist feels strongly
that what he is saying has a point and persists with his interpretation, this
only exacerbates the patient’s distressed state of feeling rejected.

Sooner or later the therapist will realise that he needs to stop and
listen from the patient’s perspective. He needs to contain the patient’s
projections and her criticisms of the therapist, and appreciate them
as communications to an object that she feels has rejected her feelings
prematurely and failed to stay with them for long enough. The ther-
apist then needs to interpret to her that this was the problem and
that she wanted him to stop and listen to her.
This sort of interpretation, which is analyst centred rather than
patient centred, initially leads the patient to feel a rush of warm feel-
ings towards the therapist for showing understanding, leading to talk
of feeling prematurely ejected from the mother’s womb and needing
the analyst to act as a marsupial pouch.
The patient’s rush of feelings of warm appreciation, which come
from the experience of having been understood, rapidly turn into a
feeling of being at one with the therapist. The problem then becomes
that the inevitable separations of the fused couple are experienced as
disastrous ejections that enrage her.
In some sessions the therapist may be aware of the fantasy of fusion
and the inevitability of its collapse when his next response to the
patient’s material highlights their separateness. At other times the
warm atmosphere is disturbed only by the end of the session, with
the inevitable change in atmosphere occurring during a break such
as at the weekend, after which the patient returns feeling furiously
critical of the analyst.

Occasionally, when the explosion occurs in a session, the patient storms

out in an angry state. When she returns, she accuses the therapist of

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Tuning into the psychotic wavelength
being ‘stupid’ for subjecting her to disintegrative states without even real-
ising the effect that he was producing. Sometimes she talks about finding
another more competent analyst, but then says that she has no choice but
to persist with her analyst, as there is no one else. This feeling of having
no choice is due to the fact that the analyst is being experienced
concretely as the problematic mother; the patient feels that she has no
choice but to come back and try to work with the analyst/mother, to try
to improve the analyst’s capacity to become a properly functioning
containing person.

With borderline patients the transference can be so intense in terms

of the concreteness of the projections that early on in treatment the
analyst may be confused about whether the patient’s critical observa-
tions are correct. For example, the patient may complain that the
therapist is restless in his chair and he may find himself wondering
whether this is an indication of his negative response to the patient’s
intense projections.
One might think of experiences with borderline patients such
as the one described above as delusional countertransference experi-
ences. One is not sure if one was being restless for the reason given,
or whether the patient’s longing for a total fusion at that moment
is so intense that any movement at all is felt to indicate separation
and disinterest. Only over a period of time can one start to feel more
able to breathe, and separate oneself from the patient’s projections.
This shift may go hand in hand with the patient gradually beginning
to experience the analyst’s involvement as committed, and feeling
that he is genuinely trying to provide an understanding container,
rather than triumphing over her.
At times patients in borderline states may appear to have crossed
the border into psychosis. For example, they may become convinced
for a while that their sessions are being recorded or that the neigh-
bours are persecuting them. However, such states of mind are
short-lived, in contrast to patients with schizophrenia.
Moreover, despite all the intensity of criticism of the therapist,
patients with borderline states remain committed to the therapy and
place great emphasis on intellectual understanding.
The difficulty for the therapist throughout the analysis of such
patients is the requirement to accept unbearable projections until
the patient feels able to explore them. This can produce a feeling that
one may be colluding with their perversity by not analysing, but such

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Psychotic processes and psychotic disorders

acceptance of unbearable projections may be required for long

periods when working with patients with borderline states.
With borderline patients the therapist must act as the reflective part
of the patient until they have the capacity to do this for themselves.
This is inevitably a long-drawn-out affair. Gradually, a reflective
part of the patient is strengthened, so that therapy no longer feels
like walking a tightrope, but as if a broader base has developed, becom-
ing for the therapist and patient more like walking a wider-based
gymnastic beam.
I have given this clinical illustration first to help the reader make
sense of the theoretical aspects.

Theoretical aspects

Patients with borderline states provide valuable learning experiences

for the clinician. I had the privilege of being initiated by Henri Rey
when training at the Maudsley Hospital. At that time, organically
orientated psychiatrists would prescribe chlorpromazine for psychosis
and diazepam for neurosis. However, when they encountered patients
who complained of despair rather than depression, and whose symp-
toms did not fit a category for medication, they were referred to
Henri Rey in the psychotherapy department. These patients suffered
from borderline disorders and provided rich material for Rey to
develop his insights into the working of their minds.
Working in the psychotherapy department as a junior doctor,
I saw ten patients individually, all in borderline states, over a nine-
month period. I learnt a lot about psychotic mechanisms from these
patients.

For example, one patient started his first session by asking if I had a tape
recorder in my drawer to record the session for his father, and yet this
patient proved not to have schizophrenia. Without any psychoanalytic
knowledge, he seemed to use strikingly concrete symbolism quite naturally.
For example, he went to stay with a female pen-pal in Paris. It turned out that
she had a boyfriend who came round with them while they visited the sites.
The patient felt like a gooseberry, unwanted. He had a dream that featured
the Eiffel Tower. He said to me, without my having said anything, ‘to you the
tower was a penis, but to me a breast as I was homesick, missing my
mother’.

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Tuning into the psychotic wavelength

This concrete thinking was also illustrated by another patient, who

had dropped out of university and led an isolated existence as a
lorry driver. Again one might think of typical symptoms of onset of
schizophrenia with social withdrawal, but he did not progress into a
full-blown psychosis. He showed himself to be at ease with concrete
symbolic thinking by describing his lorry as a womb.
Rey had a particular facility for getting in touch with the internal
worlds of borderline and schizoid personalities. Being with him
while he engaged with new patients was like having the curtain
of the unconscious opened before you for the first time. In his
paper, ‘The schizoid mode of being and the space-time contin-
uum (beyond metaphor)’, he summarises the characteristics of the
borderline patient (Rey 1994b).
When first seen by psychiatrists, schizoid and/or borderline
patients are usually in their early twenties. They complain of an
inability to make any warm or steady relationships. If they do
engage in relationships, these rapidly become intense or dependent.
They quickly begin to feel that they are fused with the object and
experience a loss of identity.
They oscillate in object choice in their minds between homo-
sexuality and heterosexuality. They tend not to be homosexual, but
often have fears that they may be. They can easily feel that they are
being persecuted by society, they often have grandiose ideas and
are preoccupied with phantasies of being big or small.
They characteristically have a feeling of deadness rather than feel-
ing the pain associated with true depression. They search for stimu-
lants to deal with this feeling of deadness, including alcohol, drugs,
hashish, cutting, perversions and promiscuity. If they are working
when they come for treatment, it is often the case that they have given
up their work or studies in favour of manual work, although they can
do well in a structured environment.
Women tend to present with a hysterical overlay, while men
are schizoid. However, Rey described a claustrophobic-agoraphobic
dilemma which is basic to both sexes in both borderline states and
schizophrenia. When such patients project out their unbearable
feelings, they then feel surrounded by them and feel obliged to phys-
ically get away from them. However, once they move on to another
place the same phenomenon recurs.
Patients with borderline states function at a part-object level with
concrete symbolisation. They use splitting into good and bad objects.

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Psychotic processes and psychotic disorders

Splitting causes formation of concrete or ‘bizarre objects’ in Bion’s

terms (Bion 1957a). They can experience great fear of separation, as if
separation means taking parts of them away.

After working for a while in the psychotherapy department I was on duty

one night when a patient came into the emergency clinic after taking an
overdose. He told me his life history and then became alarmed when
I moved to leave the room. I could appreciate that he felt that he had
concretely projected something of himself into me and was concerned
about where I was now going with it. He was relieved when I appreciated
his anxiety.

For Rey, the difference between borderline states and schizophrenia

is that, in the latter case, the container for their projections has been
destroyed so that schizophrenics are living entirely in a delusional
world of their own making. Schizophrenics do not concern them-
selves with external reality but declare and delusionally believe
whatever they wish. In contrast, borderline patients remain very con-
cerned over the functioning of the container, as seen in the clinical
illustration given above.
In borderline states, the individual’s feelings of guilt about having
damaged their internal objects result in wishes to make concrete,
omnipotent repairs to the damaged objects rather than true repar-
ation which would entail acknowledgement of the damage done. In
this context, Rey highlights the operation of manic reparation. In
manic reparation, concrete repair to the breast and the babies inside
mother that have been attacked in phantasy is made through the
phantasy of a magical penis that can restore milk to the breast and
the attacked babies. However, this phantasy of an immeasurably grand
penis serves not to make reparation but rather to deny the reality of
the individual’s destructiveness. This was vividly illustrated by a
reported dream of a man in a borderline state of balancing a baby on
the tip of his erect penis and saying to himself in the dream ‘this thing
is too fucking big to be of use to anyone’ (Rey 1994b, p. 18) In the
absence of any capacity for forgiveness or reparation the patient oper-
ates in an Old Testament world of an eye for an eye, the law of the
talion. With time in therapy, the dominance of the law of the talion
can decrease.
With reference to Piaget’s work on the development of the sense
of space, time and objects, Rey elaborates a theory of the infant’s

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Tuning into the psychotic wavelength

development of a sense of self out of his experiences of space both

inside the mother before birth and in what he calls the marsupial
space created after birth by her care of the infant. The persistence of
the concrete character of these early experiences is characteristic of
borderline states. Borderline patients feel a desperate need for a
maternal container or space, but they conceive the object of their
longings in concrete terms. They want a marsupial pouch, part of the
analyst’s mind kept just for them, in fulfillment of a phantasy of
returning to the womb. In a concrete way, they may even follow the
analyst in search of this space by following them home and watching
their house.
With regard to treatment, Rey points out that kindness and support
alone are not enough. A thorough knowledge of the mental processes,
dominating phantasies, and underlying structures is required, as well
as an affective understanding. One needs to know about part-objects
and their language. Rey was fond of saying that the whole of a psy-
chotherapeutic exchange could be summarised by answering the
question of what part of the subject, situated where in time and
space, is doing what to the object situated where in time and space,
with what consequences for the subject and object (Rey 1994a, p. 7).
The question arises, why use the term borderline to describe
these patients? Rey’s answer is that the only safe position for such
patients is the border between the depressive and paranoid-schizoid
positions. If the demand for perfection experienced in the depressive
position becomes too much, the pain is split off and projected, and
the patient reverts to a paranoid-schizoid mode of functioning.
Rey points out that the border is the only safe position where both
depressive pain and persecution from the paranoid-schizoid position
can be avoided. In this context, Rey described a dream recalled by a
borderline patient. He was in a football match where the coin was
tossed to decide who started the match and the coin landed exactly
upright in the mud!
In borderline patients there is a hypertrophy of intellectual func-
tioning, as this is felt to be the only safe area of their own and
the analyst’s mind, and thus there is a real commitment to analysis
(Steiner 1979). Although such patients may prove very challenging to
engage, their psychopathology has stimulated much creative analytic
thinking in addition to Rey’s seminal work in this area.
To my mind, Bion’s (1957b) paper ‘On arrogance’ refers to the
primary problem in borderline states, though he does not refer by

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Psychotic processes and psychotic disorders

name to borderline states in his description of a particular group of

patients. While Freud used the analogy of the archaeological uncover-
ing of a primitive civilisation to describe a central aim of analytic
work, in the case of the patients that Bion discusses what seems to be
uncovered by analysis is a primitive catastrophe, that is, an early failure
of maternal containment. The situation is complicated by the fact
that the analyst’s work of interpretation is also felt by the patient to
have potentially catastrophic consequences: his interpretations are
experienced as mutilating attacks on the patient’s methods of com-
munication through projective identification, destroying the patient’s
link with the analyst (Bion 1957b).
Bion concludes:

In some patients the denial to the patient of a normal employ-

ment of projective identification precipitates a disaster through
the destruction of an important link. Inherent in this disaster is the
establishment of a primitive superego which denies the use of
projective identification. The clue to this disaster is provided by the
emergence of widely separated references to curiosity, arrogance,
and stupidity.
(Bion 1957b, p. 86)

One can relate Bion’s observations to the clinical material presented

at the beginning of this chapter.
Steiner (1993b) addressed the technical problem of how to speak
to such patients by differentiating between what he referred to
as patient-centred and analyst-centred interpretations. In classical
patient-centred interpretations one might say something to patients
about what they are doing, thinking or wishing, often together with
the motive and the anxiety associated with it. Analyst-centred inter-
pretations recognise that patients are more concerned about what
is going on in the analyst’s mind rather than their own. The analyst
might then say, ‘You experience me as’, or ‘You are afraid that I’,
or ‘You were relaxed when I’. Sometimes, and this is the essence of
deep analytic work, it is possible to link the two together: ‘You are
afraid that I am upset because of the fact that you did such and such’
(Steiner 1993b, p. 134).
Britton (1989) takes our thinking further in describing the primary
relationship problem in the borderline as occurring within the overall
setting of the Oedipus complex. He writes:

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Tuning into the psychotic wavelength

The idea of a good maternal object can only be regained by split-

ting off her impermeability so that a hostile force is felt to exist,
which attacks his good link with the mother. Mother’s goodness
is now precarious and depends on him restricting his knowledge
of her.
(Britton 1989, p. 89)

Hence, linking to Bion’s observations, curiosity is felt to spell disaster,

as the mother’s relationship with father is felt as a disastrous exclusion.
For the patient to develop a reflective part, the oedipal triangle has
to be formed as a space in which the patient can reside, allowing the
parental couple to be internalised as a separate reflective part.
In the borderline patient, initially this reflective part is absent. This
is why an interpretation may not be received as a containing reflec-
tion but rather as a rejection. Britton graphically described the case
of a patient for whom his reflecting was experienced as a form of
intercourse, corresponding to the parental intercourse, which she felt
threatened her existence, leading her to exclaim ‘Stop that fucking
thinking!’ (Britton 1989, p. 88). The only way Britton was able to find
a place to think was to articulate his experience to himself, while
communicating to her his understanding of her point of view. In this
way the parental intercourse could take place without being felt as too
intrusive to the child’s mind, and without being felt to annihilate the
child’s link with the mother both externally and internally.
While there are similarities, there are also fundamental differences
in the underlying psychopathology of patients with borderline states
and those with major psychotic disorders, and these will require dif-
fering understandings and interpretive approaches. Like Rey, Steiner
characterised the central defensive structure of the borderline as a
‘pathological organisation’ of a ‘sitting on the fence’ state that
enabled the neutralisation of both the unbearable envy of the para-
noid schizoid position and the unbearable guilt of the depressive
position (Steiner 1987).
In contrast, the central psychopathology in psychotic disorders is
the conflict between the psychotic and non-psychotic parts of the
personality (Bion 1957a). Bion invites us to ask, in relation to our
countertransference feelings, from which part of the personality
(psychotic or non-psychotic) is the message coming, and with what
purpose in mind (Bion 1977). I will come back to these issues, but
first I would like to give an example to illustrate the differences in

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Psychotic processes and psychotic disorders

approach depending on whether the material comes from a patient

with a psychotic disorder or a patient in a borderline state.

Borderline state or psychotic disorder: differing approaches

I am grateful to John Steiner for permission to use material from his

seminal paper on analyst and patient-centred interpretations. The
material arose from a supervisory session.

The patient had recently recovered from a major breakdown and had just
left hospital. He complained about his employers, who had been unfair to
him, and his analyst, who had done nothing to rectify this unfairness. He
then described how his mother had had a breast infection when he was a
baby and moved on to speak triumphantly about his ability to hurt the
analyst. He then announced that he intended to change his job, which
would mean moving to another city and ending his analysis.
The analyst felt sad at the idea of losing his patient and interpreted that
the patient wanted to get rid of his own sadness and wanted the analyst
to feel the pain of separation and loss. The patient said, ‘Yes, I can do to
you what you do to me. You are in my hands. There is an equalisation.’
A moment later he started to complain about being poisoned and began to
discuss government policies of nuclear deterrence. He argued that these
were stupid because they involved total annihilation but that policies of
nuclear disarmament were no better because you could not neutralise exist-
ing armaments. He then complained of gastric troubles and diarrhoea,
and said he had been going to the toilet after each session recently.
He explained that he had to shit out each interpretation the analyst gave him
in order not to be contaminated by infected milk.

Steiner wrote: ‘It seems to me that the patient found the patient-
centred interpretation to be threatening because it exposed him to
experiences such as grief, anxiety and guilt’. He experienced the
interpretation as his feelings being forced back into him concretely,
like poison, and he tried to evacuate them in his faeces. His talk of
nuclear disaster indicated the catastrophic nature of his anxiety. He
needed the analyst to recognise and hold the experiences associated
with the loss of his mind and to refrain from trying to return them to
him prematurely. Steiner makes the point that although the analyst’s
interpretation was correct, it made the patient feel that the analyst

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Tuning into the psychotic wavelength

disapproved of his wish for the analyst to feel the pain of their separ-
ation. This led the patient to withdraw once more to the protection
of a psychotic organisation, wherein he felt that disturbing insight
was poison (Steiner 1993b, p. 134–135).
One can appreciate this material as a clear example of the dangers
of prematurely made patient-centred interpretations when working
with a severe borderline patient who was prone to returning to
marked psychotic states of mind. However, the material can also be
used to consider a different perspective.
Let us suppose that this patient has just left hospital after a psychotic
breakdown related to an underlying major psychotic disorder. If
a psychotic disorder is the primary diagnosis then, in Bion’s terms,
by definition the patient must be dominated by a more powerful
psychotic part that tries to deal with feelings by projection and
annihilation, overriding the sane non-psychotic part.
On leaving the hospital, the psychotic part of the patient attempts
to solve the problem of his awareness of his need for further analysis
by attacking the analyst and his own thinking mind. The nuclear
explosion and equalisation with the analyst is the solution. Of course,
this results in persecutory feelings that he is about to be poisoned, that
is attacked in return. He then attempts to disown and distance his
action by talking of nuclear weapons being a governmental problem.
However, his statement that he does not believe that it will ever be
possible to get rid of armaments, that is aggressive and paranoid
feelings, indicates that he is not able to fully rid himself of the sane
part of his personality.
The next strategy for the psychotic part is to project his attacked
needy feelings into his own body as a physical problem: if the
governmental disownment does not work, then perhaps the bodily
one will. He also projects concretely into the analyst, so that he feels
his problem to be the analyst’s words, which, like the infected milk,
can be shitted out.
The patient’s worry about his own state of mind is indicated by his
reference to the diarrhoea. In Bion’s terms, the weaker non-psychotic
part is frightened of being taken over by a mad part. This part of the
patient feels regret that the consequence of this would be that he
would be excluded from further analysis, for as well as envy, he also
has warm feelings towards his analyst, which are manifest in projected
form in the analyst’s sadness at the thought of the patient moving to
another town.

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Psychotic processes and psychotic disorders

The patient is asking the analyst to spell this out, in order to sup-
port him at a time when he has temporarily been overwhelmed by
the psychotic part of his personality. In such a case, where the analyst
is dealing with a person suffering from a major psychotic disorder
rather than a severe borderline state, the analyst’s support for the
weaker non-psychotic part would be crucial to restoring the balance
of forces in the patient’s mind.

Contrasting countertransferences

I want for a minute to consider the difference in the countertransfer-

ence experience between a borderline and a psychotic patient. It
seems that while one cannot tell before referral whether one will
encounter a borderline patient, once in treatment the therapist will
immediately recognise the borderline patient’s sensitivity to inter-
pretations and the intensity of the transference. As already described,
in borderline patients paranoid states of mind only briefly reach delu-
sional intensity. More persistent psychotic states of mind should lead
to a questioning of the borderline diagnosis, especially in the absence
of the characteristic intense personalised transference to the therapist.
The following example serves as an illustration.

A psychotic disorder masquerading as a borderline state

A patient was referred for analysis from a psychoanalytically informed

psychiatric unit. She had had a breakdown while her husband was working
in another country. She saw a psychologist for therapy while they were
abroad and fell in (unrequited) love with him to such an extent that she
stayed behind and allowed her husband to bring their newborn baby to
England on his own. She was initially admitted to a local hospital abroad
before being transferred and detained, initially under Section 2 of the
Mental Health Act 1983, in an eminent psychiatric unit in London for further
assessment.
It was noted that the patient was hearing voices but that she reported
them as coming from inside her head. Using a phenomenological
approach, she was regarded as experiencing pseudo-hallucinations, which
were therefore not regarded as of pathological significance. She was keen
to leave hospital and claimed to be sincerely committed to the opportunity of

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Tuning into the psychotic wavelength
gaining an analytic understanding of her state of mind. A diagnosis was
made of a borderline disorder.
She came to analysis for only a short time. She began to talk about her
mother-in-law, who was elderly and ill and living abroad. The patient felt an
increasing urge to leave the analysis and go to her, for no good reason, as
the mother-in-law already had close family attending to her. She became
more and more insistent on leaving the analysis and her husband also did
not seem keen to provide financial support for the continuation of the analy-
sis. Before her final abrupt departure, she reported a dream. In the dream
there were a hundred friends. Ninety-nine of them said that she was fine and
needed no help. Only one friend, a psychologist, said that she was in a bad
state and really needed analysis.

Here we have a patient who presented as apparently very keen and

dedicated to having analysis, who is described as being borderline in
pathology, and yet who leaves her analysis very quickly. How do we
explain this?
To my mind the answer is that she has a major psychotic disorder.
First, she must have been in a severely disturbed state while abroad to
stay behind when her husband went home with their baby, showing
more interest in the psychologist who did not reciprocate her feelings
for him than in her own baby. Second, she required hospitalisations.
However reasonably a patient may present afterwards, a history of
hospitalisation should always alert one to consider the possibility of an
underlying major psychotic disorder. This would make her sudden
termination of the analysis less surprising.
In psychotic disorders, the psychotic part of the personality is
the stronger. It is against understanding and dominates the weaker
non-psychotic part. The balance of power in this patient’s internal
world was made very evident in the dream she reported. In order to
maintain an analytic treatment in the face of such powerfully negating
forces, it is crucially important to have unequivocal support from the
nearest relative.
Finally, it is interesting to note how this patient managed to
convince the professionals that she was committed to an analytic
approach.
The commonest symptom of psychosis is not hearing voices or
experiencing paranoid delusions, but denial and rationalisation. The
commonest countertransference response is therefore an attack on
one’s sanity, pressure to ignore the patient’s psychosis and a pull to

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Psychotic processes and psychotic disorders

regard their presentation in more understandable terms, as neurotic

or borderline, and to overlook the underlying psychosis. I would
imagine that the psychotic part of this patient wanted to hide her state
of mind from the professionals in order to have the section rescinded
so that she could leave hospital. To achieve this she presented herself as
a patient who was dedicated to understanding herself and initially
succeeded in convincing the professionals that her commitment was
genuine.

Differing treatment parameters for borderline states

and major psychotic disorders

Embarking on analytic therapy with a borderline patient is very

different from working with a patient with a major psychotic disorder.
In the former case, despite the intensity of the transference to the
analyst, and the fear of experiencing catastrophic states of mind
accompanied by the feeling of living on a knife-edge, the patient
remains committed to her treatment, and does not need outside
support. The analyst of course may feel in need of supportive supervi-
sion with such personally demanding cases, but that is another matter.
A therapist who is thinking about seeing a patient with a major
psychotic disorder for individual therapy needs to consider the
following issues.

Being mindful of the underlying condition

If one is thinking of embarking on treatment of a patient with a

major psychotic disorder, one should never forget the presence of the
underlying condition. Any patient referred with a history of hospital
admission, especially if he or she plays down the significance of these
admissions, should alert the therapist to the possibility of an under-
lying psychosis. We all have strong wishes to play down psychosis and
give reassuring dynamic explanations to enable us to feel in control,
rather than having to face the presence of an underlying out of con-
trol state of affairs. We like to feel that through our familiar analytic
approach we can work with any patient who is referred to us and
seems prepared to commit themselves to treatment.

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Tuning into the psychotic wavelength

Accepting the risk of relapses

An underlying major psychotic disorder such as bipolar affective dis-

order has an inbuilt autonomy, like recurrent volcanic eruptions. The
therapist has to accept that however dedicated and committed they
may be to the analytic cause, further relapses and admissions are likely
to occur. It is therefore essential that some understanding and support
for the venture is established with the local psychiatric service, before
embarking on an analytic treatment.

The position of the nearest relative, and issues of confidentiality

Since a patient with a psychotic disorder is vulnerable to outbursts of

unpredictable behaviour, which may include self-harm and/or vio-
lence to others, the therapist has to be prepared to engage in discussions
with the nearest relative. Also, as the example above illustrates, it is
impossible to conduct the analysis without their unequivocal support.
In the earlier days of the British Psychoanalytical Society’s ethical
code, while respect for confidentiality was given central importance,
exceptions were made in work with patients with psychosis. In fact,
tragedies are more likely to occur if anxieties are not shared. Where
necessary relatives should feel free to update the therapist on disturb-
ing incidents and the therapist should also feel free to contact the
consultant psychiatrist or GP.

Differentiation from depression

Nowadays it has become fashionable to think of anyone who has a

history of acting out with taking overdoses or cutting themselves
as having a borderline personality disorder. However, this may not
always prove to be the case. The clue lies in the countertransference.
As I will show in a later chapter, in contrast to the intensity of the
transference in borderline states, the experience with the depressive is
quite different. They may repeatedly evacuate material in the sessions
but then show no interest in committing to any work within the
sessions. The therapist may feel disheartened until they are able
to tune into the underlying psychopathology and try to turn the
depressive monologue into a dialogue (see Chapter 19).

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Psychotic processes and psychotic disorders

Summary

In this chapter I have contrasted borderline states with major psych-

otic disorders. Borderline states are primarily approached through
individual analytic psychotherapy and provide the clinician with rich
learning experiences about psychotic processes. The knowledge
gained from such experiences can be applied to understand similar
processes occurring in major psychotic disorders. However, there are
important differences in psychopathology and management. These
differences are not always obvious. They are explored further in
Chapter 11.

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11
The psychotic wavelength

Introduction

In Chapter 10 I discussed the need to recognise the specific problems

posed by patients with major psychotic disorders, in contrast to those
(such as borderline patients) who show psychotic processes without
an underlying psychotic disorder. I argued that the ability to make
these distinctions is essential for clinical practice.
Some have argued that schizophrenia is a term that is too stigmatis-
ing and has outlasted its usefulness. From this perspective general
psychiatrists have been criticised for their apparent lack of empathy
with patients as fellow human beings and their over-reliance on
medication. However, such criticisms overlook the special nature of
major psychotic disorders, and the particular demands that they make
on all those involved.
While many professional staff may work very sensitively with psy-
chotic patients without having formulated a theoretical framework,
it is a matter of concern that some approved social workers and
members of hospital manager’s hearings do not have any theoretical
framework by means of which they can orientate themselves to the
special problems posed by psychotic disorders, especially the ability of
the psychotic part of the personality to cover up its murderousness
with denial and rationalisation.

Tuning into the psychotic wavelength

Following years of experience of intensive psychotherapy with

schizophrenic patients at Chestnut Lodge in the United States (see
Chapter 8), Frieda Fromm-Reichmann wrote:

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The psychotic wavelength

It is my belief that the problems and emotional difficulties of men-

tal patients, neurotics or psychotics, are in principle rather similar
to one another and also the emotional difficulties of living from
which we all suffer at times.
(Fromm-Reichmann 1950, p. xi)

Another leading American, Peter Giovacchini, shared Fromm-

Reichmann’s view. He argued that difficulties in the treatment of
psychotic patients do not derive so much from the contents of the
patients’ psychopathology as from the analyst’s sensitivities. He added
that being aware of our sensitivities, that is, the countertransference,
broadens the range of patients we can treat (Giovacchini 1979).
These statements are representative of a widely held view that the
difficulties presented by psychotic patients are not dissimilar to those
presented by non-psychotic patients, and the chief problem is the
analyst’s or general psychiatrist’s sensitivities. A critical examination
of this widespread assumption is necessary.
While it is obviously necessary to be sensitive in our attitude to all
patients, we also need to understand the underlying psychopathology;
in other words, what is meant by psychosis. Our ‘normal’ or ‘neur-
otic’ sensitivities can be likened to being on wavelength 1, while the
psychotic patient may be operating on an entirely different radio
frequency, wavelength 1,000! Tuning into this frequency cannot be
achieved solely through a sensitive, caring attitude.
In my experience of supervising staff engaged in the overall man-
agement of patients with psychotic disorders, I have come to appreci-
ate the need for all staff, as well as patients, to be correctly attuned.
In clinical practice I have frequently come across situations in which
the psychotic patient’s wavelength is not appreciated.
In order to illustrate what I mean by tuning into the psychotic
wavelength, I will present five case examples from everyday psychi-
atric practice. They are not analytic cases, but psychoanalytic concepts
are central to their understanding.

Case 1: Planning for reprovision

My first example, Mr A, is an illustration of what can happen if one relies

solely on humane feelings in planning for a psychotic patient’s care. This
example is taken from around the time when the large mental hospitals were

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Tuning into the psychotic wavelength
being closed in the UK in the mid 1990s. At the time I was working at one of
these hospitals. It was sited in North London and in its heyday before the
Second World War had accommodated 2,500 patients. In the 1950s, it
was one of the pioneers of the therapeutic community approach. Single-sex
and locked wards were broken down and temporary flatlets were built in
the hospital grounds, to serve as a stepping stone, where possible, for
patients’ reintegration into the community (Martin 1968).
When I arrived as a consultant in 1978, Claybury Hospital had approxi-
mately 900 inpatients. At the time of its closure in 1996, it had 400. At this
time, the management were keen to move all the patients back into the
community, to become as self-sufficient as possible. The problem was that
the most easily rehabilitated patients had already left. Psychological meas-
urement confirmed that most of the patients still left at Claybury would
require a structured environment in the community equivalent to the one
provided in the hospital (Carson et al. 1989).
However, the management remained keen to move patients on, and
started to find community homes for them. The following material was pre-
sented at a fortnightly seminar held by Dr Anthony Garelick, consultant
psychotherapist, and myself at Claybury Hospital as a forum for discussion
of the psychodynamics operating in psychosis.
A new group home was being planned to accommodate patients with
chronic schizophrenia who had previously been on long-stay wards. At first,
it was decided that the responsible nurse should have a separate office.
However, the management then felt that it was wrong to have a room from
which the residents might be excluded since this would make it feel too much
like a psychiatric ward, rather than a home. So the room was filled with
another reprovision patient.
Into this setting was placed Mr A, a 51-year-old patient with a long
history of chronic schizophrenia. Yellowing case-notes from thirty years pre-
viously recorded the interview when he was first admitted to hospital. He
had sat in the doctor’s chair and said, ‘I’m the boss.’ This statement could
be regarded as a summary of his whole psychopathology. Over the years
he had been nursed with some difficulty, mainly on the open ward. Period-
ically, if he did not get his own way, he would become aggressive, claiming
that he was the Messiah, or Jesus Christ, and would then need a period on
the locked ward to settle down again.
He had been an only child, with a disturbed early history. His mother had
reported that when she left him, at a year old, to visit his father who was in
hospital, he was crying; when she returned from the visit he was still crying.
Throughout his school life he was reported to be disturbed in behaviour, and

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The psychotic wavelength
by his early twenties he was already spending long periods of time in
hospital.
Many years later, after his mother had died, his elderly father visited him
in hospital. He seemed calm, but when father and son went for a walk out-
side the hospital, the father was badly shaken when his son suddenly pushed
him in front of the traffic. This showed how unpredictable feelings could
suddenly erupt, despite a superficially calm appearance.
Initially, staff helped to run the group home, but the aim was gradually
to turn it into a self-sufficient private home. The patients would then be
expected to do everything for themselves. When the staff moved into the
group home, they had no private room in which to discuss the patients. They
had to resort to holding their meetings on the landing upstairs. In response,
Mr A became increasingly difficult in his manner. He could not tolerate the
staff talking about him. So they had to resort to whispering on the landing.
Finally, one day, during the staff meeting, Mr A became furious, shouted
that he was the Messiah, and assaulted a member of the nursing staff. He
had to be readmitted to hospital.

There are several interesting points to be made about this case. First,
decisions about reprovision of care for chronic psychotic patients can-
not be guided solely by ordinary sensitivities. There is specific psy-
chopathology that it is risky to ignore. As Freud said, the unconscious
is timeless. The envious feelings aroused in Mr A by exclusion and
separateness remained as rife now as they had been at that first inter-
view when he had sat in the doctor’s chair and said ‘I’m the boss’. The
managers had ignored his history.
Second, the managers had succumbed to psychotic rationalisation.
They had fallen into the trap of thinking that removing the office
would remove the cause of frustration – namely, exclusion by the par-
ental figures. It is like the story of the schizophrenic who was paranoid
about the last carriage on a railway-train, so had it removed. Of course
the next one then became the last one! The source of frustration
moved from the office to the landing. The truth is that, like parents
who need the privacy of their own bedroom, the staff needed their
own room in order to be able to function; and like the children,
the patients needed to be protected from scenes that aroused unbear-
able envy.
Third, of course, one must ask whether it is reasonable to expect a
patient like Mr A, with a history of chronic schizophrenia, to continue
to function if he is gradually left to cope on his own.

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Tuning into the psychotic wavelength

Mr A’s rehospitalisation was the inevitable consequence of the

failure to consider these issues. The management had failed to dis-
tinguish between the psychotic and non-psychotic parts of the per-
sonality. In a patient with a history like Mr A’s, the mind will be
dominated by the psychotic part, which reacts to any frustration with
paranoia and omnipotence. In other words, the management failed
to appreciate the need to tune into the psychotic wavelength when
they were thinking about setting up the group home.

Case 2: A tale of a wig

Whenever we encounter a patient with a major psychotic disorder, in

our interactions with them we should be constantly asking ourselves
whether we are dealing with a straightforward communication from a
non-psychotic part or a rationalisation from the psychotic part mas-
querading as normal. We have to ask ourselves this question all the
time in reference to every communication from the patient.

The case of Mr B illustrates the need to keep this question constantly in

mind. The case shows how we can be misled and accept rationalisations.
I was asked to see Mr B when he was on remand in prison. The only
information I was given was that he had knocked off a woman’s wig.
I went with my senior nursing staff to see him. He appeared a bit vague
and said he had knocked off the wig for a lark. There was a past his-
tory, from which I gathered that a year previously he had been hospitalised
for a few months after complaining of being persecuted by electricity
coming from the television. The hospitalisation had followed the break-up
of a relationship with a woman. He had been treated with trifluoperazine
and his mental state had settled. This information made the diagnosis eas-
ier. After all, here was objective evidence of a past florid psychotic
state. Given Freud’s view of the timelessness of the unconscious, the pro-
pensity to psychotic states must still exist in Mr B. Tuning into the psychotic
wavelength in this way made me suspect that the psychotic part of Mr B was
masquerading as normal, presenting a picture of vagueness and having
done it all for a lark.
The process of assessment raises the issue of the countertransference
feelings aroused by contact with a patient in a psychotic state. One can
doubt one’s sanity and feel one is being unfair, prematurely judging the
patient adversely and assuming the attitude that the patient is guilty till

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The psychotic wavelength
proved innocent. However, awareness of such uncomfortable feelings can
alert one to the fact that one may indeed be dealing with a patient in a
psychotic state.
I filled in the necessary part of the Mental Health Act 1983, Section 37,
as did the prison medical officer, and awaited the patient’s expected
transfer from the court to our hospital.
The next I heard of the case was several months later, when I was
summoned to appear at the Crown Court. All I knew was that a serious
offence must have been committed, or it would have been resolved at the
Magistrates’ Court. When I appeared, the judge supplied me with the
facts of Mr B’s case. An Orthodox Jewish woman, wearing a traditional
wig, was walking down the street with her 9-year-old daughter. Mr B
came up to her and punched her in the face, fracturing her nose. While
she lay on the ground screaming, he tried to pull the child away from her.
Passers-by heard the woman’s screams and came to the rescue. Mr B was
arrested.
Mr B’s story had changed only slightly in detail. He said that it was
Boxing Day and he had had a few drinks with a friend and had assaulted
the woman for a dare. He insisted that there was nothing mentally wrong
with him and said that he was prepared to accept punishment. The defence
psychiatrist could find no evidence of psychosis and agreed with the patient
that the offence was simply bad behaviour. The judge said that if the
defence case was accepted, she would have to give Mr B a severe ten-year
prison sentence, in view of the fact that the charge was attempted kidnap-
ping. The defence psychiatrist’s view was that labelling Mr B as mentally ill,
sending him to a psychiatric hospital and giving him medication, when
he was without symptoms, would be equivalent to the Russians giving
neuroleptic medication to political prisoners.
If approached from an ordinary wavelength, the defence case of bad
behaviour is easy to follow. Mr B had had a few drinks and had behaved
badly. There was no evidence of first-rank symptoms of schizophrenia
and there was no evidence of psychiatric disorder that required treatment,
especially with drugs.
The other way of understanding the episode is that Mr B was functioning
on a psychotic wavelength. He had projected and disowned his emotional
problems and covered them up with a rationalisation.
Mr B’s background history was that he had been sent as a child of 10 to
a boarding school in the Lebanon, while his younger sister had stayed at
home in Iraq with his parents. It seems a likely hypothesis that unbearable
feelings of isolation, especially over the Christmas period, had led to his

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Tuning into the psychotic wavelength
acting-out behaviour. The girl he tried to drag away from her mother may
have represented his envied sister.
The judge accepted the view that Mr B was mentally ill, especially in view
of his past history of hospitalisation and response to medication. She dir-
ected that he should be placed in hospital under Section 37 of the Mental
Health Act 1983, which meant he could be discharged whenever we felt
he was ready. The defence persisted with the view that as there was no
evidence of mental illness, this decision was inappropriate.
Interestingly, as soon as the judge pronounced that Mr B was psychi-
atrically unwell and in need of treatment, Mr B, who had previously stood
silently in the dock throughout the proceedings, turned to the prison officer
next to him and thumped him. The bewildered guard asked me afterwards,
‘Why did he do that, Doc?’

I have encountered similar incidents on several occasions. The psych-

otic part of the personality hates to be confronted with the fact that
he is going about things in a mad way (i.e. that he is mentally ill), but
does not mind a prison sentence. This contrasts with the psychopath,
who typically tries to disown responsibility for his antisocial behaviour
on the grounds that he is suffering from mental illness.

When Mr B came into hospital he became acutely paranoid and antipsy-

chotic medication was represcribed. His uncle visited and we discussed
Mr B’s socially isolated position. It was arranged that when Mr B was ready
for discharge, he would go and live with his uncle’s family and work in his
uncle’s factory.

In summary, this case illustrates the need to consider whether a

patient is functioning on a psychotic wavelength, to be wary of
accepting rationalisations, and to stay with and carefully examine the
related countertransference feelings of doubt about one’s judgement.

Case 3: A patient for the day hospital

The third case illustrates how keeping the concept of the psychotic
wavelength in mind can help staff in their management of patients.

Miss C was a 19-year-old girl who I saw for the first time in my outpatient
clinic. She was brought by her older sister. She showed florid features of

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The psychotic wavelength
schizophrenia. She presented with a childlike smile and a vague manner.
She was totally preoccupied with voices in her head from the Devil telling
her not to worship Jehovah. She felt that the Devil was putting poison in her
coffee and linked this with a person bringing pictures of Jesus to her mother
when she was three. She was laughing while she was saying all this, pre-
senting a picture that closely resembled the classical description of the
hebephrenic schizophrenic. My attempts to make sense of it all left me with
a headache (the result of trying to listen to a schizophrenic who is tearing
one’s mind to pieces). I felt despairing and at a loss to know where to start
with a patient like this, who seemed to have so few resources of her own
to draw on.
Four weeks previously, Miss C had set fire to the flat where she lived with
her father. She had the delusion that her aunt from Africa had come round,
at her grandmother’s instigation, and was telling her to flick lighted matches
into the bin in the kitchen. She did this and then went to have a bath, not
realising that a fire might result. She subsequently had to escape from the
fire via the balcony. As she was flicking the matches, she saw the bin as her
father’s head.
After the fire, her father moved temporarily into a one-bedroom flat until
the fire-damaged flat was renovated, while Miss C stayed with her sister.
She continued to behave irrationally while she was there, for example
hitting her three-year-old niece for no apparent reason.
Miss C’s family came from Ghana, where her mother now lived. When
Miss C was 3 years old, her mother had a schizophrenic breakdown.
Miss C and her sister were sent back by their father, with their mother, to live
with their grandmother in Ghana. Six years later they returned to England to
live with their father, after Miss C’s sister had written threatening suicide if
he did not bring them back. The mother reportedly remained in a chronic
psychotic state with persistent paranoid delusions.
After returning to England, Miss C relied totally on her older sister for
thinking and guidance. Her father ignored them emotionally. Two years
before her breakdown, her sister had left home to live with her boyfriend.
She was concerned for Miss C, but soon had her hands full with her own
baby. Miss C spent the next two years at home studying for two subjects
for the general certificate examination. She attended a college sporadically
and did not succeed in taking her exams. She had persistently presented
a desire to study as her main concern.
It is not uncommon for a patient with schizophrenia who comes from
North Africa, where there is a great cultural emphasis on the importance of
study, to think of study as the answer to all life’s problems in an unrealistic

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Tuning into the psychotic wavelength
way. It is also not unusual for young people with schizophrenia to keep
themselves together, throughout childhood, by relying on a sibling, through
a process of massive projective identification, when the parents are not
available for their emotional needs. When they separate from the sibling in
adolescence, the breakdown occurs.
We admitted Miss C to hospital to assess the situation further. She was
under pressure to come in because her sister could no longer cope with her. If
she had refused voluntary admission, I would not have hesitated to complete
a formal section order. It is necessary to be firm in standing up to the psych-
otic part of the patient’s personality both for their own and others’ safety.
Again, the patient may engender in the countertransference the feeling
that one is acting unfairly or in an arbitrary manner. In fact, if the police had
been involved at the time of the fire, Miss C could well have been detained
in custody and then come to hospital via prison.
Miss C’s father confirmed her sister’s picture of lack of involvement. He
said that he had just left Miss C to get on with her studies over the last two
years and had noticed nothing untoward. He seemed to fill his own time
with work or drink.
In hospital, with time and medication, Miss C’s delusional experiences
receded. However, her manner remained smilingly vacant and child-like,
and she continued to talk unrealistically of returning to her studies. She
intended to return to live with her father once the flat was ready. The ward
staff did not feel optimistic about making any progress with her.
My view was that here was a young woman with schizophrenia, at the
start of her life, seemingly with few internal resources. All that she seemed
able to do was to project everything out and then live in a dream-world
(the vacant smile). She needed a long period in the right environment,
involved with caring professionals, not unrealistically trying to pursue her
studies in isolation. My plan was for her to attend our psychiatric day hos-
pital, which had active groups and therapeutic input from the nursing staff,
occupational therapists, social workers and others, as well as my own
supervisory involvement.
I firmly told Miss C that what she needed, at this point, was time spent
mixing with others in a helpful environment to develop more of a sense of
herself, not studies. Her college had contacted me and I told her that they
were in full agreement. Again this illustrates the need to be firm in standing
up to the psychotic part of the patient. My only straw of comfort in thinking
about Miss C’s case was the fire, which I felt was the only evidence I had
of life in her. It symbolised her attempt to draw her unresponsive father’s
attention to her needs.

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The psychotic wavelength
When she started at the day hospital, Miss C’s vacant manner remained
the same. Like the inpatient staff, the day hospital staff felt unable to
make a meaningful contact with her. A few days later, on leaving the
day hospital, Miss C met a man when his car stopped at the traffic
lights. She got into his car and spent the night with him. The next morning
she was tearful and upset when she told the day hospital staff about
it. However, she then reverted to her vacant smiling state. The staff felt at a
loss to know how to understand Miss C, so her case was presented at our
weekly seminar.
The issue raised was that Miss C appeared so vacant and inaccessible,
with nothing to get hold of, that her case seemed hopeless. However, if one
remembers the need to be attuned to the psychotic wavelength, her case
looks quite different. This is a young woman who uses projective processes
to empty her mind of problems. Having emptied her mind of her problems,
she is then free to produce any phantasy she likes. Here the man in the car
has the idealised penis, which she imagines can look after her totally. Later,
she starts to feel uncomfortable about the events.
I felt that a rapport with Miss C could be established only through our
understanding involvement with the acting-out and major life events that had
impinged on her. As her only available response to these events was to
evacuate and go vacant, we needed to do the initial thinking for her about
her projections. In Bion’s terms this would be the work of converting
unusable beta-elements into alpha-elements, through alpha function or
maternal reverie; in Winnicott’s terms, our aim would be to provide a state
of primary maternal preoccupation, through her key worker (Bion 1967;
Winnicott 1960). Miss C’s mother had previously been unable to fulfil these
functions for her, due to her own psychosis.
Looked at from this perspective there are many issues that can be taken
up with her:

• the unavailable ill mother

• the sister she had relied on, who had left
• the need to resort to massive projective identification by hallucinating her
aunt, to try to make contact with her father’s mind
• the issue of trying to use education and study to solve her emotional
problems
• the proneness to evacuate and look for quick ideal solutions, the idealised
penis, in preference to real involvement in the day hospital.

Looked at from the angle of attunement to the psychotic wavelength, a case

that may appear arid from an ordinary viewpoint is full of life events with

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Tuning into the psychotic wavelength
which to be involved. It is possible to help staff to orientate themselves to
this. They also need help to realise that the patient will keep resorting
to projection and escapism, and will continually need to to be brought
back to face reality. For example, a few weeks later, Miss C was talking
about going to see her mother in Ghana and had formed other unsuitable
relationships.
After the seminar, one of the nursing staff felt sufficiently encouraged to
take Miss C on for individual sessions. With the support of her sister,
arrangements were made for Miss C to move to a specialised community
placement, from where she would continue to attend the day hospital.

In ordinary analytic practice, analysts are wary of referring to separate

parts of the personality. Speaking to the patient in terms of a part of
themselves that behaves in a certain way is felt to reinforce defensive
structures, unless they have a sufficient degree of integration to rec-
ognise internal painful conflicts (Feldman 2007).
Analysts are more accustomed to think in terms of split-off parts
or autistic islands that require reintegration during analysis to form
a more whole person. They may therefore be quite resistant to think-
ing about a separate psychotic part that operates in major psy-
chotic disorders, among which I include affective disorders as well as
schizophrenia. For the moment I will concentrate on schizophrenia,
as depression will be considered in detail later in the book (see
Part Four).
Within everyday general psychiatric practice it is crucial to be
always thinking in terms of the two separate parts, psychotic and non-
psychotic, in order to relate to the patient effectively. The following
serves as a telling example.

Case 4: Making contact with an apparently

inaccessible state of mind

Miss D, a late adolescent girl with a diagnosis of schizophrenia, was admit-

ted to hospital in a vague and confused state. Her father had died two years
ago and she and her mother had moved into our catchment area. Recently,
Miss D had become so confused and disjointed in her thinking and
behaviour that her mother found her too much of a handful, and she was
admitted.
In hospital, her mental state remained the same, despite antipsychotic

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The psychotic wavelength
medication and individual time spent with the staff. She remained vague
and unforthcoming, requesting no help, and when she was questioned she
denied having any depressive or suicidal feelings. This situation went on
unchanged for several months.
I was on leave when a decision was made to allow her out of hospital
to spend a weekend at her mother’s place. That weekend, with no prior
warning, she jumped out of an upstairs window, fracturing a leg. She
was initially treated in an orthopaedic ward in the general hospital, where
I also ran my outpatient clinic. While she was recovering on the ortho-
paedic ward, she came on crutches, with her leg in plaster, to see me in my
outpatient clinic.
She was in a frightened state and asked if she could be readmitted to our
psychiatric hospital ward as soon as she was ready for discharge from the
orthopaedic ward. At the time I was struck both by her frightened state and
her clear expression of a wish to be readmitted, in contrast to her usual
vague state.
On readmission to the psychiatric ward, however, Miss D went back to
her previous unforthcoming state, acting as if nothing had happened. We
seemed to have reached an impasse; it felt as though Miss D would continue
for ever in this state of mind.
It then occurred to me to look at the situation in terms of two divergent
parts of the self. On reaching adolescence, one part felt quite unequipped
emotionally to cope with life and felt frightened, bewildered and in need of
constant support and help in a non-pressurised environment; while another
part, which in Bion’s terms would be called the psychotic part of her per-
sonality, was totally impatient, intolerant of frustration, and dealt with the
needy part by trying to get rid of the patient.
Following this line of thought, one could look at the suicide attempt, not
as an expression of depression and despair by a needy part of the self,
which would be a more normal way of looking at things, but as a murderous
assault by one part of the patient on another part. This explains Miss D’s
frightened state when she came to me from the orthopaedic ward request-
ing readmission; we can understand this as the frightened needy part of her
seeking protection from the murderous part.
Following this insight, I put it to Miss D that she had not jumped out of the
window, but that the needy part of her was actively pushed out of the
window by an impatient part that hated her neediness. Saying this to her
was like pressing a magic button. Seemingly from nowhere her mental state
changed. Instead of continuing in her habitual slow, vague and confused
state, she began to talk rapidly. She denied that what I had said was the

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Tuning into the psychotic wavelength
case, started to stress the importance of religion, and in the next ward group,
instead of her usual silence, advocated organised holiday trips.
Miss D’s internal state had now been brought into the open. The murder-
ous part was in full view, advocating going on holiday rather than being a
patient, propounding adherence to religion and omniscience as a substitute
for thinking. Through religion, which was not to be challenged, she pro-
pounded that she was a very moral person; anyone questioning her views
was made to feel that they were the intolerant one. As Miss D’s psychotic
murderousness was no longer hidden it became possible to challenge her
on whether this was the only way to go about dealing with her emotional
needs and lack of confidence.
While account had to be taken of Miss D’s severe disabilities, she then
began to make progress. She moved to live in a group home, responded
to help in socialising, accepted continued support from her mother and
attended for outpatient monitoring.

This case shows how thinking in terms of Bion’s concept of the two
divergent parts of the personality helped to overcome an impasse. It
also illustrates that not all situations with psychotic patients are amen-
able solely with drugs. It offers a good example of how a murderous
part of the personality, dominated by the death instinct, tries to cover
up its tracks and present as a more rational, reasonable person.

Case 5: Evaluation of suicide risk in a woman with

longstanding schizophrenia

This case illustrates the need for senior nursing staff to appreciate the func-
tioning of the psychotic part of the personality. Mrs E was a woman in her
fifties, with a long history of schizophrenia. Her husband had died a few
years previously, and since then her admissions to hospital had become
much more frequent. Her elderly mother, who lived some distance from her,
was the main monitor of the patient’s mental state, with some back-up from
the community psychiatric nurse and social services.
Mrs E’s latest hospital admission had followed her getting the flu. This
precipitated a catatonic state, in which she took to her bed and did not eat,
until her mother discovered her when her daughter failed to visit her as usual.
Mrs E had to be admitted to hospital on a compulsory order, as when she
was seen at home she denied that there was anything wrong, saying that
she was feeding and looking after herself satisfactorily. In fact, she was so

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The psychotic wavelength
dehydrated on admission that initially she required an intravenous drip and
management on the medical ward.
She was soon transferred to the open psychiatric ward at the hospital.
There she presented with a calm exterior, denying that anything was troub-
ling her. She went for a walk with the nurses and managed to get away from
them. It was getting late and it was a very cold winter’s night. The ward
sister was concerned, as it had been established that she had neither gone
home nor gone to her mother’s place.
Fairly near to the hospital was a large forest. The ward sister had wide
clinical experience, and I had often discussed with her the splits in psychotic
patients, and the presence of a murderous part of the personality. This
dynamic was already in evidence within this patient, who had dealt with the
ill-flu part of herself by starvation and dehydration, while claiming at the
same time that she had been caring well for herself.
The ward sister was sufficiently worried that she managed to persuade
the police to send a helicopter over the forest, quite a feat in itself, as she
was worried that the patient might die of hypothermia. The police in fact
found her there. The patient claimed that she had just lost her way and had
decided to sleep in the forest.
The next morning, when seen in the ward review, she was terribly polite.
There were several empty chairs and she asked which one she should sit on.
She made no mention at all of the recent incident. I pointed out the murder-
ous hypocrisy of the part of her that was now being so polite, and yet had
tried to get rid of the needy part of herself that she had got in touch with
through getting the flu. Of course, there had been no one else available
at home, since her husband’s death, to offer the alternative of a caring
attitude.
In contrast to Miss D, Mrs E’s internal mental structure was so ingrained
that she continued to behave in similar ways, with further admissions,
although at least the staff (inpatient and outpatient), as well as her mother,
were now fully aware of the underlying dynamics that made repeated
episodes of self-neglect likely.

Summary

In this chapter, I have endeavoured to demonstrate through clinical

examples the need for a theoretical framework in approaching major
psychotic disorders that differs from the framework we use in thinking
about neuroses or borderline states.

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Tuning into the psychotic wavelength

The issues that need to be considered include the following:

First, major psychotic disorders have to be related to in their own

right. We cannot rely solely on understanding and empathy gained
through experience with less disturbed patients. We have to develop a
capacity to tune into the psychotic wavelength in order to understand
our patients’ conflicts and resulting states of mind and behaviour.

Second, when approaching major psychotic disorders, we have

always to think in terms of two separate parts of the personality, the
psychotic and the non-psychotic, and ask ourselves which part we are
being confronted by at any particular moment in time.

Third, we need constantly to bear in mind that the commonest

symptoms of psychosis are not hallucinations, delusions or first rank
symptoms, but in over 95 per cent of cases, denial and rationalisation.
We therefore must keep asking ourselves whether in listening to the
patient we are hearing denial of problems and plausible rationalisations
by a psychotic part covering up its murderous intolerance of frustra-
tion, rather than a reasoned argument or complaint emanating from
the non-psychotic part. Keeping this framework in our minds can
help us to stay attuned to the psychotic wavelength.

Once the psychotic part of the patient has been recognised as a

separate entity to be studied in its own right in major psychotic dis-
orders, one is in a position to give further consideration to the needs
of patients presenting with severe and enduring mental illness. This
includes the need to build up a supportive environment or exoskeleton
around the patient, and this is the subject of Chapter 17.

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12
Dreams and delusions

Introduction

Freud always considered The Interpretation of Dreams to be his most

important work ( Jones 1972). He famously described dreams as ‘The
royal road to the knowledge of the unconscious activities of the mind’
(Freud 1900, p. 608). In psychosis, delusions replace dreams as the key
to understanding the underlying conflicts. In order to understand
these conflicts, we need to decipher the meaning behind the delusions.
I will briefly consider the role of dreams in current psychiatric
practice before turning to delusions. Some organically orientated
psychiatrists regard dreams as the meaningless residues of the day’s
work by the brain. Others of us might think differently. I will start
with a case that vividly illustrates the importance of dreams as a guide-
line in psychiatric assessment.

Case 1: The dream as a guideline

Mrs F presented as a new outpatient. She was in her forties, of Kurdish

extraction, seen with a link worker. Her sole presenting problem was that
she would wake up terrified every night after a nightmare in which the
ceiling was coming down. She would then turn to her husband and say to
him, ‘I don’t know who you are’, and he would have to reassure her.
This had been going on for three years, but it had become worse over the
last three months. Mrs F reiterated that she had no other problems.
She had been brought up on a farm and had had an arranged marriage
when she was 17. She was grateful that her husband turned out not to
be a bad man. She had three children who were all still living at home,

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Tuning into the psychotic wavelength
the youngest of whom was now 17. They had come to the UK ten years
previously, because of the political problems in their country of origin.
I was unable to elicit anything abnormal until I asked about her husband’s
health. She said, ‘Oh yes’, and mentioned that he had had stomach cancer
for the past three years and had undergone chemotherapy. He had told her
not to mention his illness to the children, but she felt that they might suspect
something anyway.
Freud thought that dreams represented our minds’ attempts to deal with
emotional conflicts at night through dissociation, repression and symbolism.
We can see clearly here that the ceiling falling down in the dream is a
symbolic representation of her husband’s illness. We can see dissociation
at work, as she tries to distance herself from her perception of her husband’s
illness and his dying. We can see repression and return of the repressed,
her anxieties emerging at night in her nightmares.
Culturally Mrs F’s role was as the housewife, she looked after the house
and children, while her husband was the one in charge. She was emotion-
ally isolated since she did not speak English and had no friends or family
over here.
We decided to refer her to a Kurdish-speaking women’s centre and to
arrange to see her with her husband and a link worker. We were also
aware that the whole family might need some help.

This example illustrates how reported dreams can play a role in

everyday psychiatric clinics in alerting workers to the patient’s internal
concerns. Of course psychotherapists routinely recognise the import-
ance of enquiring about dreams in their assessment interviews, but
we might consider enquiring about them in general psychiatric
assessments, as we search for understanding.

Case 2: The importance of dreams as indicators of

progress in therapy

In a review on the function of dreams, Segal points out that we have

expanded our thinking beyond Freud’s classical theory. Freud held
that repressed wishes found their fulfilment in dreams by means of
indirect representation, displacement, condensation and symbolisa-
tion. A compromise is reached between repressing agencies and return
of the repressed. Dream-work is the work needed to achieve this
compromise. Segal points out that Freud never altered his views on

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dreams, following his later formulation of the duality of libidinal and

destructive forces (Segal 1981c).
Many aspects of dreams have received further consideration since
Freud’s seminal discoveries (Flanders 1993; Quinodoz 2002; Sharpe
1937). My aim here is simply to illustrate how dreams can act as
indicators of progress in analytic psychotherapy, and as such could
be appreciated by a trainee when seeing an individual psychotherapy
case under supervision.
The following material, taken from a woman in her thirties in
twice weekly analytic therapy, illustrates the important role that
dreams can play in indicating a progressive strengthening of the ego.

Mrs G presented with a diagnosis of depression linked to chronic fatigue

syndrome. She came from a strict religious sect. Her mother had a history
of depression, but had never received treatment for it.
Mrs G was married with no children. She was not working due to episodes
of severe fatigue, often feeling exhausted when she woke in the morning.
She had had one lengthy hospital admission. She felt that antidepressants
had not worked for her and did not want to stay on medication. A cognitive
approach had been attempted as part of her treatment, but this had not
helped either. She experienced the cognitive daily diary tasks as demands
that exacerbated her symptoms of fatigue. Through contact with a friend
she had been referred for analytic therapy.
She was afraid that the development of her own mind would have a
catastrophic effect on her family, especially on her religious father, who
would not be able to tolerate her having a separate mind.
In analytic terms, one could see Mrs G as having an ego-destructive
superego, a part of her that was present from early on in development, that
never changed, and that constantly criticised her for not being perfect. In
severe depression, the ego-destructive superego holds the ego in a vice-like
grip, refusing to allow it to breathe and develop. The task of therapy with a
patient like this would be gradually to displace it by a more mature reflective
superego. As Mrs G got more involved in her therapy her dreams provided
indications of this gradual displacement.
Initially Mrs G’s dreams were full of dismembered body parts or heads
blown off. Gradually they changed into representations of conflicts between
two parts of herself. One part, identified with an extreme restrictive religious
attitude, was linked in her mind to a dream of being imprisoned in a barren
concrete building. A crack was starting to appear in one of the walls, but
she was still trapped inside.

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Tuning into the psychotic wavelength
Another dream featured a large black metal mechanical spider that had
her in a vice-like grip. It was not hard to appreciate this in terms of her
feeling of being in the grip of her depression.
Much later on in Mrs G’s treatment, her husband was left some money,
and for the first time the couple could put a deposit on a home for them-
selves. Despite her pleasure in this, her depression still maintained a grip on
her, although she tried to underplay it. At night, she would be overtaken by
a compulsion to clean all her pots and pans, and she would then wake
exhausted and fit for nothing the next day.
When I referred to the grip that the depression still had on her, and
related this to her spider dream, she recalled that that night she had had
another dream of a black spider. She had awakened absolutely terrified.
The spider was the size of the consulting room wall and she was entrapped
in it. This time, though, it was made of bamboo. An acquaintance of her hus-
band’s, who was friendly towards her, managed to break off one of the legs.
The scene in the dream then shifted to her father driving the car. They
were taking a day return trip to where she bought the flat. She didn’t want to
go, but agreed in the end. Her father was very angry while driving. She was
crammed in the back with her siblings, like in childhood. However, she had
a famous young actress with her. This woman stood in her mind for all her
good wishes for herself: attractive, independent with a good mind.
In her associations she was able to consider the father in her dream as an
internal object, part of her own make-up, rather than just an external father.
She was able to talk of the two problems that she had to face, her religion
and what she referred to as ‘her madness’, her crippling depression and
tiredness, linked to identification with the demands of the controlling father
in the driving seat.

In this example the patient’s dreams develop in complexity and detail

as she makes progress in coming to grips with her depression, and
her dreams go from part-object representations to representations of
whole objects.

Dreams in the context of psychotic disorders

In patients with a major psychotic disorder, whether schizophrenia or

recurrent manic depressive disorder, dreams can be deceptive in terms
of raising one’s hopes for change because of the insight apparently
expressed in the dream.

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Dreams and delusions

Bion observed that in schizophrenia, as the patient progresses, he

may start to report dreams, the consequence of his introjection of
meaning from the analytic encounter. The dreams have arisen as a
result of work done by the non-psychotic part of his personality.
However, if the psychotic part is in the ascendance, the dreams may
be the night-time equivalent of hallucinations during the day, repre-
senting material to be evacuated: ‘to the psychotic a dream is an
evacuation from the mind strictly analogous to an evacuation from
his bowels’ (Bion 1958, p. 78).
However, the psychotic part cannot stop the functioning of the
non-psychotic part, with its capacity for observation; it can only
evacuate the insights reached. Steiner (1993a) described the antagon-
istic quality to this complex relationship between the two parts of
the personality.
Steiner noted: ‘Both Freud and Bion describe the co-existence of
psychotic and non-psychotic parts of the personality in the psychotic
patient, and both speak as if a sane and psychotic person exist within
the one individual’ (Steiner 1993a, p. 67).
Freud wrote:

The problem of psychosis would be simple and perspicuous if the

ego’s detachment from reality could be carried through com-
pletely. But this seems to happen only rarely, or perhaps never.
Even in a state so far removed from the reality of the external world
as one of hallucinatory confusion, one learns from the patient after
their recovery that at the same time in some corner of their mind
(as they put it), there was a sane person hidden who, like a detached
spectator, watched the hubbub of illness go past him.
(Freud 1940, p. 201)

Steiner also noted that for Bion,

The non-psychotic part was concerned with a neurotic problem,

that is to say a problem that centred on the resolution of a conflict
of ideas and emotions to which the operation of the ego had given
rise. But the psychotic personality was concerned with the prob-
lem of repair of the ego.
(Bion 1957a, p. 56)

The problem with dreams in psychotic patients is that they may

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Tuning into the psychotic wavelength

well represent an evacuation of sanity in order to avoid disrupting the

status quo and having to face the need for psychic change. This evacu-
ation is the work of a psychotic part in envious rivalry with sanity,
which is projected into the analyst.
I learned this lesson the hard way over many years of analytic
involvement with a patient with recurrent manic depression (see
Chapter 14). I learned that dreams reported by patients with recurrent
psychotic disorders should always be considered as possible evacu-
ations of insight rather than necessarily the signs of internal progress
that they might be in the case of a patient with a more neurotic
disorder.

Just before a prolonged manic episode, my patient had a dream in which

she was both the onlooker at a Roman orgy and a participant in it. She did
not like what she saw but could do nothing to stop it. Schreber also reported
disturbing dreams prior to his relapses. In both cases, the dreams seem to be
predictors of relapse, illustrations of awareness arrived at through the work
of the non-psychotic part which is about to be overwhelmed by the power
of the momentum emanating from the psychotic process.
After her fifth manic phase, my patient reported a dream which seemed
to give hope. In the dream she was having another baby and saying to
herself that this time she needed to look after it if she did not want to return
to hospital. In fact despite my attempts to work on the dream with her, she
developed another severe depressive episode, and when she recovered
from this she had lost all recollection of having had the dream.

This alerted me to the fact that material that may appear terribly
sensitive and full of meaning may prove to be an evacuation of insight
by the psychotic part and that it will not necessarily be possible to
utilise this material for therapeutic purposes. It is easy to get very
enthusiastic about the expressed content in psychotic disorders, but
time helps one to become more aware of the power of resistance
to change.
Yet we still have to look after patients who are resistant to change.
In such patients with schizophrenia, where delusions replace dreams,
the challenge remains to decipher their meaning in order to find clues
about the cause of a relapse. Case 3 illustrates such a situation.

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Dreams and delusions

Case 3: Deciphering a delusion – what lies behind

the smoke detector?

I was asked to visit Miss H, a patient in her late fifties. She had a diagnosis
of chronic schizophrenia. She had never married and had lived all her life
in her parents’ house. Her parents had died a number of years ago. She
had no other siblings or close family. She used to work in a factory but had
been made redundant. She had been referred to our day hospital, but had
recently stopped coming, refused all medication and become reclusive at
home. Her care coordinator was worried about her increasing isolation
and self-neglect leading to a need to consider formal admission.
Miss H lived in a gloomy, neglected terraced house that was in need of
general attention. When I arrived the smoke detector in the hallway was
bleeping, indicating the need to replace its battery.
Miss H remarked to me that the battery needed replacing. Then she
switched her view and said that her neighbours were bugging her through
the smoke detector. It was a bugging device. She was quite convinced that
this was the case. She was in a withdrawn mental state, lacking insight into
her delusional experiences.
She was subsequently admitted under the Mental Health Act 1983. In
hospital she was prescribed medication but I also then had the opportunity
to review her current life situation with her and other involved professionals.
When I initially saw Miss H at home, I had no associations to the bug-
ging, merely experiencing it as a presenting symptom of a patient with a
relapse of her psychosis. However, I was now able to think differently. The
way the psychotic part of the mind works in psychosis is to project out and
disown mental pain. It projects into objects in order to identify the object
with what it is getting rid of, so as to distance itself from the problem.
Once she had been admitted and was being cared for by others in
hospital, I think that Miss H felt less burdened and more supported. This led
to a reduction of her need to project concretely into my mind that her smoke
alarm was a bugging device so that I could start to feel freer to associate
to the delusion and think about its meaning as a communication.
The question then became, ‘What is it that has been bugging the
patient?’ What was it that she had needed to disown into her next-door
neighbours and was now coming back at her through the smoke detector?
I then realised what was bugging her. She had lived all her life in the
parental home. She was no longer working and in any case her pay would
only have covered day-to-day living expenses. She had no money for the

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Tuning into the psychotic wavelength
house, which was in need of urgent renovation including a new roof. The
psychotic part disowned the worries that arose from thinking about all of
this and projected the worry into the next-door neighbour. However, the
worry would not go away and came back in the form of the neighbour
bugging her through the smoke detector.
I put this to Miss H, who at that moment was able to see the problem and
consider a possible solution, whereby the house would be sold by the coun-
cil and arrangements made for her to move into a comfortable flat that
would be financially manageable. Miss H appeared to be grateful for the
understanding and response.
One might consider that Miss H’s acceptance of this proposal arose out
of the functioning of the non-psychotic part of the mind that is capable of
thinking and reflection, the part that could realise that a new battery was
required in the smoke detector and that the solution to her current difficulties
lay in a new infusion of energy from outside helpers.
The psychotic part of the personality cannot metabolise and think; it can
only project and disown what it cannot face. It may also enter into competi-
tive envious rivalry with offered help, insisting that its way should prevail.
A few days later, not wanting to face the need to move, Miss H’s psychotic
part projected her worries further. This time the bugging was experienced
not as coming from the next-door neighbour but from a house twenty doors
away and she even wrote from the ward to this house, whose owners were
complete strangers to her, complaining of the bugging. A continued dia-
logue with Miss H became necessary to help her to face up to the problem.

Her case shows how delusions in psychosis, like dreams in neurosis,

can be seen as important communications of the patient’s concerns.
However, in the psychoses, we also have to take account of the separate
functioning of the psychotic and non-psychotic parts of the personal-
ity, and be mindful of the fact that the delusion is caused by the
psychotic part disowning the work of the non-psychotic part. After
the meaning of the delusion has been deciphered, the challenge is
to find a way to create and maintain a constructive dialogue about
it with the patient.

Summary

Dreams may provide important clues in first assessments in general

psychiatry. They may also offer indications of the patient’s progress in

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Dreams and delusions

psychotherapy. In supervised psychotherapy, trainees can learn first-

hand about the depth of meaning that dreams can have.
Patients with major psychotic disorders may report dreams that
seem very insightful, but it is always important to consider the possi-
bility that they may be an evacuation of insight. We therefore need
to be aware of the differences between dreams presented in neurotic
disorders and those presented in psychotic disorders, and their poten-
tially different clinical implications.
In schizophrenia, the challenge moves from understanding the
hidden meaning in a dream to deciphering a delusion. Arriving at an
understanding of the delusion may help us to understand the cause of
a relapse. Typically, in contrast to dreams, the patient will be unable
to provide associations to the delusion and one has to rely on infor-
mation gathered from others as well as the workings of one’s own
mind to arrive at an understanding.

165
13
Utilising the counter transference
in psychosis

Introduction

This chapter examines the importance of countertransference experi-

ences in work with psychotic patients. In conjunction with a consider-
ation of the content of delusions, countertransference experiences
are of crucial importance when trying to understand the patient’s
communications. It takes time to gain confidence in examining and
using one’s feelings in this way. One is helped if one has had this
experience in personal analysis, as well as the opportunity of exploring
one’s countertransference in supervision with less disturbed patients.
However, junior doctors do not start psychiatry with the luxury of
these experiences. They are thrown in at the deep end, finding them-
selves on the receiving end of psychotic patients’ projections from
their first day in psychiatry. This is not a subject that normally receives
consideration in standard psychiatric textbooks.
I will begin by reviewing some theoretical psychoanalytic contri-
butions on the transference and countertransference in psychosis. I will
then use some clinical examples to illustrate the central importance of
utilising the countertransference in clinical practice.

Some theoretical considerations

In psychoanalytic terms the countertransference has been defined as

‘The whole of the analyst’s unconscious reactions to the individual
analysand – especially to the analysand’s own transference’ (Laplanche

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Utilising the countertransference in psychosis

and Pontalis 1973, p. 92). In terms of psychosis, this means our emo-
tional reactions to what the patient projects into us. Since projection
is predominantly an unconscious process, we become aware of it
only through aspects that are more preconscious and accessible for
examination, as the clinical examples will illustrate.
However, before considering countertransference in psychosis, we
must first clarify that transference indeed occurs, and consider its
intensity and effects.
In 1915, Freud expressed the view that no transference occurred in
schizophrenia. He thought that these individuals’ repudiation of the
external world represented an attempt to return to a primitive object-
less narcissistic state. Since the psychoanalytic method relied on the
interpretation of the transference, there was no place for this approach
in schizophrenia and ipso facto no countertransference experience
to explore.
Herbert Rosenfeld (1952) revived interest in the analytic tech-
nique in psychosis, using Melanie Klein’s seminal work with small
children as inspiration. In Klein’s work, through interpretation of the
positive and negative transference from the beginning of the analysis,
the fundamental principles of analysis were retained, and a transfer-
ence neurosis developed. Rosenfeld writes:

All the experience thus gained has been used as guiding principles
in the analysis of psychotics, particularly acute schizophrenic
patients. If we avoid attempts to produce a positive transference
by direct reassurance or expressions of love, and simply interpret
the positive and negative transference, the psychotic manifesta-
tions attach themselves to the transference, and, in the same way
as a transference neurosis develops in the neurotic, so, in the
analysis of psychotics, there develops what may be called a ‘trans-
ference psychosis’. The success of the analysis depends on our
understanding of the psychotic manifestations in the transference
situation.
(H. A. Rosenfeld 1952, p. 65)

Rosenfeld drew attention to Freud’s (1924) statement that ‘Transfer-

ence neuroses correspond to a conflict between the ego and the id,
narcissistic neuroses to a conflict between the ego and superego, and
psychoses, to one between the ego and external world.’ In Rosenfeld’s
view this implied that Freud did not think the superego could play a

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Tuning into the psychotic wavelength

significant role in schizophrenia (Freud 1924, p. 149; H. A. Rosenfeld

1952, p. 68).
Rosenfeld emphasised the usefulness of the classical Kleinian
account of the early development of the ego and superego, linked to
introjection of the good and bad breast, in understanding psychosis.
The degree of harshness of this early superego could affect the indi-
vidual’s capacity to work through the depressive position. Persecutory
delusions, such as experiencing critical voices or paranoid delusions
of being observed or followed, could be explained as manifestations
of a harsh superego. The analyst may be the recipient of projections of
an idealised object in order to protect the good object and Rosenfeld
emphasised the need to resist acting out in the countertransference
through direct expressions of love rather than sticking to interpret-
ation. If feelings are experienced as unbearable then the patient
might regress from the depressive position to paranoid-schizoid states
or become manic; either way Rosenfeld strongly advocated a close
adherence to the analytic interpretive approach.
He regarded problems encountered in early object relationships
as the primary issue to be addressed in schizophrenia, analysing
on classical Kleinian lines, though he conceded that, ‘One has to
assume that a certain predisposition to the psychosis exists from
birth’ (H. A. Rosenfeld 1963, p. 168).
In part Rosenfeld’s statement of his views evolved in response to the
approach at Chestnut Lodge where the technique of strict adherence
to classical transference interpretation, as opposed to the introduction
of more non-analytic supportive responses, was not accorded the
same central importance. However, Searles, who worked there, was
also very aware of the intensity of transference phenomena and the
need to avoid being drawn into any acting out of an erotic transfer-
ence, which could be covering over underlying feelings of despair.
Searles’ theoretical concepts of schizophrenia were based on
Mahler’s (1952) ideas on symbiosis. He writes:

The aetiological roots of schizophrenia are formed when the

mother-infant symbiosis fails to resolve into the individuation of
mother and infant – or, still more harmfully, fails even to become
at all firmly established – because of deep ambivalence on the part
of the mother which hinders the integration and differentiation of
the infant’s and young child’s ego.
(Searles 1961, p. 524)

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Utilising the countertransference in psychosis

He developed his own formulation of progress through an ‘out-of-

contact’ phase, a phase of ‘ambivalent symbiosis’, towards a ‘full or
preambivalent symbiosis’ and finally the phase of ‘resolution of
the symbiosis’.
Searles summarises:

I consider it valid to conceive of the patient’s transference to the

therapist as being in the nature, basically, of a relatedness to the
therapist as a mother figure from whom the patient has never, as yet
become deeply differentiated. Furthermore, I believe that this ‘sick-
est’ – least differentiated – aspect of the patient’s ego functioning
becomes called into play in any relationship which develops any-
thing like the intensity that the therapeutic relationship develops.
(Searles 1963b, p. 662)

Despite their differing theoretical frameworks, both Rosenfeld and

Searles highlight the intensity of the transference in psychosis and
therefore the stimulation to act out in the countertransference to seek
some quick relief for the patient rather than stay more thoughtfully
with the situation.
This points to the need to consider the place of countertransference
feelings in thinking about patients with psychosis, a subject given rela-
tively little specific mention in the literature. An exception to this was
David Rosenfeld (1992), a psychoanalyst from Argentina who wrote:

I feel that the study of the countertransference (and of psychotic

transference) are the via regia to future investigations in the treat-
ment of the psychoses, just as dreams were the royal road to the
investigation of the neuroses. The patient makes the therapist
experience intense and violent emotions, which he cannot express
in words.
(D. Rosenfeld 1992, p. 4)

In a general review of the countertransference, Hanna Segal points

out that there is a difference from the transference.

The analyst’s capacity to contain feelings aroused in him by the

patient can be seen as an equivalent to the function of a mother
containing the infant’s projections, to use Bion’s model (1967).
Where the patients act instinctively, however, the analyst subjects

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Tuning into the psychotic wavelength

his state of mind to an examination – a reflection, albeit, much of

the time preconscious.
(Segal 1981b, p. 83)

Segal remains critical of aspects to the countertransference ‘where

analytic sins have been committed in its name. In particular, rational-
isations are found for acting out under the pressure of countertrans-
ference, rather than using it as a guide for understanding’ (Segal
1981b, p. 87).
She was referring to experiences with analytic supervisees in
training, with non-psychotic patients, who say things like ‘the patient
projected into me’ or ‘made me angry’ rather than realising that such
feelings indicate a failure on their part to understand and use the
countertransference constructively.
Segal’s comments indicate the need for caution in our attempts
to use the countertransference. Freud had warned that as a result of
the patient’s influence on the physician’s unconscious feelings, ‘no
psycho-analyst goes further than his own complexes and internal
resistances permit’ and consequently emphasised the need for the
analyst to submit to a personal analysis (Freud 1910, pp. 144–145;
Laplanche and Pontalis 1973, pp. 92–93). Unfortunate incidents of
acting out in the analytic setting, such as Jung’s relationship with his
patient Sabina Spielrein, help us to understand how the emphasis on
the need to control and master countertransference feelings developed
(Britton 2003).
It was many decades before Paula Heimann (1950) redressed the
balance by stressing the fact that all analysts were having countertrans-
ference reactions and using them to increase their sensitivity towards
their patients. Such reactions need to be recognised and thought
about in order to minimise the risk that they may stimulate the analyst
to act out. Joseph has also written about how the patient invariably
nudges one to act out. This is the price of involvement, but it needs
constant monitoring and thinking about within the total transference
situation ( Joseph 1985).
The experience of the countertransference in more neurotic
patients contrasts markedly with the experience with psychotic
patients in general psychiatry, where every day one is projected into by
the patients in ways that threaten to overwhelm one’s mind. Clinicians
must not only be aware of the risk of mishandling the countertrans-
ference, as in neuroses, but also learn how to recognise it and survive

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Utilising the countertransference in psychosis

with their own questioning faculties intact, even when subjected to

the most powerful projections. Yet, if one can survive the experience
and get support from others with one’s thinking and associations,
the countertransference indeed becomes the via regia to understand-
ing psychosis.

Clinical issues

When working with psychosis in everyday psychiatry, the clinician

needs to develop the ability to understand the patient’s presenting
delusions as a form of communication. Understanding one’s counter-
transference reactions as projective communications from the patient
will help in making sense of the delusional material and will facilitate
a movement from an initial psychotic monologue into a meaningful
dialogue with the patient. The following vignettes illustrate the cru-
cial importance of taking into account one’s countertransference
experience when dealing with psychotic states.

Monitoring one’s changing countertransference experience

A patient previously unknown to our service presented to the emergency

clinic in an unpleasant and demanding mood. He was referred on to my
outpatient clinic where he presented in a similar mood, indiscriminately
angry and unsatisfied with any suggestions I offered to try to help. In the end
he stormed out, somewhat to my relief as I did not fancy trying to instigate a
section in the outpatient setting. At the time I felt that I was seeing someone
with a difficult personality disorder with poor tolerance to stress who could
become quite unpleasant if things were not the way he wanted them.
I was familiar with the countertransference feelings stirred up by a patient
with a severe personality disorder who cannot face their own depressive
states and deals with them by blaming others for neglecting their needs,
making one feel very negative towards them. In the case of this patient there
was no evidence of any delusions and at the time I did not consider that I
might be the recipient of a powerful projection from a patient with schizo-
phrenia, with a psychotic part that was angry about his currently being in a
needy state.
The difference in his state the next time I saw him took me by surprise. He
had been admitted to our hospital. At this point I learned that the background

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Tuning into the psychotic wavelength
history was that he had a diagnosis of paranoid schizophrenia, had lived
in a group home, but had recently been moved on to independent accom-
modation which lay in our catchment area, without anyone being informed
of the move.
His affect now was completely cold and flat. He said that he had a rat
in his stomach. This came across as a very concrete delusion. I felt that I had
no associations to it, and did not realise at the time that this in itself was a
very marked countertransference reaction. I felt that all my analytic beliefs
in psychosis were being challenged and found wanting, as I could not make
any sense of the delusion. I felt that all the organically orientated psychi-
atrists who regarded analytic contributions to understanding psychosis as
manufactured phantasies, based on no scientific evidence, were right, cer-
tainly in this case. I remembered an eminent organic psychiatrist, when I
was training in psychiatry, saying in relation to the varying contents to
delusions, that there was pathogenesis, the cause of the condition, and
pathoplasty, the variations in the individual make-up that led to the varied
forms that delusions took, but that delusions could be looked at entirely
from an organic perspective.
We kept the patient in hospital and treated him with antipsychotic medi-
cation and supportive team involvement. Three weeks later, when seeing
him for review, I found that my countertransference had completely changed.
I was able to think and feel warmly towards the patient with sympathy for his
current problems. Moreover, the delusion of the rat in his stomach had now
become full of meaning.
I was no longer thinking of it as a rat in his stomach but as his rattiness
that he could not stomach. The psychotic part of the mind cannot think; it can
only seek relief through acting as a muscular organ to evacuate the thinking
done by the non-psychotic part. It collects memories, Bion’s ideographs, for
the purpose of evacuating or communicating the problems it is encountering.
Here is a patient with chronic schizophrenia who is being moved into
independent accommodation and expected to cope on his own. The non-
psychotic part is troubled by this. The psychotic part deals with the rattiness
that it cannot stomach by concretely projecting it in the delusion of the rat
in his stomach. In Segal’s terms this is a symbolic equation, or in Bion’s
terms the formation of a bizarre object, where what has been projected,
and what has been projected into have become one and the same.
Since the patient’s aim was to disown his rattiness in order to avoid
having to think about it, it produced the countertransference response in
me of being unable to have any creative associations at the time. This also
accounts for the patient’s flattened and cold affect when he described having

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Utilising the countertransference in psychosis
the rat in his stomach, as the aim of the delusion was to obliterate all associ-
ated emotional feelings. However, at the same time the psychotic part could
be seen as aiming to communicate the patient’s problem by expressing it in
the form of a delusion, in order to seek help. Getting his state of mind into
others led to his admission.
When the patient felt more relaxed and contained on the ward, from
both medication and the team’s involvement, his need to project so con-
cretely receded. I then felt that I had the space to think in my own right and
I could appreciate the symbolic meaning of the delusion of the rat in his
stomach. Moreover, instead of being dominated by the projection of a cold
affect that flattened my sensitivities, I was now able to experience warm,
caring feelings. When I put it to the patient that he had been left on his
own and that what he wanted from us was active support, he expressed
appreciation for this understanding.

This case illustrates the central role that the countertransference plays
when relating to a patient’s delusional material. In an area where one
might be tempted to think that one’s own personal reactions are not
relevant, namely in an encounter with a patient in a severe psychotic
state, I hope that I have shown that paradoxically they are of the
utmost importance, and that we need constantly to note our reactions
and think about them, until we find an opportunity to use them in
the service of the patient’s needs.

Paralysis in the countertransference

The case of a young man of 23 with a diagnosis of schizophrenia was

presented for discussion at a fortnightly psychosis workshop I used to run
jointly with Dr Garelick, consultant psychotherapist at Claybury Hospital, for
professionals in training. The problem was that he remained in a persistently
disturbed state.
This young man was the eldest of three children. As a child he was
always seeking his mother’s attention and from adolescence was openly
aggressive to his father. On leaving school, he failed to settle into a job.
There was a strong psychosomatic theme to his childhood medical his-
tory. As a baby he had an operation for undescended testes and at age 11
he presented with tics and a squint. At 15 he had his ears pinned back and
at 17 had one eyebrow raised, both operations undergone for no good
reason, according to his mother.

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Tuning into the psychotic wavelength
He spent time in his teens in remand homes for petty crimes. Eventually,
after setting his clothes on fire, he had his first psychiatric admission at 18.
He had a series of short admissions in psychotic states, which at first were
thought to be drug induced. Later he was diagnosed as schizophrenic and
placed on depot antipsychotic medication.
He was persistently aggressive towards his father and disinhibited in his
behaviour towards his mother; he wanted to kiss her and talked continuously
of wanting sex with her. He was therefore sent to stay with his grandmother.
Increasingly disturbed behaviour with paranoia towards her neighbours
had led to the current admission.
After seven months on an acute ward he was transferred to a rehabilita-
tion villa. Following an initial settled period, he again became increasingly
disruptive. He was responding to voices, and kept absconding from the
home and returning, complaining by turns of being persecuted by the staff
and by his parents.
He had the delusion that he had a silver and silk lined scrotum that made
him attractive, and that he had a three-year-old son by his girlfriend whom
he wanted to give as a gift to his family. In reality, he had only a superficial
relationship with a girl in the rehabilitation villa.
He developed a belief that if his girlfriend sneezed, he would get better.
This later changed into a persistently held delusional belief that if one of the
doctors sneezed in his presence, he would be cured. As his paranoia and
thought disorder increased, his medication was changed to clozapine, the
drug of choice for the most intransigent cases of schizophrenia.
At this point the presentation of his history concluded and the case was
opened for discussion.

The workshop discussion

The presenting junior doctor was asked how he understood the situation. He
replied that it was a case of loss of ego boundaries in schizophrenia and the
treatment was clozapine.
He added that the patient’s mother colluded with him in referring to his
illness as ‘the sneeze’, because she was frightened of his anger. He also
reported that while the patient kept himself isolated, he worked very hard
in the hospital factory making crackers. Prior to this he used to deliver the
hospital post, but kept opening it to read! He also talked about joining
the army.
I felt that the problem was how to make contact with this patient beyond
just prescribing clozapine. It was necessary to stand up to his intimidating

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Utilising the countertransference in psychosis
behaviour but also to become involved with him and attempt to understand
the way his mind was working. His history showed that the patient had
found ways to disown his emotions by projecting into his body and request-
ing repeated operations. When this failed he then turned to petty crime and
drug taking. Finally he had resorted to projecting his desires and difficulties
more directly into others, ending up by tormenting his family.
The staff’s problem now was to find a way of thinking and helping the
patient to think when they were at the receiving end of such concrete projec-
tions. However, as Dr Garelick pointed out, there seemed to be something
more positive around now than previously with this patient. His hard work
in the hospital cracker factory suggested a movement towards reparative
attempts, in contrast to his earlier mindless destructiveness. Nevertheless, he
seemed to centre all his hopes on a quick cure through the doctor’s sneeze!

The doctor’s countertransference experience

Workshop members then asked the presenting junior doctor about his coun-
tertransference experience while he was with the patient. It emerged that
he and his senior registrar shared the same experience, namely that they
were both extremely worried about what might happen if they were to
sneeze in a session with the patient, fearing that this would have a cata-
strophic effect. Both doctors had become immobilised by the power of the
patient’s projections. They needed to be freed to think, and to feel comfort-
able about blowing their noses or sneezing in front of the patient!
In the ensuing discussion about the power and concreteness of the
patient’s projections, the presenting junior doctor recalled how the patient
had acquired a lock of his girlfriend’s hair and swallowed it, expressing a
wish for a magical merging with her through oral incorporation. This ideal-
ised incorporation led people to link this with his delusion of the special
attractive silver and silk scrotal lining.
The workshop seemed now to be freeing itself from concreteness to ask
further questions about the sneeze. It transpired that the patient’s phantasy
was that he would be enveloped by the sneeze which, through processes
of splitting and projection, would contain minute fragments of the other
person. Thus the patient would take in the other person, the doctor, and
identify and merge with them in an idealised identification.
Now the workshop members were in a position to fully understand the
doctors’ countertransference experience. The doctors feared that, if they
sneezed, they might lose their patient as potentially responsive by giving
him a magical cure. The fear was that the patient would then remain

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Tuning into the psychotic wavelength
forever in an inaccessible, mad, unthinking state that they would have been
responsible for producing.
Understanding their countertransference fears of sneezing helped to free
the doctors to think, enabling them to address the patient about his conflict-
ing wishes on the one hand to achieve an isolated omnipotent identification
and on the other hand to find a way of being with others as separate
supportive fellow human beings.

The case again illustrates the importance of paying careful attention

to the countertransference experience in attempting to overcome an
impasse, beyond relying solely on medication for the answer.

Doubt in the countertransference

Whenever we encounter a patient with delusions, we are likely to feel

doubts about the fairness of our reactions in judging his experience as
delusional. We oscillate in our minds between seeing the material as
straightforward and as pathological. We are likely to feel a tremendous
pressure to take the patient’s story at face value as we can then avoid
any uncomfortable feelings of chaos, madness and uncertainty. We all
hate to feel that we have lost our bearings. We have to constantly ask
ourselves whether we are hearing a straightforward communication
from the non-psychotic part of the patient’s personality or a rational-
isation from the psychotic part in denial about its disturbed state.
In these situations the way to move forward is through a full, open
discussion with the team and the carers to sort it out. Only when
dealing with psychotic states will one have the countertransference
experience of uncertainty about whether patients’ statements are
true or delusional, so this experience can be a clue to alert one to the
possibility of an underlying psychosis. Since patients are likely to deny
and rationalise their problems, one has to turn elsewhere to get
information as to the true state of affairs, whether from the nearest
relative or key worker. Problems occur when doctors are unable to
understand or accept the conflict inside themselves, which may lead
them to accept everything their patient says uncritically and discount
any different view expressed by the close relatives or professionals as
intolerant and prejudiced. This is particularly likely to occur at times
when decisions are being made about compulsory admissions or in
relation to tribunals making decisions about discharge.

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Utilising the countertransference in psychosis

A real danger can arise at hospital managers’ hearings, where mem-

bers are unable to accommodate the uncertainty engendered by the
patient’s communications because they lack the theoretical framework
that would enable them to differentiate between the psychotic and
non-psychotic parts, and rely on a solely logical legalistic approach.

A patient was brought into hospital by the police because he had behaved
aggressively and inappropriately to two total strangers, young women on a
bus. The police were called and decided that he was mentally ill, so brought
him straight to hospital and did not charge him. At first he was placed on
the locked ward, where he assaulted another patient and was also threaten-
ing to the nursing staff. He had only recently been transferred to the open
ward when he appealed against his detention. The staff felt that the assault
was a serious one and that the patient needed more time in hospital for
further careful assessment.
The manager’s hearing took the line that there was no legally demon-
strated proof that the patient had ever committed an offence in the com-
munity, since the police had never charged him, and in the absence of
such evidence his continued admission was not sustainable.

Occasionally, what might appear delusional may prove otherwise, so

we always need to keep an open mind.

A patient had been admitted the previous year in a florid and chaotic
psychotic state in a state of self-neglect, after a friend had alerted the
mental health team about her concerns. The patient was a woman from the
Far East who was living an isolated life in the UK. A year later, she had a
relapse that necessitated a further admission.
While she was clearly again in a bewildered florid psychotic state, she
reported that a tenant living in her place had been murdered. The junior
doctor was sufficiently questioning about this to phone the local police. At
first he received a negative response, but he was not convinced. When he
persisted further, he found out that indeed a tenant had been murdered
and his torso dismembered.
When this was discussed with the patient, her response was dismissive.
She showed a complete lack of interest in this extraordinary event.
Apparently the tenant had occupied a downstairs room in her place. She
showed no curiosity at all about when it had occurred, saying she was
upstairs at the time praying in her temple. When asked how the murder
had been discovered, apparently the next day through a broken window,

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Tuning into the psychotic wavelength
she again showed no interest, dismissively saying that she had been pray-
ing at an outside temple.
Even though the murder actually occurred and was not a delusion, the
patient’s total lack of interest in an event that anyone in a non-psychotic
state of mind would have shown some curiosity about was quite extraordin-
ary and indicative of the capacity of the psychotic part of the mind to
annihilate curiosity.

Humour, humanity and perseverance

Humour is an important means by which we can communicate a

common interest and involvement, and links with humanity and car-
ing. Other involved professionals may share in the humour, where a
common sense of purpose is present. For humour to occur one needs
to have been able to separate oneself out to think independently.
Humour is impossible when one feels overwhelmed by psychotic
projections that obliterate difference.
In a personal communication, Ronald Britton summarised the
role of humour:

I seriously think ‘Don’t take yourself too seriously’ implies a third

position.

In other words, humour enables one to step aside from the intensity of
involvement in the transference/countertransference situation, adopt-
ing the third position in a reflective parental role. The patient may
move into the third position with you, for example when my patient
on admission said that he was God’s older brother, but smiled and
joined me in the reflective position, when I said that he must have been
really pissed off with his younger brother getting all the publicity!
The message to the patient is ‘Don’t take yourself too seriously’,
meaning do not become too dogmatic in your assertions. In fact, the
patient who asserted he was God’s older brother remained very con-
trolling and pedantic in his way of talking when our paths crossed
again many years later.
In severe psychotic states, where the patient persistently presents
in an overwhelmingly concrete fashion, humour and reflectiveness
can still have a place among the staff. When dealing on a daily basis
with severe psychotic states, humour represents a countertransference

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Utilising the countertransference in psychosis

response of interest, self-belief and survival. It is an implicit statement

that one has preserved and supported one’s own separate viewpoint.
Humour is linked to an appreciation of the power and complexity
of the underlying psychopathology and provides us with a means of
sharing this appreciation with others, who are also involved in a situ-
ation where they are seemingly faced with overwhelming odds and
yet surviving them.
The following serve as clinical illustrations.

An ‘intermittent explosive disorder’

I was asked to go abroad to give a talk to an organisation that special-
ised in early intervention services in psychosis. They indicated that
their priority was a presentation of the latest statistics around such
services in the UK, rather than a dynamic understanding, so I had to
amend my original presentation, and went to the meeting with some
apprehension. However, when I arrived, somewhat contradictorily,
they now said that they were much more interested in what I person-
ally had to say. I was still concerned that the meaning of whatever
I said might become lost in translation.

I was made most welcome and well received at the conference. In the
afternoon, a young doctor, a member of an early psychosis intervention
team, presented a case that was giving him problems. The set-up of the
service was similar to the UK, where patients are followed weekly by
the team for two to three years.
The patient was a man in his early thirties who had never left home. He
developed paranoid beliefs that he was being followed and watched, for
which he sought help. He had been placed on antipsychotic medication by
the early onset service and delegated for supervised individual sessions to
the young doctor. The doctor described how the patient was not forthcom-
ing in the first year, but in the second didn’t seem to stop talking.
The patient had said to the therapist, ‘I don’t suffer from schizophrenia
but an intermittent explosive disorder!’ The history was that prior to becom-
ing troubled by his paranoid state, he had for the first time in his life had a
brief relationship with a woman. He described sex as boring. His sister was
now trying to get him involved with a female friend of hers to encourage
another relationship.
The challenge was to find something to say to help the doctor out of an
impasse in which he felt impotent. The shared humour was to realise that the

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Tuning into the psychotic wavelength
patient was quite right in what he was saying about having ‘an intermittent
explosiveness disorder’, even if his insight was very limited.
He was right that he did not suffer from schizophrenia; rather, he had an
affective disorder dominated by a severe ego-destructive superego that had
prevented him from separating from the parental home and developing a
mind and life of his own. Only in his thirties was he beginning to show
some signs of change, which were noted and encouraged by his sister.
Of course any sign of movement stimulated an envious backlash from
his superego, leading to his experiences of being watched and followed.
For the first time, recently, he reported that he had had two very minor
temper tantrums. While most of us may have emotional outbursts as every-
day occurrences, for him these felt very unusual, and led to his self-diagnosis
as having an intermittent explosive disorder.
This discussion helped to free the doctor from regarding the patient as
having a paranoid schizophrenic disorder, which had made him feel that he
could only be a passive listener unsure of what to say, and enabled him to
consider adopting the role of an auxiliary superego supporting the patient’s
developmental growth. In this context, one would agree with the patient
about the correctness of his self-diagnosis, while pointing out that the explo-
siveness is in fact a manifestation of health to be encouraged, not stifled.

Having survived the initial pressures around the presentation, the

doctor, the involved audience and I had arrived at an understanding
that enabled us to experience a shared humour over the interesting
way the patient presented his problems through his self-diagnosis.

The broken alarm clock

A penalty of involvement with psychosis is that one is constantly
liable to be misunderstood. The doctor may be tuning into the
psychotic wavelength as the priority, while others who do not
appreciate the need for this may complain that the way he is talking to
the patient shows a lack of sensitivity to their feelings.

Many years ago I was asked to attend another event abroad in which as
well as giving a talk, I would be involved in a case discussion. The case
history was to be presented by the psychologist who saw the patient to be
discussed. Apparently the patient, who was seen in his group home, had
disrobed in a recent session, upsetting the psychologist, who then did not
attend the event as he was reported to be unwell.

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Utilising the countertransference in psychosis
The plan was changed for the patient alone to come, with the group
home manager to attend and provide the background history, and for me
then to interview the patient. I learned from the group home manager that
the patient suffered from a recurrent schizo-affective disorder and if he
stopped his medication, he would become increasingly disturbed and very
difficult to contain in the group home setting. However, there were very
few hospital beds available, as the government policy was that most
patients with psychotic disorders were to be managed in group homes.
Recently the patient not only had stopped his antipsychotic medication,
but also was diabetic and was being inconsistent about taking his insulin.
When I saw the patient he presented in a quite relaxed state. He said that he
spent his days going to the library. He had been up all last night preparing
what he would be saying to me. He talked at some length about how in
his adolescence he had spent some time in Australia with his mother, and
waxed lyrical about the particular texture of the leaves of the eucalyptus
tree. His group home manager had warned me that this was what he tended
to do. The patient then said that he did not have any problems apart from
the fact that his alarm clock had broken, so that he needed someone to
wake him in the morning.
I saw the situation as a crisis in which the group home manager needed
to be listened to and given support. The psychotic part of the patient had
gained the upper hand, so that he was disruptive of his sessions with the
psychologist, unreliable with his insulin injections and failing to take his
antipsychotic medication. The psychotic part had been up all night acting
as a lawyer preparing for his appearance in court the next day to present
his case to me. There was only one glimmer of hope in the patient’s disown-
ing of the insight arrived at by the non-psychotic part, that he was in an
alarming state which he was trying to ignore. The presence of this insight
was indicated by his referral to the broken alarm clock, by means of which
he suggested that others would need to awaken him to the true state of
affairs and stand up to the psychotic part of his personality to prevent
him losing his place in the group home. He had been there for a few years
and valued it.
I put all this to him, and emphasised the importance of his cooperation
with the group home manager, if he wasn’t to relapse and lose his place-
ment. This was a situation where it was necessary to confront the psychotic
part when it was getting out of hand. The group home manager was very
grateful for my intervention and support, and could appreciate the humour
and symbolic meaning in the patient’s statement that he was perfectly fine
apart from his alarm clock being broken.

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Tuning into the psychotic wavelength
Unfortunately, the people who had invited me to the day event and to
interview the patient did not see the situation from this perspective. They
were especially doubtful about the need to confront the patient and regarded
the patient as too cognitively impaired to understand the symbolic meaning
to the alarm clock. They had expected me to be non-challenging, and more
uncritically accepting of the material that the patient chose to bring and to
become involved in an exploration of his references to the eucalyptus leaves
and their association to his feelings about his mother. They were unhappy
with my view that there was something that felt quite perverse, slippery
and triumphant about the way the patient brought this well-worn story,
which to me seemed to cover up the danger of an imminent relapse.

While establishing an empathic understanding of the reality of suffer-

ing from schizophrenia is important in building up a relationship with
a patient, and at times it is important to accept that psychopatho-
logical symptoms can be protective against the threat of disintegration
(Thorgaard and Rosenbaum 2006), at other times, as this case illus-
trates, one has to stand up to the psychotic part to try to forestall a
more serious relapse.

Summary

Historically speaking psychoanalysts have remained wary about mak-

ing use of their countertransference. While exploring the counter-
transference can facilitate increased sensitivity and empathy, if not first
carefully thought through it can lead to inappropriate acting out by the
analyst or to blaming the patient for one’s own lack of understanding.
However, paradoxically, in psychosis where one initially can feel
quite bewildered by the presented material, countertransference
experience remains one of the most important and essential tools
in reaching an understanding of delusional content. This is because
the main defence against the awareness of psychic pain is projection of
this by the psychotic part. The awareness is disowned into objects to
create delusions and into caring people to create their countertrans-
ference feelings. With delusions, unlike with dreams, we cannot ask
the patient for associations but have to undertake the reconstruction
work ourselves on their behalf.
The clinician’s countertransference feelings will mirror the patient’s
state of mind. If they have projected feelings that they have experi-

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Utilising the countertransference in psychosis

enced as totally unbearable and have murderously attacked, then the

clinician’s mind will be affected so that he or she feels deskilled,
unable to think or have constructive associations. If the projection
becomes less intense and the aspect of the patient that wants help has
more room to emerge, then one may start to develop constructive
associations.
As we are always dealing with two parts of the personality, a com-
mon countertransference feeling is doubt about whether to believe
that a communication is a statement of fact or the attempted rational-
isation of a delusion. Feeling that we are faced with this conundrum
can sometimes be a useful sign alerting us that we are in the presence
of a major psychotic disorder, since such countertransference feelings
are not typically encountered in the same way in borderline states
or neurotic disorders.
Finally humour, linked with the interest aroused through sharing
of countertransference experiences with involved staff, is important
in maintaining interest and combating burnout when working in
very demanding situations.

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PA RT F O U R

The Psychotic Wavelength in

Affective Disorder s
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14
Why the cycle in a clinical psychosis?
A psychoanalytic per spective on recur rent
manic depressive psychosis

Introduction

The opportunities for psychoanalytic study of manic depressive

psychosis have become more limited since the closure of the specialist
analytically orientated inpatient units in the NHS and the changes
at Chestnut Lodge in the United States.4 In this chapter, I discuss the
case of a patient with recurrent manic depressive psychosis, who was
followed in the NHS over a fifteen-year period. Both past and more
recent contributions from the analytic literature are reviewed for the
light they shed on this clinical material and the condition in general.
Based on the case study, an explanation for the repetitive nature of the
psychosis is suggested.
At the beginning of the twentieth century, Kraepelin divided
major psychotic disorders into the organic and the functional. In
the latter category he included dementia praecox (schizophrenia)
and manic depressive psychosis. Kraepelin viewed manic depressive
psychosis as a biological derangement, though he thought that in
some cases psychological factors might act as precipitants. Kraepelin
wrote, ‘The real cause for the malady must be sought in permanent
changes which are very often, perhaps always innate’ (Kraepelin 1921,
p. 180).
The psychopathology of manic depressive psychosis can seem to
have ‘a life of its own’. Recurrent manic depressive psychosis can pro-
duce unpredictable violent and destructive behaviour, especially dur-
ing the manic phases, requiring extensive periods of hospitalisation.

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The psychotic wavelength in affective disorders

There are very few case reports in the literature of analytic follow-up
of recurrent manic depressive states over an extended period of time.
Perhaps this can be explained, not only by the difficulty posed by
the patient’s psychopathology, but also the need for institutional back-
up facilities. Indeed Fenichel (1946, p. 414) wrote: ‘the most extensive
planned psychoanalytical study of the manic-depressive disorders,
needed for the benefit of the patient and for the benefit of science,
must be undertaken within the institutions’. The situation has not
been helped over the years by the closure of the specialist analytically
orientated inpatient units in the UK, at the Maudsley and Shenley
hospitals (Freeman 1988; Jackson and Williams 1994), and the pressure
for change at Chestnut Lodge in the United States (Silver 1997).
When I started work as a general psychiatrist, I decided that I
wanted to see a patient analytically in the health service, with a disorder
that I would not expect to see in my private practice. I was curious to
learn more about the disorder through analysis, and wanted to apply
any general understanding I gained to the non-analytic patients, as well
as sharing any insights with my nursing and medical staff.
One might have expected that singling out one patient for analytic
treatment would lead to resentment among the staff, as creating a
special situation. However, because my analytic involvement was seen
as part of a regular commitment to the unit, tensions did not arise.
Murray Jackson (1989) reported a similar experience when giving
analytic psychotherapy to a manic depressive patient.
I chose this particular patient because, at the time, her husband was
supportive of an analytic approach, rather than a continued physical
one. I had been impressed that during a period when she had been in
hospital in a severely withdrawn state, her husband did not want her
to have ECT, but to stay with the depression. When he expressed this
view, she started to improve.
From my contact with her, I came to appreciate many features
particular to recurrent manic depressive states. I will present the clin-
ical material before considering the overall psychopathology in the
context of the background psychoanalytic literature.

Background history

Mrs J, now in her late forties, was brought up in the East End of London, part
of an extended working-class family group. Her mother suffered from severe

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Why the cycle in a clinical psychosis?
depression and was agoraphobic, but was never hospitalised. As a child,
her mother was reported to have been very busy, with little time for her,
and Mrs J was said to have sat silently for hours on her own, described as
‘a miserable kid but mother’s favourite’. Her father thought that children
should be seen and not heard. Mrs J had a brother three years older than
her, who was said to be mildly delinquent as a child, and was admired for
this by his mother. Her mother had a stillbirth when Mrs J was 11. Through-
out her adolescence her mother remained very controlling and was not to
be contradicted.
Mrs J married a man from a similar working-class background, whose
father had left home when Mr J was very young. Mrs J has two children, who
have now grown up and left home.
Two years after the birth of her daughter, Mrs J moved from the East End
to North London. At times Mrs J complained of feeling isolated from her
background, though her new neighbours provided some support and did
not ostracise her because of her illness. At times she has attended our psy-
chiatric day hospital, which is adjacent to the outpatients’ department
where I saw her for sessions. The staff and day patients over the years have
become somewhat like an extended family for her.

Psychiatric history

Mrs J had her first breakdown in 1970 aged 23. She was admitted to
hospital in an agitated state several weeks after the birth of her first child.
During the analysis, she described what had gone through her mind at the
time. She had developed the delusion that her daughter, who reminded her
of her mother’s stillbirth, was too beautiful to live. She had to fight an impulse
to kill her daughter, finally cutting her own wrists. When Mrs J did not die,
she went to the neighbours, was admitted to hospital and given ECT.
From my experience with this patient, as well as other cases of puerperal
psychosis, I think that the baby daughter represented her individuality,
whose separateness could not be tolerated by another part of herself, which
was identified with an extremely narcissistic mother figure (see Chapter 15).
In real life she was always supportive of her children’s needs, in contrast to
a markedly self-depriving attitude.
Five years later, she was again admitted with depression and treated
with ECT. This admission took place a year after the birth of her son. The
precipitant was a police inquiry at her husband’s place of work. Since
marrying, she had become totally reliant on her husband and was terrified

189
The psychotic wavelength in affective disorders
that he would be taken away. From that time on she became dominated by
an obsession with keeping the house tidy.
In 1980, 1981 and 1982 she had further hospital admissions for
depression, and was treated each time with antidepressant medication.
In December 1982, arrangements were made for her to start analysis in
January 1983. In January she had her first admission in a hypomanic state.
Since then, she has had yearly admissions, always in a hypomanic state,
lasting from three to five months, until the last three years.
During her admissions, she was given major tranquillisers as necessary,
the prescribing responsibility left to the ward doctor. Since 1992, she has
been on lithium, taken in therapeutic doses, but this did not have any
immediate impact on her admissions pattern.
It was striking that all her admissions prior to analysis were for depres-
sion, and since for hypomania. She had had periods of hypomania prior
to analysis, but they had not been severe enough to require hospitalisation.
The daily analytic support given during early protracted depressive
phases meant that these could now be contained in the outpatient setting,
but analytic intervention seemed to increase the length and severity of the
manic phases of Mrs J’s illness.

Analysis

Onset

The analysis began in a dramatic and unexpected way. The day she was due
to start analysis, Mrs J presented in a hypomanic state requiring immediate
hospitalisation. The day before admission, her husband had been quarrel-
ling with his mother. Mrs J then heard a man’s voice over her husband’s CB
radio calling her a whore, a prostitute and a Greek lover (it did not strike me
at the time that Lucas is a common Greek name). She replied to the man’s
voice, saying that he should not talk like that in front of the children, and that
she would meet him the next day at the local shopping green.
When she went next day to the green, she felt she was being followed
and that she was going to be robbed. She then found herself going to the
bank and opening a new account in her name. During the day she grew
more and more hysterical and in the evening her husband took her into
hospital. On arrival, she was convinced that he was the upset one who was
going to be admitted, as he had fallen out with his mother. She thought that
he had said to her, ‘It’s all right for you, you’ve got Dr Lucas’.

190
Why the cycle in a clinical psychosis?
Looking back on this, I feel that she was reacting excitedly to the opening
of a new account which the analysis provided, while her fear that it might
expose her problematic relationship with her mother was disowned and
located in her husband.
This initially hypomanic period lasted three months. She was far too
restless ever to sit still in sessions. She spent a lot of time watering plants,
and relating excitedly to other patients, often unable to control herself sexu-
ally. Towards the end, she expressed anxiety about lapsing back into
depression if she could not keep up the mania, like Cinderella returning
from the ball. Despite many different types of interpretation, her manic state
seemed to have a life of its own. Eventually she returned to a depressive
state, and became an outpatient.

Depressive phases

In the ensuing sessions, in the first depressive phase, she sat in a chair,
hardly moving and deathly pale, as if drained of all vitality. She stared
ahead blankly. At times she would stare out of the window as if she was
evacuating her aliveness through her eyes, and I would feel as though there
was no one left in the room to talk to.
Anything I said felt like trying to conjure something out of nothing, and I
thought to myself that other analysts would not put themselves in this situ-
ation, as it seemed so hopeless. To get any response, I had to ask her what
was on her mind. Her replies were very pertinent, but the way she spoke
had a deadening and distancing quality. For example, one comment she
made was that she sat in a similar state at home, staring blankly at the
television screen, and her husband was irritated by his inability to make
contact with her. My attempt to interest her in what she had just said was
greeted by silence. I felt that she only spoke because I asked her questions,
as though she was still obeying her father’s principle that children should
only speak when spoken to. At one point she wondered why I put up with
her, describing herself as a stuffed dummy. I felt that we were re-enacting
a deadly feeding situation in which she was tremendously passive and
could not criticise anything that I gave her. When I pointed this out to her,
she said that friends had commented that she said nothing and kept herself
hidden. This reply may sound misleadingly responsive; my dominating
feeling was that I was having no impact on her.
Mrs J remained silent in sessions for months on end, unless I asked her
what was on her mind. In the midst of this aridity, I was surprised when she

191
The psychotic wavelength in affective disorders
reported an isolated dream, which seemed like an unexpected ray of hope.
In her dream, it was my birthday, and I was being given the bumps; she had
a larger house and both old and new acquaintances were present. I hoped
that the dream indicated a celebration of my presence offering a larger
place for her feelings. She rarely brought dreams, so it was interesting that a
few years later, again in the midst of an arid depressive phase, she reported
a similar dream, except that now it was her birthday. I hoped that this
indicated a shift of an alive focus into herself, though objectively I had no
external evidence for this movement.
The pattern of sessions in the depressive phases remained the same over
the years. Sessions started with a few quick sentences, very hard to catch,
followed by silence. This pattern mirrored her behaviour at home, when
every morning she would get up at 6 a.m. to clear everything away in a
panic, and then sit still.
I had drawn attention many times to the quick way she started sessions,
followed by silence, yet the pattern persisted. She then often would not say
anything else unless I asked her what was on her mind. Then she would say
something directly related to her state, for example, describing how her
daughter was frightened of visiting her grandmother (Mrs J’s mother) as she
was such a jealous and possessive person.
I formed the impression that as a result of the analysis, Mrs J was becom-
ing conscious of what went on in the depressive phase, commenting, for
instance, that she seemed to drain away her own aliveness. Yet the pattern
persisted in which I would try to catch, rescue and enliven whatever she had
said in her deadly dismissive way. When she then once asked me if she
would ever change, I felt I could not find any evidence within myself at the
time for an optimistic reply.
I felt that Mrs J was clinging on to an identification with an all-powerful
mother figure, resistant to change out of both fear and obstinacy. She
had become the all-powerful mother and I the helpless child. At times she
became tight-lipped when I addressed her, as if she was actively refusing to
take in food. This tight-lipped mannerism is something I have often since
noticed with psychotically depressed patients in hospital, who refuse to
acknowledge their needy state.
In the depressive phases of her illness, Mrs J had nothing good what-
soever to say about herself. She became socially crippled with agora-
phobia and imagined that other people were unremittingly critical of her
appearance and behaviour. Sometimes her obsessional preoccupations
with tidying the house increased prior to her manic eruptions, although the
suddenness of the change to hypomania always took me unawares.

192
Why the cycle in a clinical psychosis?
At times, in the depressive phase, Mrs J talked more openly, but I still felt
that what I would call, in shorthand, ‘the deadening dynamic’ was ever
present. It was this self-suppressing quality that seemed to make an eruption
into another manic episode inevitable.

Manic phases

The first feature I would like to emphasise was the feeling of helplessness
engendered by the autonomy and strength of the manic process. By the time
of the third manic episode, Mrs J likened its start to an out-of-control period
and said, ‘This time my mania needs to be faced and worked at’. My ward
registrar noticed how desperately she tried to stop it progressing.
At the onset of the fourth manic episode, she had a dream of a Roman
orgy in which she was both a participator and an onlooker, not liking what
she was seeing but helpless to stop it. I also felt like a helpless onlooker.
In the first four manic episodes, I felt that the dominating purpose was to
triumph over me and anything that I said. Towards the end of the second
manic episode, she said in a triumphant voice, ‘Isn’t it about time that
you gave up?’ I felt a dreadful despair, akin to the feelings I have already
described, when Mrs J deadened and distanced herself in the depressive
phase. These triumphantly deadening forces came across as a powerful,
highly organised structure in her personality, along the lines described by
Leslie Sohn in his paper on the narcissistic identificate (Sohn 1985b; see
also Chapter 15). However, by the time of Mrs J’s fifth manic episode, I was
hoping that some change might have occurred. Although she was still
extremely overactive, for the first time she was able to stay in her chair
during sessions, and started to talk in a more concerned way.
At the onset of this manic episode, she recounted a dream in which the
hospital was closing (it was in fact scheduled for closure) and I was leaving,
and she said to me, ‘What about myself?’ She thought that the dream
showed evidence of self-concern, and she contrasted it with what she called
‘her usual sadistic dreams’ when hypomanic. By this, she explained she
meant dreams she had experienced in which she was being stabbed in the
chest or penetrated anally by a hot poker.
She also started to express gratitude openly for the analysis, saying, ‘I
know you may not think it, but I do take in what you say. You must think I am
worthwhile and are trying to help me see this’. She also thanked me for
persevering with her, saying ‘I am not an easy person, you know’, and
added that she felt ‘more worthwhile now as a person’.

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The psychotic wavelength in affective disorders
On the ward, she made an interesting statement to the nursing staff. She
said that on previous admissions, when high, she felt as though she was
behaving like a call-girl and so should have been paid for it. She now saw
that this was not the way forward and said, ‘I may as well work as a pimp
for Dr Lucas – be Dick’s angel’. She said that she would leave her husband
and marry Dr Lucas, but then checked herself, and said that her husband
was OK, and that she would marry Dr Lucas when her husband died.
I felt that she might be giving some recognition to the analysis, and her
husband’s supportiveness, as well as more openly expressing her hatred of
this dependency, ‘being a pimp for Dr Lucas’. However, when she started
to talk of her analysis in idealised terms at home, her daughter’s reported
response was, ‘Well, if Dr Lucas is so fucking good, why do you keep going
back into hospital?’
I think that Mrs J’s daughter’s view was more realistic than my hope that
change was beginning to materialise, although for a short while after the
fifth manic episode abated, things did look more hopeful.

A brief more accessible period

Following the fifth manic phase, there was a short period of about a week in
which Mrs J appeared more open to considering her state. She reported a
dream in which she had had another baby and found herself saying, ‘This
time I am going to have to support the baby if I’m not to go back to hospital’.
I felt that the dream represented the central problem of her need to
look after herself as represented by the baby, rather than flatten her own
individuality and resubmit herself to an internal tyrannical mother figure.
I pointed this out to her.
Her response was that she was afraid that her husband and son were
going to be mugged. They had recently objected to spending time at her
mother’s, as she was so domineering. She then recalled a recurrent child-
hood fear when she went to school, that not only her parents but also the
house would have vanished when she returned home. I felt all this indicated
her dire fear of deviating from total submission to the internal mother figure
for fear of losing everything.
For a few days she continued to be responsive to what I said, making me
feel more hopeful, but this did not last long. She then reverted, in a more
determined way than ever, to obliterating herself. This was evidenced by
heightened obsessionality in the house, washing and ironing excessively,
as if she was trying to wash herself away. One night this process reached a

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Why the cycle in a clinical psychosis?
crescendo when she entertained active suicidal thoughts of going to drown
herself, there and then, in a nearby canal, because she was unable to iron
all the creases out of her sheets.
By this time, Mrs J was talking in an alarmingly cold and deadly manner
about the possibility of committing suicide. Somehow we seemed to survive
this phase and her manner became warmer again. However, it was interest-
ing that by this point she had no recollection of her dream about the need to
look after the baby. This episode seemed to illustrate how anything positive
that seemed to be struggling to get itself established could be swept away
by the presence of well-organised negating forces, bringing us back to the
manic depressive cycle repeating itself.

Later manic episodes

Instead of lessening in intensity, Mrs J’s last two manic episodes increased in
severity. She became quite aggressive and defiant, setting off fire alarms,
and finally, in her last major admission she had to be sectioned for the first
time. Her husband became quite disheartened, saying that he thought he
would stick by her but nothing he did made any difference. I felt the same
way. The last session before a summer break was typical of her state then.
She came in and pulled up her dress to reveal shorts. She talked in a manic,
very fast, controlling way.
I pointed out how dismissive she had been in the previous session about
those who cared about her, her husband, me, the ward staff, etc. She then
turned on me saying, ‘I’ve got VD, AIDS. I’m going to fuck you with it!’ I said
that she wanted to attack and fuck my mind and her memory in me, so that
she could keep a manic mindless state going which allowed no room for
caring for herself.
She opened her bag and threw the contents on the floor. She picked
out her lipstick and brush and said this is Ann (the caring ward domestic)
and this is Joan (the caring ward sister), naming them. I pointed out her
conflicting states of mind, on the one hand dismissing those that cared about
her and on the other hand recognising them. She said, ‘Quite right!’
She then walked around the room in an intimidatory manner, telling me to
shut up.
I reminded her that before I had sectioned her she had said that I did not
have the balls to do it. I said that it was important she felt that I had the balls
to stand up to her mania and not be intimidated. I felt both her contempt and
my impotence. In the countertransference, while talking, I felt as if I was mad

195
The psychotic wavelength in affective disorders
to be trying to create some understanding in the face of a hurricane. Yet I
also felt unimpressed with her mania and her attempts to fault me and make
me feel guilty.
She then looked sidelong at me in a would-be flirtatious manner and
said, ‘I only did it for you’. I pointed out that having got rid of her memory
and sanity by projecting them into me, and fucking my mind with mental VD
and AIDS, she could then recreate a relationship with me in any way she
chose.
At the end of the session, I helped pick up her bits and pieces from the
floor. It felt as though we were trying to put her mind back together by
picking up the scattered contents of her bag. As she left she said, ‘I only did
it for you, as it’s not yours’. I was left to speculate on the meaning of the
abortion that she seemed to be implying.
Another version of abortion was in evidence later in that admission,
when at the height of her manic disturbance, for the first time, she required
nursing on the locked ward. She was in a terrible state. Openly defiant, she
said that ‘her friends’, a known group of psychopathic hospital patients,
would get her out. I pointed out, with feeling, that she appeared to have lost
all contact with those that really cared about her such as myself and her
husband. I told her that her wishes for a better life seemed to be in danger of
being swept aside by her mania if no one spoke up for them.
She appeared visibly moved by this intervention, which I made at the end
of the session. She said ‘thank you’ as she left, and it felt genuine. However,
after leaving the room, she stuck her head round the door and said, ‘but no
thanks!’ At the onset of the last, severest and most protracted of her manic
episodes, she had said, ‘I’ll go on like this forever and there is nothing that
you or anyone else can do about it’. This statement felt real and convincing.
The outlook then seemed very bleak indeed.

The last few years

Paradoxically, Mrs J’s state improved significantly after that last hypomanic
episode. For three years there were no further hospital admissions, and then
only a brief admission lasting one week, following a summer break when
she had exhausted herself helping her daughter with her new baby.
She was aware of her exhaustion and that it followed being of help to her
daughter. It seemed that the build-up of resentment that preceded the past
protracted manic episodes was missing this time.
One can only speculate on the reasons for the seeming improvement.

196
Why the cycle in a clinical psychosis?
Some might say that lithium was a factor, yet she had been taking it consist-
ently for six years.
After the last major admission, her mother died. She was herself sur-
prised by the absence of a bereavement reaction. It was striking that
her elderly father, now freed from looking after the mother, would come
around to Mrs J’s house and constantly criticise her housework. His
behaviour seemed to mirror Mrs J’s primitive superego, whose commands
she would obey, when in the past she had been driven obsessively to clean
the house.
She is now no longer obsessional about cleaning and is, in her own
words, ‘deriving much contentment’ from how well her children have
developed despite all her own problems.
We can now enjoy reflective work together in her sessions. She no longer
seems to need to evacuate her feelings as soon as she becomes aware of
them. Perhaps, after all this time, analysis has helped in the growth of good
object relationships. However, it was not so very long ago that I felt no hope
that such a state of affairs would ever materialise. This may illustrate that
with major psychotic disorders, one has to be prepared to persist, over
many years, with a very uncertain outcome and accept the possibility that
there may be no tangible reward for the effort. However, the experience of
working with a patient like Mrs J may stimulate many reflections that can be
applied to understanding in one’s everyday psychiatric practice.

Discussion
In ‘Mourning and melancholia’, Freud (1917) understood mania as
a state where the emotional energy that had been bound in the painful
suffering of melancholia became available once the ego had got over
the object loss. The excess energy liberated caused the manic patient
to act ‘like a ravenously hungry man seeking new object cathexes’.
In ‘Group psychology and the analysis of the ego’ (Freud 1921),
mania was seen as a temporary escape from the ego ideal. This was
reflected in society by our need for organised festivals such as the
Romans’ Saturnalia (illustrated in my patient by her Roman orgy
dream).
Abraham (1924) viewed mania as the ego throwing off the yoke of
the superego by merging with it. Like Freud, he emphasised the oral
roots of the psychopathology. Later writers, such as Rado (1928) and
Lewin (1951), also emphasised that the aim of mania was a narcissistic
fusion with the feeding breast.

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The psychotic wavelength in affective disorders

In an earlier paper Abraham (1911) suggested that mania occurred

when an individual’s depression was no longer able to withstand the
assault of repressed instincts. Like Freud and later Klein, Abraham
stressed the dominance of obsessional mechanisms, and emphasised
that the mania occurred when these failed.
Abraham thought that a ‘free period’ between the manic and
depressive states was the most propitious time to start analysis. He
wrote:

in those patients who have prolonged free intervals between their

manic or depressive attacks, psychoanalysis should be begun during
that free period. The advantage is obvious, for analysis cannot be
carried out in severely inhibited melancholic patients or inattentive
manic ones.
(Abraham 1911, p. 156)

The validity of this concept needs questioning. With my patient, there

were no free periods. In the depressive phase, at times, superficial
contact with the patient could deceive one into believing that the
underlying pathological state of affairs was not in operation. In other
cases, a patient may be so identified or fused with an omniscient
internal mother that they appear calm and settled. A general psychi-
atric mental state examination may mislead the clinician into regard-
ing them as ‘normal’ and ‘free from pathology’. Clinically it proves
extremely difficult to make analytic contact with a manic depressive
patient at any time. They are never ‘free’ from their underlying psy-
chopathology and, in that sense, there can be no ‘free period’.
Klein drew attention to the clinging to pathological object rela-
tionships that occurs in manic depressive states. The early superego,
due to splitting processes, is extremely moral and exciting. The indi-
vidual clings to this superego because ‘the idea of perfection is so
compelling as it disproves the idea of disintegration. The problem
of dependence and identification is too profound to be renounced’
(M. Klein 1935, p. 271).
In her 1940 paper, Klein contrasted manic depressive states with
mourning, noting that individuals who suffered from the former had
been unable to establish their good objects and so felt insecure in their
inner world (my patient had a recurrent childhood fear that the house
would have gone when she returned from school).
Segal described in detail two central Kleinian concepts, that of the

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Why the cycle in a clinical psychosis?

manic defence and manic reparation. The manic defence was based
on the omnipotent denial of psychic reality, in order to defend against
underlying persecutory and depressive feelings. It is characterised by
triumph, control and contempt.
Manic reparation is to be distinguished from reparation proper. It is
based on omnipotent control of the object and is paramount when
love and concern, the hallmarks of genuine reparation, are weak
(Segal 1973b, 1981d).
Rey added a new dimension to our understanding of manic states.
In depression, the maternal breast, as part-object, represented the des-
troyed mother, and through identification, the subject felt depressed.
In contrast, in manic states, the identification was with the penis as the
object of reparation, with a magical ability to recreate the mother’s
attacked babies and breasts; that is through a phantasy of making her
pregnant and refilling her empty breasts with milk (Rey 1994a).
However in the manic state, Rey argued that this identification is
with a pseudo-penis that repairs nothing. It denies the reality of the
destroyed objects, presenting itself as the universal substitute, while
the aggressive impulses continue to destroy the object. As no repara-
tion proper took place in the manic phase, the subject inevitably
returned to his depression at the level of maturation previously
reached, and so the cycle would repeat itself.
Rey saw the breast and penis as part-object prototypes representa-
tive of mother and father. The role of the penis was to integrate and
repair. Manic reactions were seen as a pathological deviation, where
there was identification with an immeasurably grandiose aspect of
the erect penis. One might also add that the primary relationship
was to a grandiose aspect of the breast, linked with the mother’s
underlying narcissistic personality structure. So manic mechanisms
can be seen to predominate, whether the patient is in the depressive or
manic phase.
Other authors have stressed the presence also of the ‘life instinct’ in
mania. H. S. Klein from his analytic experience with a young manic
patient commented, ‘technically it is extremely important to realise
that what may appear to be aggressive behaviour on the part of the
patient is due in fact to the very intensity of his life instincts’ (H. S.
Klein 1974, p. 267).
In the depressive phase, H. S. Klein noted that his patient was
projecting his aliveness into his analyst, which could have been for a
variety of reasons. The wish to be alone with the severe omnipotent

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The psychotic wavelength in affective disorders

superego meant a need to distance oneself from a thinking part and

the associated container-analyst. He also felt that the aliveness might
have been projected into the analyst for safekeeping under the threat
of retaliation from the murderously severe superego.
Patients may vary in their degree of resistance to change and some
authors have written positively of the effects of analysis in manic
depressive states (Jackson 1989; Rey 1994a). However, the resistance
to change in a psychotic patient has a particularly organised quality,
related to the functioning of the psychotic part of the personality
(Bion 1957a). The psychotic part of the personality functions quite
differently from the non-psychotic part. It is intolerant of frustration,
and uses projective mechanisms as a substitute for thinking. The
resulting emptiness is replaced by identification with an omnipotent
and omniscient internal mother figure.
Bion wrote: ‘I do not think real progress with psychotic patients
is likely to take place until due weight is given to the nature of the
divergence between the psychotic and non-psychotic personalities’.
In their work at the Willesden Centre, Sinason (1993) and Richards
(1993) have formulated this in terms of an internal cohabitee. In a
truly major psychotic disorder, one would expect the psychotic part
of the personality to predominate.
If, as a result of analytic intervention, the non-psychotic personality
gets stronger and becomes increasingly able to think and resist the
psychotic part’s attempt to evacuate its thoughts, then a conflict may
result. The psychotic part finds itself in envious rivalry with this
development and may try to prevent the patient receiving help, result-
ing for example in my patient’s husband becoming disheartened that
no intervention by him helped and my experience of ‘thank you but
no thanks!’
Mrs J’s deadly moods of dismissal could be regarded as illustrative of
what many analysts mean by evidence of the death instinct. Certainly
the problem of engagement remained a central issue. In a collective
study in the United States of twelve cases of manic depressive psych-
oses using intensive psychoanalytic psychotherapy, it was interesting
that the research group highlighted the main problem in therapy as ‘a
lack of interpersonal sensitivity’ (Cohen et al. 1954).
Britton (1995) has described a situation that can arise in analysis,
where through projective identification, the part of the patient that is
capable of love and desirous of communication, and the patient’s
knowledge of this experience through previous analysis, resides

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Why the cycle in a clinical psychosis?

entirely in the analyst’s mind. He discussed the implications for ana-

lytic technique in such situations, which primarily arise in working
with borderline patients:

If this knowledge of the existence of a person capable of love and

desirous of communication now apparently only exists in the ana-
lyst’s mind, his own loneliness and frustration may prompt him to
demand the patient admits it, or he may be tempted to try to sell it
to the patient.
(Britton 1995)

Reviewing my experience with Mrs J, I realised that this was what I

had been doing with her most of the time. I was constantly trying to
sell analysis to her, as an alternative way of functioning. However,
involvement with a major psychotic disorder is different from
involvement with a psychotic process. Major psychotic disorders have
dominating characteristic psychopathologies of their own and perhaps
it was inevitable that I was placed in this position by my patient.

Why the repetitive cycle to the psychosis?

The manic phase of a recurrent manic depressive illness has often,

analytically speaking, been understood in terms of a defence against
underlying depression (Segal 1973b). Cohen et al. (1954) from their
studies regarded mania as an escape from an unbearable depression
to a more tolerable state. Indeed, I was struck by the dread that
my patient expressed about returning to a depressive state at the end
of her first manic episode in hospital.
However, my experience with Mrs J suggested the need for a dif-
ferent emphasis if the recurrent nature of her psychosis was to be
explained.
The manic phase can be viewed as the uncoiling of a clockwork
spring that has been progressively tightened during the depressive
phase. The depressive phase is dominated by dependence on a tyran-
nical object, which demands total obedience and suppression of indi-
viduality. This was vividly illustrated in my patient by her obsessive
drive to clear everything out of sight at home and then sit still in a
catatonic state, a pattern that she would repeat day after day for
months on end.

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The psychotic wavelength in affective disorders

During the depressive phase, hidden resentment about this state of

affairs builds up gradually and silently. It is like the patient saying,
‘Why should I be the one staying at home doing all the housework,
while you (the internal mother) are the one always out having a ball?’
These feelings of resentment gradually tighten the spring until
eventually it unwinds explosively in the manic phase. I have learned
from my patient that, once started, the explosive unwinding process
continues with a momentum of its own, until all the previously sup-
pressed anger has been spent.
It is impossible to halt this process once it has begun. Through the
reflectiveness of the analytic situation, my patient became aware of
this internal state of affairs. She likened it to an out of control period.
She was even able at the start of one manic episode to encapsulate her
awareness in her dream of watching a Roman orgy that was about to
take place, in which she was going to be a participant, and in which
she had the feeling that there was nothing she could do to stop it
happening.
Major external life events are not necessarily required to trigger
off another cycle as, once the anger has been spent, the pull to merge
with the tyrannical superego can again reassert itself.
Any past or present experience of good object relationships is
important in supporting the growth of reflectiveness and providing
strength for a more productive type of object relationship.
Working with Mrs J gave me the opportunity to acquire increased
awareness and understanding of the dynamics underlying a recurrent
psychosis. It made me realise that the dynamics maintaining a recur-
rent psychosis can remain hidden from view in many cases managed
in everyday psychiatric work.
As a general psychiatrist, one has to go on supporting staff, patients
and their relatives in living with difficult circumstances. The experi-
ence gained through analytic case studies can help us to cope with
seemingly intractable states of mind.

202
15
Puer peral psychosis
Vulnerability and after math

Introduction

The puerperium is a particularly vulnerable time for a depressive

psychotic breakdown, with important consequences for both mother
and child. Hospital admission rates somewhat misleadingly suggest
that puerperal psychosis is a rare condition (1 in 500 deliveries).
In this chapter, evidence is given to suggest that puerperal psychosis
may occur as frequently as 3 in 100 deliveries, and that many less
severe cases remain undetected and untreated in the community.
While general psychiatric experience helps in the overall manage-
ment of such cases, psychoanalytic insights can enable us to under-
stand the central psychopathology. Understanding interventions in
these cases can be therapeutic for the mother, as well as having major
implications for the baby’s development.

The puerperal psychoses

In the nineteenth century, puerperal psychoses were thought of

as specific entities, different from other mental illnesses. Later psy-
chiatrists, including Kraepelin and Bleuler, regarded puerperal psych-
oses as no different from other mental illnesses (i.e. depression and
schizophrenia) – they just happened to occur in the puerperium.
This is the current view and is reflected in the latest classifica-
tion of mental disorders, the International Classification of Dis-
eases (ICD-10: WHO 1994). The ICD discourages the diagnosis of

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The psychotic wavelength in affective disorders

puerperal psychosis, favouring depressive illness or, more rarely, schizo-

phrenia. It defines mental disorders associated with the puerperium as
those commencing within six weeks of delivery.
The incidence of puerperal psychosis based on hospital admission
rates is about 1 in 500 deliveries. This is substantially higher than the
incidence for psychosis in non-puerperal women of the same age. It
occurs most frequently in first-time mothers with a past history and a
family history of mental illness. It most commonly starts in the first
two weeks post-partum, but rarely in the first two days. No differing
hormonal pattern has been found in women who develop puerperal
psychoses compared to others.
The risk of recurrence is 15–20 per cent in a subsequent preg-
nancy. Of those with puerperal psychotic depression, at least half
will suffer a subsequent depressive illness that is not puerperal
(Gelder et al. 1990).
Puerperal psychoses need to be distinguished from other, more
common causes of mood disturbance post-partum. Up to 50 per cent
of women experience ‘maternity blues’. This is an emotionally labile
state on the third to fourth day, which then resolves itself. Its cause
remains unknown, but it is without pathological significance.
Postnatal neurotic depression occurs in 10 per cent of women
post-partum. These women tend to be socially isolated and emotion-
ally unsupported. In other words, they may come from a broken
home, and have an absent or unsupportive partner. The child may be
unwanted, or the mothers may find it hard to tolerate their babies’
demands. Medication does not help, and extreme cases may result in
the battered-baby syndrome.
Murray et al. (1991) have shown that emotionally unresponsive,
depressed mothers can have an adverse effect on their infants’ emo-
tional and cognitive development. This highlights the need for
involved health professionals, such as general practitioners, midwives
and health visitors, to be aware of the emotional aspects of pregnancy,
childbirth and early infant care, so that they can provide ongoing
support.
A patient with puerperal psychosis may present in a confused
state (see Case 1 below). In the past, this confusion might have been
attributable to an organic cause, puerperal sepsis. However, with anti-
biotics and sterile procedures at delivery, sepsis is now a thing of
the past. Thus, a confused state post-partum is indicative of the onset
of a puerperal psychosis.

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Puerperal psychosis

Because of the typically mixed symptomatology at initial presenta-

tion, it used to be hard to decide whether the psychosis was due to an
affective (manic depressive) or a schizophrenic illness, and some psy-
chiatrists would sit on the fence and use the term ‘spectrum psych-
osis’. However, research has convincingly shown that virtually all
puerperal psychoses are affective in origin (Kendell et al. 1987).
Kendell et al. (1987) demonstrated that of 120 patients admitted
with puerperal psychoses, only 4 met the criteria for schizophrenia,
and only 1 started de novo in the puerperium. Kendell noted that
women with a history of manic depressive illness had a much higher
incidence of admission in the puerperium than those with a history
of schizophrenia or depressive neuroses.
Kendell et al. (1987) concluded that the high risk for psychosis in
the first thirty days after childbirth in first-time mothers suggested
that metabolic factors are involved in the genesis of puerperal psych-
oses. However, as unmarried motherhood, first-baby births, caesarean
sections and perinatal deaths result in increased admissions or con-
tacts, psychological stresses also contribute to the high morbidity
(Kendell et al. 1987).
The general psychiatric treatment for puerperal psychosis is as
for all depressive illnesses: drugs (antidepressants and major tranquil-
lisers) and ECT. Early use of ECT is advocated to help the mother
recover more quickly, so that she can start looking after her baby
sooner.
Two special issues arise concerning the general management of
psychosis in the puerperium. The first consideration is the need for
mother-and-baby facilities. It is often advocated that each psychiatric
ward should have separate side rooms available for this purpose. The
nurses involved should be experienced in managing babies as well as
trained in general psychiatry. The alternatives are specialist mother-
and-baby units, such as those at the Maudsley, Shenley and Cassel
Hospitals, in England (Zachary 1985).
The second issue that must be kept in mind is the risk of infanticide
(and suicide). Severely depressed patients may have delusional ideas
that their baby is malformed or otherwise imperfect, and try to kill
the baby in order to save him or her from further suffering.
While general psychiatrists acknowledge the contribution of emo-
tional and physical stresses to depression in the puerperium, their
primary concern is to identify a biochemical change that can account
for the high incidence of psychotic depression in the puerperium.

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The psychotic wavelength in affective disorders

Psychodynamic understandings, based on psychoanalytic concepts,

are absent from general psychiatric formulations. Psychoanalytic
contributions in the literature tend to address general issues of
mothering, rather than to focus specifically on puerperal psychosis
(Raphael-Leff 1983). Using case material I hope to show how
analytic insights can help us to understand why the puerperium
is such a vulnerable time for a depressive psychotic breakdown,
and the aftermath for both mother and child. Finally I wish to
emphasise that the underlying psychodynamics are far commoner
than is generally realised.
I will now briefly present three case studies, each of which high-
lights different issues relating to the dynamics underlying puerperal
psychosis. I will conclude with a further discussion of some of the
issues raised.

Case 1: Some general psychiatric perspectives

Mrs K was a 30-year-old woman who was admitted to my acute ward

in a psychotic state, eleven days after the birth of her first child, a boy.
Her case raises many clinical issues to do with the attitude towards
puerperal psychosis and its management in general psychiatry.
Mrs K had been married for four years. She worked as an artist. She
had been apprehensive about having a baby, but responded to pressure
from her husband. She had no previous knowledge of analytic theory,
but interestingly brought drawings of babies at the breast with her, in which
the breast had teeth.
For five days after delivery Mrs K was well. Then she started to have
disturbed sleep, and became overactive and over-talkative. At times, she
appeared incoherent and confused. She was discharged from the maternity
unit on the eighth day. Her condition worsened at home. She was confused
and forgetful, unable to finish a task she had begun. A deputising general
practitioner was called, who gave her a tranquilliser injection. She slept for
a few hours but, as soon as the injection wore off, her disturbed behaviour
returned.
The day before her admission, Mrs K’s behaviour became increasingly
bizarre and unmanageable. She kicked her husband, called him a robot,
and started to break things. She was seen by her GP and the duty social
worker, and admitted to our psychiatric unit on a supervision order. On
admission she was over-talkative and restless, with grandiose delusions that

206
Puerperal psychosis
‘My mother is the Queen’ and ‘I am a millionaire’. She was emotionally
labile, elated and jovial one moment, and weepy and tearful the next.
She was disorientated in place and time, but recognised her husband,
the nursing staff and doctors. Formal memory function was difficult to assess
because of her poor concentration and distraction. Her judgement was
impaired and she had no insight.
Her mental state fluctuated constantly, with her manifest symptoms chan-
ging from hypomanic to more paranoid and schizophreniform in character.
It took three months for her condition to become more settled, though the
staff still found it difficult to develop any meaningful rapport with her. The
main medication given was haloperidol, a major tranquilliser, though ami-
triptyline was added later to address the depressive component of her
illness.
Her family were seen and extensively involved in the situation. Mrs K’s
mother did not get on well with the patient’s husband or his mother. Mrs K’s
mother was bizarre and paranoid in manner, and, at the height of her
daughter’s confused psychotic state she telephoned her on the ward to
berate her for her behaviour. In contrast, Mrs K’s mother-in-law seemed a
very sensible woman, who looked after the baby when the patient was
admitted.
After three months, we seemed to be getting nowhere. Though she
was less floridly ill, Mrs K was still not well. We sent her home for a
weekend, but whenever her mother-in-law gave her the baby, she became
agitated and gave him back immediately, saying that she did not have
the confidence to look after him.
It was at this point that we presented her to a problem case conference
at the hospital. The case conference was attended by a consultant who had
worked on a specialised mother-and-baby unit. He reported that research
had shown that admission direct to a mother-and-baby unit facilitated bond-
ing, and that patients spent less time in hospital and were more confident
with their babies as a result.
Accordingly, we felt very guilty and promptly arranged for Mrs K to visit
a specialised mother-and-baby unit with her husband, with the aim of then
transferring her with the baby.
However, following the visit, Mrs K said that she did not want to go there.
That evening she went home, pushed out her mother-in-law and replaced
her with her own mother. On the Monday, she returned to the hospital in a
confident state, saying that she could now manage the baby, as if she had
clicked back into normality. Shortly after this, it was possible to discharge
Mrs K for outpatient follow-up.

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The psychotic wavelength in affective disorders
This case highlights many clinical aspects of puerperal psychosis and
raises the question of how to understand Mrs K’s sudden apparent recovery.
It is characteristic with puerperal psychosis to have a lucid period follow-
ing delivery (Mrs K’s first five days during which she appeared well). At
the time of discharge from hospital, Mrs K started to become unwell with
confusion. This was ignored by the obstetrics staff, as it was easier to let
her be discharged. When she went home she became more disturbed,
so that she had to be admitted on a formal basis.
Puerperal psychoses are unusual in presenting with symptoms of confu-
sion, which in other circumstances is usually a symptom of an organic
psychosis. The mixture of depressive, hypomanic and schizophreniform
features initially makes a precise diagnosis difficult. Mrs K’s psychosis
eventually clarified itself as a manic depressive or affective disorder.
The resolution of Mrs K’s psychosis is of interest. It seemed to be
going on interminably. However, when the issue of the mother-and-baby
unit was raised, Mrs K suddenly reinstated her mother in place of her
mother-in-law and herself suddenly seemed to revert to normal. How is
this to be understood?
Some psychiatrists have attributed sudden resolutions like this to some
hormonal or biochemical imbalance post-partum that must have righted
itself. We could postulate another explanation on dynamic lines. The
puerperium is a particularly vulnerable time for the reawakening of any
unresolved conflicts a woman may have in relation to her mother. Mrs K
would seem to have denied all her confused, unresolved real feelings to her
mother and instead held herself together by identifying with an adult mother
figure. However, when her baby was born Mrs K became temporarily
identified with her previously suppressed ‘baby part’. This led to an eruption
of confused manic, paranoid and depressive feelings. At the same time,
after the initial eruption, she began to struggle to recompose herself.
The situation was dramatically resolved after Mrs K was confronted with
the possibility of the mother-and-baby unit; perhaps this represented a
priority for the needy ‘baby part’ of her. She opted for the alternative,
displacing her ‘sane’ mother-in-law at the weekend, quickly reidentifying
with her mother, and becoming again the ‘capable adult’.
In other words, before the puerperal breakdown, Mrs K held herself
together through her ‘capable adult’ exterior. Practically, she was capable
of coping with situations. Her inner chaos was repressed and became
identified with her unborn baby.
The birth of her child resulted in the eruption of undifferentiated psychotic
material. The dramatic resolution of Mrs K’s psychosis can be understood as

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Puerperal psychosis
a reassertion of her denial of her needy-baby part. Her caring mother-in-
law, who was looking after the baby, was replaced by the patient’s
own mother, with whom she was immediately reidentified in the role of a
‘capable adult’.
Although, to the outside world, Mrs K now appeared to be well again,
the underlying psychodynamics remained as they had been before the
breakdown. I will return to the question of the role of the mother-and-baby
units with psychotic patients in the discussion.
A year later, I received an anxious phone call from the obstetrician.
Mrs K wanted to stop her contraceptive and have another child. I said I
would see her about this. When I saw Mrs K she was quite sure that she
wanted to conceive again. I could only advise her to wait another year or
so, so that her son had at least two years of her in a trouble-free state, before
the next pregnancy. I had no idea if she would relapse, and could only point
out that the general risk of relapse was one in six. I said that, while we had
no way of knowing, she had been very unwell for a long time after her son
was born. She felt that, as I was forewarned, and it was the second child,
it would be less severe and more manageable the next time. In fact, she
was right. She had another child soon after and she did have another
breakdown, but it was less severe and did not last as long as the first one.

Case 2: The risk of infanticide

Mrs J was a patient with recurrent manic depressive psychosis, who

has been followed analytically over a number of years within the National
Health Service. Her case is discussed at length in Chapter 14. Here I want
to concentrate on issues of the psychodynamics of the puerperium, and
their profound effects and sequelae. Mrs J’s case also shows that while
psychopathology can be handed down from one generation to the next,
there is a possibility that the hand-down might be averted.
Mrs J’s grandmother was the eldest of eight children born to a family
living in the East End of London. After Mrs J’s mother’s birth, Mrs J’s grand-
father went off with the army to India. He returned several years later to sire
seven more children. His wife was said to have been a very domineering
woman. One can imagine the effects all this might have had on Mrs J’s
mother, and how her delusional idea of being the centre of her own
mother’s world would have been shattered by her father’s return from
India – a narcissistic blow from which she was unable to recover.
It was therefore not surprising to learn that on becoming a mother,

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The psychotic wavelength in affective disorders
Mrs J’s mother expected family life to revolve around her. She suffered
from lifelong agoraphobia and depression, but was never hospitalised.
She expected Mrs J to help her and not to cause problems of any kind.
Mrs J’s father reinforced her mother’s projections by expressing the view
that children should be seen and not heard. He would blame Mrs J if her
mother was in a mood.
When Mrs J was 11, her mother had a stillbirth. Throughout ado-
lescence, her mother remained very controlling and would not speak to
Mrs J for a week at a time, if her instructions were not obeyed. Awareness of
this background can help us to appreciate Mrs J’s mental state at the time
her daughter was born.
With her daughter’s birth, Mrs J had her first psychotic breakdown.
After the birth, she became very agitated, but was sent home. There she
developed the delusion that her daughter looked like her mother’s stillborn
child. She had the thought that ‘she was too beautiful to live’. She felt that
her daughter would not have any life of her own and that she should kill her.
She had a fight to resist the impulse to kill her daughter, and in the end
she cut her own wrists. With blood everywhere, and realising that she was
not dying, she went round to the neighbours. She was hospitalised and
given ECT.
It was with apprehension that five years later she had her son, as she did
not want her daughter to be an only child. She had no breakdown at the
time of his birth, but since then, she has developed recurrent manic depres-
sive episodes. Some years later she started analysis, during which she was
able to describe her experience following the daughter’s birth.
Mrs J was determined that her children should have an experience differ-
ent from her own. The children have no inhibitions about speaking their
minds about their mother’s behaviour. They seem to contain her projected
life instinct. For example, on her 46th birthday, her daughter telephoned to
apologise that because of a work commitment she could not be with her
that day. When Mrs J responded, ‘At my age birthdays mean nothing’, her
daughter had no inhibitions about saying, ‘Well, I hope I don’t think like
that at your age’. Of course, by projecting the criticism into her daughter,
Mrs J typically avoided the issues raised by her own attitude. However, it
was also clear that her daughter was not intimidated about speaking up, in
contrast to Mrs J’s relationship with her own mother.
Mrs J made sure that her own children were not suppressed as she had
been. For example, she insisted that her husband let her son, when young,
sometimes win at the game of Monopoly. In contrast, she continues to be
extremely self-depriving in attitude. Her deadly submissive relationship with

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Puerperal psychosis
her mother was only too familiar to me as it was acted out daily in the
transference. The power of her mother’s projections and their effect on
Mrs J were evident: ‘If you can’t beat them, join them – and squash yourself!’
In patients with this kind of psychopathology, there must always be a
conflict between submitting to, and totally identifying with, the all-powerful
deadening mother figure, and supporting the needy self. The conflict can be
avoided by a total identification with the mother figure. However, there are
times when a conflict of interests cannot be avoided. The puerperium is such
a time. From total identification with a godlike mother figure, the provider of
all life, in pregnancy – suddenly there are two figures on the scene when
the baby is born, and the baby represents the patient’s life instinct, previ-
ously neglected needs, and individuality. The way in which the underlying
conflict can be brought into the open by the puerperium is what makes
this a uniquely vulnerable time for a depressive psychotic breakdown –
more so than any other time in the life of a woman with predisposing
psychopathology.
With Mrs J it was very apparent that having her daughter brought her
internal conflict into the open. Her envious and jealous internal mother
would not allow her to have individual feelings. Her individual aliveness
was concretely projected into her baby – who was idealised and immobil-
ised for protection – ‘too beautiful to live’, reminiscent of her mother’s
stillborn child. Her conflict was then acted out in her struggle with herself
over the question of who should survive, herself or the baby.

Like Mrs K, Mrs J required hospitalisation in the puerperium, in an

acute psychotic state. However, I believe that there is a danger of
underestimating the size of the problem of puerperal psychosis. Not
all cases lead to admission to a psychiatric unit, and may even go
undetected at the time. The third case illustrates this point.

Case 3: The tip of an iceberg?

Mrs L came to analysis when she was in her fifties because of troublesome
feelings of depression, isolation and a sense of lack of identity. She had an
autistic son, for whom she had struggled to get appropriate help for twenty
years. When he started to improve, she turned to her own needs.
Mrs L exhibited typical features of endogenous depression, with early
morning wakening, diurnal mood-variation, lack of energy and hypochon-
driasis. She had headaches, which she worried might indicate a brain

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The psychotic wavelength in affective disorders
tumour. She felt that her life was not her own, under the pressure of constant
demands from her elderly mother and her autistic son.
Both Mrs L’s parents had had previous marriages. Her mother, who was
33 when Mrs L was born, had a son eight years older from her first mar-
riage. Mrs L’s father was 59 when she was born. He was a retired army
officer, Victorian and eccentric in his ways, but warm-hearted. Her mother
was quite dismissive towards him.
When Mrs L was born, her mother had a depressive breakdown. Mrs
L was sent away for three months to a nanny, who is said to have neglected
her. Mrs L became ill with jaundice and gastro-enteritis. It was three months
before the neglect was discovered and Mrs L returned home.
Throughout her childhood, Mrs L’s mother remained predominantly in a
withdrawn state in bed. However, she was very dominating and ridiculing
in manner towards her daughter. Mrs L would be instructed by her grand-
mother not to upset her mother. She had a very lonely childhood. She lived
in the countryside and would befriend the animals and plants. Her one
talent was painting. Her mother was so envious of any challenge to her
authority that she put kitchen rubbish on a painting of Mrs L’s which had
won a prize in her adolescence.
Mrs L’s husband also had a difficult upbringing and had had some
analysis. He was generally supportive, but preoccupied with his business,
which took him away for lengthy periods. So she was often left alone again,
just as she had been in childhood.
When her autistic son was born, it was a precipitate labour. After he
was born, he cried perpetually for months on end. Mrs L went to stay with
her mother, but her mother could not tolerate the crying baby, so Mrs L went
back home on her own. She said that she had been depressed for two
years, but received no treatment. It took two years before she was able to
get the first specialist assessment of her son. Several years later she had her
second child, a healthy daughter.
I do not wish to go further into Mrs L’s history, but to make the point that
here is a woman presenting with symptoms of a major depressive illness
who was clearly depressed after her son’s birth. However, she received no
treatment – raising the issue of how many more major depressions go
undetected in the puerperium.
Mrs L’s opening remark at the start of her analysis was striking. She
said, ‘I want to be a calm sensible person with no feelings’. Since her
mother had spent her time ridiculing any doubting or thinking, this statement
represents Mrs L’s wish to conform to her mother’s requirements. Again a
basic dynamic in major depression is evident, the urge to give up the sane

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Puerperal psychosis
thinking-and-feeling self in order to conform to the demands of the
omnipotent internal mother figure.
The lack of availability of a containing mother was graphically illustrated
in a dream. In the dream Mrs L went to get food from a supermarket. There
was no basket and she came out with her arms full of tin cans. Suddenly an
aunt (her mother’s sister) shouted from a house window: ‘Where is your
mother?’ She dropped the cans and opened her mouth to speak. It was full
of blood and bits of glass.
This dream makes the oral origins of the psychopathology very appar-
ent. When she was severely depressed, Mrs L would also report a sensation
that she had swallowed two tablets of stone that lay heavily on her stomach,
that is the unresponsive stone breasts of mother. This image also evoked
the Ten Commandments, not to be disobeyed.
At times Mrs L could be very self-castrating, identifying with the maternal
superego. For example, she could even criticise herself for making a ‘wrong’
choice between two side roads to go down when in fact both were blocked
with traffic.
Over the years, the material Mrs L brought to her sessions illustrated
her struggle between the alternatives of submitting to and identifying with
her mother, and, through the work of the analysis, her efforts to support the
growth and expression of a sensitive, independent thinking-and-feeling self.
I will briefly report some sessional material to illustrate the oscillation of
these two states of mind. Mrs L’s daughter, now in her mid twenties, had
been unhappy with her shared flat. She was talking of returning to live at
home. Mrs L was unhappy with this; the house was already cramped with
her husband’s business office at home, without having to cope with her
daughter’s needs and belongings all over the place again. Her daughter
was unresponsive to Mrs L’s suggestion that she find another flat-share
nearby, but became excited at the prospect of buying her own flat with her
parents’ help. Mrs L’s husband’s initial reaction was that they should sell
their home, buy a house in the country, and buy a larger flat in London
in which their daughter could also live. His response could be understood
as an impractical first reaction, the result of current pressure from his self-
employed business and a wish to escape.
In the subsequent session, we noted how Mrs L seemed to be ignoring her
own assessment of the situation, as conveyed to me, with the conclusion
that her daughter should be supported in buying her own place. Mrs L said
that both her husband and daughter would have felt her to be a nuisance
if she brought her views to them. She was talking to me in a very superficial
style, like the grandmother who had instructed her not to trouble her mother.

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The psychotic wavelength in affective disorders
When I pointed this out, she was able later to impart her views to husband
and daughter, with a satisfactory outcome. However, she ended the session
by saying that she felt guilty (not expanding on this).
The next day, Mrs L uncharacteristically arrived seven minutes late.
She said that she had been held up by roadworks, due to installation of
unnecessary extra pedestrian crossings at the top of a hill. She then said,
‘Oh dear’, in a contrived way. I pointed out the double message, in that,
while I had taken in her frustration in a real way she also related to me
as someone who should not be troubled by her genuine feelings. This
reminded me of not disturbing her mother, and her reference to guilt at
the end of the previous session. She then spoke of the insanity of increasing
roadworks, narrowing the end of side roads to single lanes, causing further
congestion, and cars dangerously waiting in the main roads to turn into
side roads.
I talked about her feeling of madness at submitting to me, like her
mother’s stifling – as if the space for the flow of her feelings was progres-
sively being restricted, as with the traffic – and suggested that this was not
dissimilar to the previously reported problem of standing up for space
for herself in her house. This reminded her of a dream she had had two
days previously (when the question of her daughter’s possible return was
on her mind). In the dream she was standing in an underground train
which was packed, giving no breathing space. An unpleasant man next
to her squeezed her hand, crushing it. She was supposed to say nothing,
but refused to keep quiet and shouted so that everyone could hear,
‘Don’t do that!’
As she spoke these words to me, they sounded quite unconvincing, like
a stage act. I again referred to the switch in her voice to a stifling, accom-
modating mode. She referred again to the house: she liked it; it was a
listed building; and she had put a lot of herself into it over the years. Never-
theless, there were space problems with it, and, while she was thinking over
this at home, she heard a voice saying, ‘What are you complaining about?
You have nothing to complain about’. I took this as her expectation that
I would react to her needs like her grandmother saying, ‘What are you
complaining about, regarding the space in your mother’s mind? You should
put up with it and like it’.
Following this, she described another reason for her continual self-
stifling, apart from guilt. She was afraid that if she ceased to cling to the bad
depriving object she would be exposed to an underlying state where she
would be alone, with no one at all wanting her. This explains why agitation
is such a prominent symptom in depressive illness.

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Puerperal psychosis
Not only does identification with the omnipotent mother obviate the feel-
ings of envy that separateness brings, but also it provides a means to avoid
terrifying feelings of aloneness by remaining forever in a relationship with a
bad object that blames you and that you blame.
Although the persistence of pathological relationships is an important
issue in the assessment of the degree to which analytic interventions will be
effective, the main reason for presenting Mrs L’s material in this chapter is to
illustrate that not all patients with puerperal depression are admitted to
hospital. Puerperal depression, of the psychotic type, has a wide spectrum
of severity, and many patients at some point will seek analytic therapy. This
raises the possibility that the cases admitted to hospital are only ‘the tip of
the iceberg’. I will expand on this theme in the ensuing discussion.

Discussion

In response to a leading article in the British Medical Journal on the

mothering skills of women with mental illness, Bourne and his col-
leagues at the Tavistock Clinic complained about the lack of attention
to the condition of postnatal neurotic depression (Bourne et al. 1993).
They argued that while the incidence of psychotic illness is signifi-
cantly greater after delivery than at any other time, its incidence is
relatively rare (1 in 500 to 1 in 1,000 deliveries) compared with post-
natal neurotic depression (10–20 per cent of mothers). Bourne et al.
(1993) argue that it is the cases of neurotic depression that are dealt
with (or not dealt with) mainly in the community that really matter. It
is here that community workers need education in counselling skills.
I would not dispute the prevalence of postnatal neurotic depres-
sion, or the need for increased community awareness (Kumar and
Robson 1984; Paykel et al. 1980). However, I would argue that the
psychopathology underlying affective disorders or major depressive
illness as so convincingly described by Freud (1917) and Abraham
(1924) is much more common postnatally than is usually realised.
In other words, those admitted to hospital with florid puerperal
psychoses are only the most extreme cases, the ‘tip of the iceberg’.
Reactive or neurotic depression is reckoned to be four times as
common as endogenous depression (see West 1992). On that basis, if
the incidence for postnatal neurotic depression is 1 in 10 deliveries,
for psychotic depression it would be 1 in 40 deliveries, much higher
than the oft-quoted 1 in 500 to 1,000 deliveries.

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The psychotic wavelength in affective disorders

At any one time, the prevalence rate for endogenous (psychotic)

depression is estimated at 2–9 per cent of women (see Gelder et al.
1990), and since the puerperium is such a vulnerable time for affective
disorders these statistics again suggest a truer prevalence rate of at least
2 or 3 cases per 100 deliveries.
A study by Cox et al. (1993) substantiates this figure. In the study,
the prime intention of which was to look at related stress in post-
natal neurotic disorders, the overall incidence of depression was
9.1 per cent. However, 3.5 per cent of cases were classified as major
depression (Cox et al. 1993).
The conclusion is clear. The true incidence of puerperal psychotic
depression is much higher than is indicated by the 1 in 500 admission
rate. The suggested incidence is more of the order of 3 in 100 deliver-
ies. Most cases do not get admitted to hospital. They are treated in
the community by general practitioners and community psychiatric
nurses, or referred to psychiatric outpatient departments; or their
depression goes unrecognised and they struggle through it on their
own, like Mrs L.
I will now briefly consider some of the issues raised by the
case presentations. All three cases highlight the pathology central to
endogenous depression. Abraham (1924) succinctly summarises five
roots to the psychopathology:

• a constitutional factor
• a special fixation of the libido at the oral level
• a severe injury to infantile narcissism by successive disappoint-
ments in love
• occurrence of the first disappointment pre-oedipally
• repetition of the primary disappointment in later life.

Mrs L’s case includes all Abraham’s points: the constitutionally

inherited family history of depression; the patient’s mother having a
breakdown when the patient was born; the fixation of the libido at
the oral level, with the sensation of having swallowed the tablets of
stone breasts when depressed; the severe injury to infantile narcissism
as evidenced by the mother’s unresponsiveness; the first disappoint-
ment pre-oedipally, starting at birth with being left with the neglect-
ful nanny; the repetition of the primary disappointment in later
life, with her mother’s lack of support at the time of the birth of
the autistic child. In ‘Mourning and melancholia’, Freud (1917)

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Puerperal psychosis

emphasised the predominance of a narcissistic type of object-choice

as the key to understanding melancholia. If there is a conflict with the
loved person, who will not tolerate difference, then the relationship
is maintained by a substitution of identification for object-love. The
identification of the ego with the object that has forsaken them
involves them giving up their own individuality.
The idealised identification so predominates that, for long periods,
no sense of loss of individuality is felt. However, any situation where
there is a threatened move from an ‘at-oneness’ to a two-person
relationship is intolerable to the narcissistic object-choice.
Thus, in cases with this underlying psychopathology, any situation
which highlights the existence of a needy separate ego can precipitate
a major depressive breakdown. Precipitants can range from minor
ailments, like influenza, to bereavement, job loss, illnesses of old age
and especially the caesura of birth.
With birth, the violence of the conflict between the demands
of the narcissistic identification and the separate needy ego, as
represented by the baby, is experienced all over again. In extreme
cases, the violence can lead to acts of infanticide or suicide. The
law has long recognised the special circumstances to infanticide
(Infanticide Act 1922, amended 1938). Infanticide is seen as a special
case of diminished responsibility. Section 1 of the Act states:

Where a woman causes the death of her child under the age of
twelve months, but, at the time the balance of her mind was
disturbed by reason of her not having fully recovered from the
effects of childbirth or lactation consequent upon the birth of
the child, she shall be guilty of not murder but infanticide.

Judges take a sympathetic view of the woman’s illness, and in fact,

most are referred to hospital or put on probation; only 1 per cent is
sent to prison (Gelder et al. 1990). In most cases, the mother had a
depressive disorder and killed the child because she imagined that
she was saving it from anticipated suffering. About one-third of
mothers who commit infanticide also try to take their own lives
(Resnick 1969).
It is important to re-emphasise that, when we talk about a major
depressive illness in the puerperium, we are referring to a psychotic
illness. This means that our ordinary empathic understanding is not
enough: with these cases too, we have to tune into the psychotic

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The psychotic wavelength in affective disorders

wavelength. In other words, events will not unfold according to our

preconceived notions, as graphically illustrated by Mrs K’s case.
Ordinary empathic understanding might lead us to believe that
Mrs K’s lack of progress, and fear of taking responsibility for her child
on weekend visits, was due to our failure to support the early bonding
process by arranging a placement in a mother-and-baby unit.
The way events subsequently unfolded turned these assumptions
on their head. To understand them one had to tune into the wave-
length on which Mrs K’s psychosis operated. Her case also raises
questions about the assumption that mother-and-baby units are
always the preferred option for all postnatal disorders. If a mother is
mentally incapable of giving full attention to her baby’s needs, careful
consideration should be given to the question of whether the baby
is better off in a regular stable environment, say with the grand-
mother, or on a mother-and-baby unit. A situation where a baby has
to contend with different nurses feeding him may lead to a failure
to develop a healthy projective-introjective process. Psychotic break-
down processes may then predominate, with the risk of creating
another generational problem. While specialist mother-and-baby and
family facilities, such as the one described by Zachary (1985) at the
Cassel Hospital, may be beneficial for less severe cases of postnatal
neurotic depression, further thought may be needed with psychotic
cases. Here it should not be assumed that the mother-and-baby unit
is necessarily best, but the baby’s interests should be the priority in
deciding on the placement.
Depressive illness has a wide spectrum of severity, even though
the basic psychodynamics remain the same, and with some patients
who are quite unamenable to dynamic interventions one has to resort
to purely physical treatments (Mrs K). For example, I recall one male
patient, who fragmented and projected his feelings into hypochon-
driacal symptoms in all the organs of his body and drove his relatives
mad by continually talking about his symptoms. One would literally
have had to know which part of his mind had been projected into his
big toe to be able to talk to him.
Other cases are amenable to analytic psychotherapy or analysis, and
many will have such cases (like Mrs L) in their clinical practice. Some
cases lie in between, so that both physical treatment and dynamic
understandings may have their place. In general psychiatric outpatient
departments, there are many cases where a prescription for anti-
depressant medication and the provision of dynamic understanding

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Puerperal psychosis

both prove appropriate and helpful. Such cases straddle the inter-
face between biological psychiatry and psychoanalysis, raising many
fascinating issues (see Chapter 16 for further discussion of these).
While we should be under no illusion that all cases of major depres-
sion are suitable for analytic psychotherapy, nevertheless I have found
that even brief interventions at critical periods in such patients’
lives can be therapeutic – and in the puerperium we have two lives
to consider. Awareness of the conflict, and concern for the baby’s
interests, can be important in providing a supportive structure to
mothers in vulnerable states.
One place where women with this problem may instinctively
turn for support is infant observation. Very often, far more than I
think is realised, the mother seeks tacit support in caring for her child
from the observer’s time and interest. Mothers who volunteer for
infant observation have often had a depressed, unresponsive mother,
and they may hope for support in helping them to avoid repeating
this pattern with their child.
Welldon (1991) has described how female psychopathology can
be looked at in three-generational terms: grandmother, mother,
daughter. Sometimes the handing-down of the severe restrictive
superego, as Welldon (1991) has argued, can be averted.
All patients who are prone to major depression must undergo a
crisis of allegiance when their baby is born. Most will not come
into hospital, but evidence of the conflict may be apparent to others.
Understanding interventions may be therapeutic for the mother
and her partner, as well as having major implications for the baby’s
development.

219
16
Manag ing depression – psychoanalytic
psychotherapy, antidepressants or both?

The severity of the psychopathology of patients with depression can

vary enormously. Some may be receptive to analytic psychotherapy,
while others require treatment with medication. An analytic frame-
work of understanding still has a place in work with the latter
group, and can aid general psychiatrists in relating to their depressed
patients. When trying to understand and relate to patients with
depression, Freud and Abraham’s seminal papers remain as clinically
relevant, nowadays, as when they were first written (Abraham 1924;
Freud 1917). Analytic thinking can help us to make sense of many of
the symptoms of depression, including early morning wakening,
diurnal mood variation, agoraphobia and hypochondriasis. It is also
important to help the supportive relative with their countertransfer-
ence experiences, when their partner is undergoing a depressive
episode.
In this chapter I conceptualise depression as a situation where a
pathological ego-destructive superego has taken over the driving seat
(O’Shaughnessy 1999). In the treatment of depression, we aim to
unseat this pathological superego and replace it with a more benign
and mature superego that fosters ego development. Understanding
depression in this way can provide an overall framework of approach
to the treatment of this debilitating condition, whether we are treating
the patient with antidepressant medication, psychotherapy or both.
In order to understand depressive illness, we also need to dis-
tinguish it from other causes of low mood and recognise its special
psychopathology. Freud’s seminal paper, ‘Mourning and melancholia’
(1917), helps us to go beyond ordinary empathy by recognising the

220
Managing depression

underlying narcissistic structure. However, Freud’s insights are usually

not incorporated within general psychiatric training and practice.
Conversely, I would argue that psychoanalytic therapists do not think
enough about depression in terms of a psychotic disorder, nor,
as a rule, do they consider when medication might be needed in
this context.

Different meanings of depression

We need to be aware that there are four quite different ways that we
may talk about depression. Edith Jacobson (1978), in her studies
on depression, referred to them as normal, neurotic, psychotic and
grief reactions.

Normal depression

Jacobson’s normal depression is akin to what Melanie Klein referred

to as the depressive position. It is essentially a state of health, a capacity
to bear guilt, stay in touch with mental pain and emotional prob-
lems and bring thinking to bear on situations. In Kleinian terms,
we oscillate between our ability to stay with painful situations or
seek temporary relief through splitting and projection, returning
to the paranoid-schizoid position, or flight into manic idealisations
(Segal 1973b).

Neurotic depression

Neurotic or reactive depression can be understood, simplistically

speaking, as an exaggerated response to stress due to low ego strength
combined with a failure of the external support system. Such
depression is basically a cry for help.

An asylum seeker was admitted to hospital after running in front of cars. A

flatmate reported that he had tried to jump out of a window until he was
restrained and then took a few paracetamol tablets. He clinically pre-
sented in a withdrawn and retarded state, as if undergoing a severe
depressive episode, but was fine the next day after we indicated that, if

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The psychotic wavelength in affective disorders
contacted by his solicitors, we would write a supportive asylum appeal
letter.

Suicide attempts in cases of reactive depression can be seen as a

wish for temporary oblivion and a cry for help in relation to clear
external precipitants, such as a family row or break-up with a boy-
friend. In such cases a supportive response from the carers can be
sufficient to deal with the crisis and medication is not indicated. In
contrast, in suicide attempts by patients with features of psychotic
depression, who are typically older, there is a real intention to kill
themselves, and the treatment would typically involve medication and
admission to a psychiatric hospital (Lucas 1994; Stengel 1964).

Grief reactions

In ‘Mourning and melancholia’, Freud (1917) movingly described

the process of mourning. In grief we try to turn away from reality and
cling onto the lost object through a hallucinatory wishful psychosis,
such as hearing the voice of our lost loved one. However, in submis-
sion to the reality principle we eventually have to relinquish the
external object and reinstate it as a memory inside us. To do this we
have to go through the work of mourning (Freud 1917).
Freud highlighted the similarities of mourning with melancholia, a
condition that would now be referred to as a severe depressive episode
(ICD-10: WHO 1994). In melancholia too, Freud surmised that a loss
must have taken place; however, the nature of the loss in melancholia
is more difficult to discern. He concluded that it therefore must have
been an internal narcissistic loss, occurring at an unconscious level,
and requiring to be understood in its own right (Freud 1917).

Psychotic depression

In modern day terminology, Jacobson’s psychotic depression would

be termed a severe depressive episode with psychotic symptoms
(ICD-10: WHO 1994). Depression is, in fact, a very common condi-
tion. Some 3 per cent of the population are seeking help at any one
time, another 3 per cent who remain undetected are struggling on
their own in the community, while 10 per cent also undergo manic

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Managing depression

episodes. In manic depression, there is a 15 per cent risk of suicide,

and up to 50 per cent of patients may have visited their GPs in the few
weeks preceding suicide (Gelder et al. 2001).
It is useful to be familiar with the clinical presentation, as otherwise,
if the patient does not complain of depression but only emphasises
one of the many commonly experienced symptoms, one may fail to
realise that the symptom is part of an underlying syndrome. The
typical symptoms, familiar to all practicing psychiatrists, include the
following: diurnal mood variation, early morning wakening, and
psychomotor retardation – a slowing up of all physical and mental
processes – with resulting loss of appetite and weight, decreased
libido, amenorrhoea, constipation and retardation (stupor). Other fea-
tures include agitation (a ceaseless roundabout of painful thoughts),
poor concentration (depressive pseudo-dementia), agoraphobia,
depersonalisation and derealisation, a loss of energy (mimicking
anaemia) and hypochondriacal features including headaches, chest
pain, stomach pains with associated cancer phobia, and atypical
facial pain (depressive equivalents) and suicidal thoughts (Gelder
et al. 2001).
There are compelling arguments in favour of regarding depressive
illness as a biological disorder. Many psychiatrists see the symptoms
of a slowing up of psychological and bodily processes as indicative
of a medical disorder that requires physical treatment. Also in depres-
sion, common neurotransmitters in the brain are depleted, and anti-
depressants work by raising their levels, supporting the view of a
biochemical disorder. According to traditional psychiatric teaching
there is no place for psychotherapy, other than of a supportive
kind, while the patient takes his medication and recovers from the
episode. However, I would argue that the usefulness of psychoanalytic
thinking is not restricted to the less severe cases.

The psychoanalytic understanding of depression

It is impossible to do justice in a précis to the richness of Freud’s

(1917) paper, ‘Mourning and melancholia’. Freud points out that, in
depression, the dominating internal relationship is with an object
demanding total obedience, with the associated illusion of being
totally looked after by the object. This absolute identification breaks
down when needs arise, but not completely, so that the identification

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The psychotic wavelength in affective disorders

with the idealised object still remains, and the ideal object is criticised
for having let one down. As Freud put it, ‘an object loss was trans-
formed into an ego loss’ (Freud 1917, p. 249). So, when the patient
announces to the world that they are useless, they are not really criti-
cising themselves, but a purported ideal that has temporarily let them
down. Their apparent self-tormenting can then be understood as a
tormenting of the ideal object that is felt to have abandoned them
at a time of need. The sadomasochistic process of self-criticism
that characterises depressive episodes continues in a relentless fashion
until it has run its course.
Some experienced nursing staff will have no difficulty in intuitively
understanding the need to let this process run its course in hospital,
without demanding excessive physical interventions.
In depression no true mourning, which would involve relinquish-
ing the object, can occur because of the unresolved ambivalent
dependence on an ideal object. It is striking how, after months of
self-berating, patients may recover their former composure without
showing the slightest curiosity about their whole recent experience
in hospital.
Freud emphasised the oral roots to the psychopathology of depres-
sion, with regression to oral narcissism, as evidenced by a patient’s
refusal to eat when in a severely depressed state (Freud 1917).
Expanding on this theme, Abraham (1924) brilliantly and succinctly
summarised the dynamic factors underlying depression, as follows:

• a constitutional factor of an overaccentuation of oral eroticism

• a special fixation of the libido at the oral stage
• a severe injury to infantile narcissism
• occurrence of the primary disappointment pre-oedipally
• repetition of the primary disappointment in later life.

The case of Mrs L described in Chapter 15 offers a particularly clear

illustration of these dynamic factors at work. Freud initially referred
to melancholia as a narcissistic neurosis. After the introduction of
the structural model, he described it as a disease of the critical agency
or superego (Freud 1917, 1923).
In his paper ‘On narcissism’, Freud compared the healthy state of
taking in mental food from parental figures, the anaclitic state, with a
self-centred state in which no development occurs, the narcissistic
state (Freud 1914). In depression, the narcissistic state predominates

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Managing depression

and takes the form of a delusion of not only being at one with an
all-providing primitive godlike superego, but also living in fear of
being cast out, as though from the Garden of Eden, if any questioning
or curiosity develops.
If one develops any need, whether emotional or physical, such as a
bout of flu, this is felt to be a criticism of the primitive god-like
superego, who should have prevented it happening, or of oneself for
not following the correct path to prevent getting ill in the first place
and this may trigger another depressive episode of self-berating.
The commonest symptom of depression is extreme agitation, as
at the moment of curiosity or questioning, one feels separated from
the godlike superego. This results in a feeling of being completely
unheld, like a newly born baby left on a changing mat shaking with
the ‘Moro reflex’.
This central insecurity, which the patient experiences at the
slightest challenge to their total submission to the narcissistic object,
explains why anxiety is the most prominent of all symptoms of
depression, and why general psychiatrists often use the overall term
‘agitated depression’.
In her paper ‘Mourning and its relation to manic depressive states’,
Klein (1940) also emphasised a central theme of insecurity in indi-
viduals with depression, explaining it in terms of their inability in
childhood to establish their good objects and so feel secure in their
inner world.
Bion’s insights on the role of the maternal container add further
depth to our appreciation of the nature of the agitation:

Normal development follows if the relationship between infant

and breast permits the infant to project a feeling, say, that it is dying
into the mother and to reintroject it after its sojourn in the breast
has made it tolerable to the infant psyche. If the projection is not
accepted by the mother, the infant feels that its feeling that it is
dying is stripped of such meaning as it has. It therefore reintrojects,
not a fear of dying made tolerable, but a nameless dread.
(Bion 1967, p. 116)

Each of the various symptoms of depression invites consideration

from a dynamic perspective. Agoraphobia might be understood in
terms of fear of separation from the idealised identification, since
having any separate identity would bring down the wrath of a jealous

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The psychotic wavelength in affective disorders

god. An analytic patient of mine, when depressed, would develop

agoraphobia, linked to fears of having developed a shape to her body,
as if this represented individuality and would draw hostile notice
to her.
Symptoms akin to mourning can be understood in terms of
the feeling that the ideal object has been lost, with both the self
(depersonalisation) and the outer world (derealisation) feeling unreal.
Patients with depression typically wake early and feel worse in the
morning, feeling better as the day goes on. Biological psychiatry has
unsuccessfully tried to explain these features in terms of diurnal
variations in steroid levels, but the symptoms can be also considered
at an analytic level.

A man with severe unrelenting depression, whom I saw supportively for a

year, came weekly to the outpatient clinic accompanied by his wife. After I
had left, he was admitted and received ECT, but sadly then took his own life.
His problem was that he could not come to terms with the fact that, in a fit of
rage during the war, he had killed a Japanese soldier who was on the point
of surrendering, because the Japanese soldier had recently killed his friend,
whom he had found with his head smashed open. He would wake up early
from a recurring nightmare. In the dream, a man had been shot in the head.
His skull was open and he was dying. The patient was holding him, waiting
for the doctor to come. The man died just before the doctor came.

There were of course many striking aspects of this case, including the
impossibility of reparation, as the patient could never forgive himself
for having committed his murderous attack. However, the point that I
wish to highlight here is the patient’s waking early with the recurrent
nightmare and then feeling worse in the morning, but improving as
the day went on, that is his symptoms of early morning wakening and
diurnal mood variation.
We have an internal as well as an external world, and this helps to
make sense of the patient’s experience at a psychological level. The
patient wakes up early in order to escape a terrifying and critical
internal world. Patients with depression feel worse on wakening as
they find themselves totally dominated by their unforgiving internal
world. As the day progresses they start to feel better, since the external
world is a far more humanly responsive one than their internal world.
Consideration of this dynamic may also introduce a way of talking
with patients and their relatives about the internal experience.

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Managing depression

The place for medication

Since the godlike primitive superego of patients with depression

demands that all feelings or other signs of need be repressed, these
feelings may be projected into the body and felt only as physical
sensations, referred to as ‘depressive equivalents’. While depression
raises fascinating questions about the relationship between the mind
and bodily experiences, as transmitted through neuronal networks, at
the end of the day, we may be left with a patient with no insight
seeking relief from very distressing physical symptoms. This is where
antidepressant and anxiolytic medication enter the picture.

A patient gave a history of being a corporal in the army many years ago.
When he was 30, he had an attack of pericarditis. This destroyed his
delusion of immortality. He held on to this belief by projecting his anger at
the loss into his body. He became consumed with hypochondriasis, com-
plaining of pain in every organ. If visitors came round to see his family, he
would dominate the conversation and talk of pain from his big toe to his
testis, abdomen, chest and head.
If his behaviour became too much for the family, he would be admitted to
give them respite and he would receive medication or ECT. I inherited him
when he was in his sixties. On admission, he again talked incessantly about
his symptoms. However, I was struck by the way he managed to chase the
female nurses round the ward with his walking stick, in a sexually provoca-
tive way. Interestingly on the morning of his birthday, his mind temporarily
returned to his head. He behaved normally, in a patients’ group, inquiring
about other patients’ welfare. However, he then reverted to his former ways.
This patient lacked any insight and all treatment inevitably remained at a
physical level. However, we can still take a psychoanalytic interest in the
way his mind was functioning.

One has to accept that, for some people, the severity of their psycho-
pathology is such that one can treat them only at a physical level.
Others, whose psychopathology might not be so severe, may come for
psychotherapy while taking medication, while others may opt for a
purely psychotherapeutic approach.
When working with patients in psychotherapy, medication can be
utilised to reduce the intensity of symptoms when these threaten to
become incapacitating, for example, when patients are unable to get
up in the morning to attend their sessions or when their suicidal

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The psychotic wavelength in affective disorders

feelings threaten to become overwhelming. The doctor prescribing

the medication, whether the general practitioner or specialist, can
work in harmony with the analytic psychotherapist, provided that
they share an understanding of the patient’s condition and agree on
the purpose of each aspect of the treatment plan.
It is very important to include the patient’s spouse or partner in
the management of all cases of severe depression. The partner needs
support and education in the dynamics of the disorder in order to
help them to endure extended periods where the patient will not
listen to their advice. Understanding the transference and counter-
transference issues in depression can help the patients and their
relatives as well as the professionals to understand and cope with the
experience.

The transference and countertransference in depression

The transference

If one conceptualises a major depressive episode as a psychotic epi-

sode, then one cannot rely on one’s ordinary empathy. It is necessary
once more to tune into the psychotic wavelength in order to make
sense of the disorder and understand the transference phenomena.
The patient has a belief that things should never have gone wrong.
Their object relationship is to a god-like figure. If anything goes
wrong, someone is to blame because it could have always been pre-
vented from happening in the first place. There is no desire for under-
standing, only a wish to return to a previous trouble-free state.

An example would be a man driving a car who knocks over another

man riding a motorbike. The motorcyclist is lying on the ground uncon-
scious. His motorbike is in flames. The driver gets out of his car and
beats himself on his chest, saying to himself, look what a terrible person you
are for what you have done, but he does not lift a finger to help the
motorcyclist.

This leads on to the countertransference experience for those trying

to help the patient, whether psychiatrists, analytical therapists or
relatives.

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Managing depression

The countertransference

The first issue to be appreciated is the clash of interest between the

patient and the carers. Patients are not interested in gaining insight;
their only concern is to find a way to regain their previous illusion of
perfection. The therapist or relative, on the other hand, tries to per-
suade the patient not to be so demanding and critical of themselves
and to take a more reasoned, forgiving and understanding approach.
The countertransference feelings experienced by the carer are frustra-
tion and irritation, as anything that is offered in terms of helpful advice
is rejected, while the patient persists in remaining in a troubled state.
While the process of self-berating goes on, it feels to the profes-
sionals and carers as though there is no sign of light at the end of the
tunnel and that the process will go on forever. Often patients them-
selves will ask if their state of depression will ever end. The carers
need help to appreciate that patients’ self-berating over the loss of
their illusion of perfection is an internal process that will go on with a
momentum of its own until it abates. The carers may need help to
understand that they should not take the patient’s rejections of their
offers of help personally.
The relatives’ need for support becomes much more pressing
when manic states arise (see Chapter 14), which involve an element
of triumphing over the object of dependency. This is projected
onto the nearest relative, with acting out behaviour of verbal abuse
and sexual affairs. Such behaviour is potentially very destructive of
relationships and once patients have come down from their manic
state, there can be a real risk of suicidal behaviour. In such circum-
stances, it is even more important to help and support the rela-
tives in understanding and coping with their countertransference
feelings.
I will conclude with a discussion of the two superegos, the mature
benign reflective superego and the ego-destructive superego that
takes over in depression, as this can provide us with an overall
framework for thinking about depression.

The superego in depression

Freud (1923) introduced the concept of the superego in The Ego and
the Id. He described how one part of the ego sets itself over against the

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The psychotic wavelength in affective disorders

other and judges it critically. The superego incorporated Freud’s pre-

vious concepts of the dream censor, the special agency in the ego, ego
ideal and unconscious sense of guilt (Laplanche and Pontalis 1973).
Klein described an early pre-oedipal stage to the formation of the
superego. She thought that a very harsh superego was already in evi-
dence at the oral stage, which becomes modified over time, with
experience, gradually becoming more benign, less demanding and
more tolerant of human frailty (Segal 1973a).
Freud commented on the particular characteristics of the superego
in melancholia, noting an ‘extraordinary harshness and severity
towards the ego’ in both obsessional neurosis and melancholia (Freud
1923, p. 53). However, the superego was more dangerous in melan-
cholia where it could be seen as ‘a pure culture of the death instinct
[which] often succeeds in driving the ego into death’ (Freud 1923,
p. 53).
Klein also referred to an early very harsh superego, formed as a
result of a defusion of the instincts, which stood apart and was
unmodified by the normal processes of growth (M. Klein 1958;
O’Shaughnessy 1999). It is necessary to take the operation of this
abnormal superego into account in cases of depression.
Bion outlined the characteristics of this ego-destructive superego
in the following way: ‘It is a super-ego that has hardly any character-
istics of the super-ego as understood in psychoanalysis: it is “super”
ego. It is an envious assertion of moral superiority without any
morals’ (Bion 1962, p. 97). He further comments,

In so far as its resemblance to the super-ego is concerned [it] shows

itself as a superior object asserting its superiority by finding fault
with everything. The most important characteristic is its hatred of
any new development in the personality as if the new development
were a rival to be destroyed.
(Bion 1962, p. 98)

The following example illustrates the extraordinarily murderous

character of the ego-destructive superego.

A patient with a long history of depression had reached mid-life. He had no

previous history of self-harm. He had never worked and had lived with his
mother until she died two years previously, when he went to live with his
single brother, who went to work. He spent his days visiting different sisters,

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Managing depression
who remained very loving and supportive. He had recently become some-
what more agitated, but persistently denied suicidal feelings, including on
the very day that he actually committed suicide by repeatedly stabbing
himself with a kitchen knife, with his brother returning from work to find
him dead.

His family needed help to understand that their loving feelings had
been appropriately directed in supporting a dependent part of the
patient that had never been allowed to develop by his ego-destructive
superego. When the patient reached mid-life and this murderous part
of him was called to account for its destructiveness in never having
allowed the patient to develop a life, it turned on the ego and killed it.
In my discussion with the patient’s relatives in the aftermath of his
suicide, one of his sisters recalled how months previously, he had said
that his body was tired of living, which suggested that his ego had
been located in his body where it could be attacked by the superego.
Bion thought that the pathological superego arose out of early
failures in communication between the infant and mother. In de-
pression, the ego-destructive superego takes over the driving seat
and attacks the self. In such a situation, O’Shaughnessy (1999)
summarises:

No working through can take place, only an impoverishment and

deterioration of relations, with an escalation of hatred and anxiety
that results in psychotic panic or despair. In this dangerous situ-
ation, the significant event for the patient is to be enabled to move
away from his abnormal superego, return to his object, and so
experience the analyst as an object with a normal superego.
(O’Shaughnessy 1999, p. 861)

To end on a more positive note, in contrast to the previous

example, there are also cases where patients may actively seek help
through analytic psychotherapy.

A young woman came to therapy with a five-year history of disabling

depression. She had been hospitalised early in the illness and had been on
antidepressant medication for a number of years. She came from a strict
religious background. She wished to develop her own mind, while facing
up to the guilt of developing a different attitude to her parents. She was
determined to come off medication. She described her feelings in therapy

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The psychotic wavelength in affective disorders
as going round and round in reflecting on painful events; however, the
movement was like a spiral rather than a circle, so that there was a gradual
forward movement. The active involvement of the therapist on the side of
a mature reflective superego helped lessen the effects of the patient’s
ego-destructive superego and support the development of her own mind.
Prior to analytic therapy, this young woman would typically wake in an
exhausted and tense state, often unable to get up for the day, and recalling
recurring nightmares of being chased by gunmen. After some time in the
therapy, she had a different dream in which I was associated with helping
her with her internal world. She reported waking from this dream in quite a
different state of mind, with a pleasant feeling rather than an exhausted one.

Summary

It is vital to distinguish major depressive episodes from low mood.

If we regard major depressive episodes as manifestations of an under-
lying psychotic disorder, we need to make a special effort to tune
into the wavelength of the psychopathology in order to understand it
and become empathic to the ongoing process.
Psychoanalysis as well as biological psychiatry has much to con-
tribute in the understanding and management of depression. A
biological and a psychoanalytic approach are not necessarily mutually
incompatible.
The psychoanalytic theory of an abnormal ego-destructive super-
ego operating in depression has implications for the overall frame-
work of approach to treatment of this condition. The priority in
treatment, whether through medication or analytic psychotherapy,
is to unseat the primitive ego-destructive superego and gradually
enable its place to be taken by a more mature and reflective superego.
Only when the reflective superego is back in place can any meaning-
ful analytic work be done to strengthen the patient’s ego or
individuality.

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PA RT F I V E

Implications for Management

and Education
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17
Developing an exoskeleton

Introduction

The onset of a schizophrenic breakdown in an adolescent is an alarm-

ing state of affairs. The psychosis may have been hidden through
projective identification, with the parents acting as the container, until
emotional separation in late adolescence results in a massive fragmen-
tation of the personality. In this situation what is urgently needed is to
build up what I would call an exoskeleton around the patient, that is, a
containing structure that is responsive to the patient’s needs, takes in
his or her projections and responds to them in a containing way.
It can take years to build an effective exoskeleton around the
patient. This containing structure may involve family, committed
professionals, a day centre, or possibly a group home with the back-up
of the inpatient ward as a safety net.
The aim of this chapter is to underline the patient’s chaotic and
dangerous state of mind during the first years after the emergence of
a severe psychotic disorder like schizophrenia. I will discuss the prob-
lems that the patient’s relatives may encounter in their attempts to
mobilise the relevant psychiatric services into a committed team to
develop an effective containing exoskeleton. I will use material from a
particular clinical case to illustrate the difficulties. This case also raises
the issue of what psychoanalysis has to offer within this context.

The early years of schizophrenia: living with the unbearable

I want to use the history given by the mother of a young man

who was developing schizophrenia, who shared her concerns with

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Implications for management and education

me during those early most difficult years. This case raises important
issues for further consideration.
This family’s history poses a challenge to the current widely
expressed views that schizophrenia is not an illness, but rather an
invention, that the concept should be abandoned, that it can be pre-
vented by creating the conditions for saner societies, and that in first-
onset psychosis the emphasis should be on non-hospital, non-drug
intervention (Bentall 2004; Davies and Burdett 2004; Read 2004;
Read et al. 2004).

Mr M was a young man of 25. He had started to become ill five years pre-
viously. He became psychotic, left home, took drugs and took to wandering
round the country, and then to wandering around abroad while he was
unwell. Mr M’s parents were very intelligent, sensitive people, he had a sister
who was quite well and there was no family history of schizophrenia. His
mother at this time was trying to cope with this nightmare on her own.
In those early years when Mr M took to wandering around England it
was clear to his mother that he was very ill. In fact he had been ill for several
years before she was able to get professional help for him. The profes-
sionals were not prepared to take responsibility for sectioning him. They
seemed unwilling to listen to his parents. Many professionals along the
way gave Mr M’s age as the reason for their failure to intervene, telling his
parents that it was up to their son whether he accepted help or not. His
mother described this viewpoint as in itself completely mad, and another
way to allow his GP and the Social Services to distance themselves from
becoming involved in his care.
During Mr M’s wanderings in England he was repeatedly seen and
observed to be ill, but no one would take responsibility for his condition. For
his parents it was like trying to get blood out of a stone to get the profes-
sionals to give them any information about their son. Mr M’s age and issues
of confidentiality were repeatedly used to justify their refusal to discuss his
state with them.
Mr M then went off to France, where within twenty-four hours his illness
was recognised and he was repatriated. When his mother was able to
identify that he was returning to England, she managed to alert the profes-
sionals and finally, with the aid of a social worker, succeeded in having him
admitted to a hospital on a section and then transferred to the local psychi-
atric service. He was in a florid psychotic state. It was very upsetting for his
mother, as at first he was very hostile towards her, saying that he would
never return home again.

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Developing an exoskeleton
He eventually settled with medication and returned home. He continued
to see his local psychiatric consultant for outpatient follow-up and was pre-
scribed oral and depot medication. His parents also arranged analysis for
him, though this involved considerable travelling from the countryside for
daily sessions.
Before exhibiting any psychotic features Mr M had presented a picture
of a troubled adolescent, and at that time his mother had turned to a very
experienced, but non-medical, adolescent psychoanalyst for advice. When
he subsequently became psychotic, the analyst told her to sit with him
twenty-four hours a day. This advice made her upset and angry as she felt
that it failed to address the issue of how frightening the situation had
become for her.
After Mr M’s initial admission, his mother tried to get him involved in
a variety of activities during the day. At this stage, she did not feel that
his being in an environment daily with patients with chronic psychoses
would be therapeutic and the professional staff did not have any suitable
alternative day facilities to offer. Initially Mr M responded to her suggestions
of activities or studies with great enthusiasm, but this quickly turned to
avoidance. He soon became socially isolated.
Early on in his illness, Mr M had stood on the banister rail, at the top of
the stairwell, threatening to jump. He then laughed at his mother saying,
‘I’m only doing it to frighten you!’ He had also said that he didn’t want to
grow up but wanted to remain an 8-year-old boy.
His behaviour became totally draining. For example, when his mother
would pick him up in the car after his analytic sessions, he would drag her
through some alarming paranoid state of mind and after an hour calm down
again, by which time she would be thoroughly exhausted. These episodes
also occurred at other times of day, such as in the evening at home, and
increased in frequency.
If his parents left him to get up in the morning, he would often stay in
his bedroom till the afternoon. He would passively agree to any idea
suggested, but imparted no conviction of a real involvement. His father
became so concerned by his state that he felt unable to leave him on his
own. He would sit with his son as if he was undergoing a physical crisis,
waiting for the crisis to remit, as advocated by his first analyst. His mother
did not agree with this approach and felt that there was a need to make the
professionals more aware of Mr M’s alarming states of mind so that they
would intervene.
Mr M’s disturbing states intensified. When the relatively innocuous step
of arranging for him to attend a fortnightly befriender’s group led to an

237
Implications for management and education
acute psychotic reaction, in which he experienced worms eating into his
body, his mother felt that she could no longer manage him by herself.
When she managed to get hold of Mr M’s community nurse to see him
while he was in this state, the community nurse arranged a review meeting
with his psychiatrist. For some time, his mother had been worried about
potential suicide, but felt that there had been no choice other than to live
with the risk and manage her son’s moods on a day-to-day basis.
His consultant psychiatrist was also worried about his state and thought
that he should come into hospital for a few weeks, to get his medication
adjusted. It transpired that this primarily meant the addition of antidepres-
sant medication. His mother felt guilty about the need for admission, as if
she was abandoning Mr M. At first the hospital reminded her of an old
Victorian institution, and she imagined her son being institutionalised and
lost forever in depressing Dickensian surroundings.
At the same time, with his admission she felt a great weight being taken
off her shoulders and her overriding memory afterwards of the time he spent
there was that she had been very impressed by the Victorian hospital. It
seemed to her to have been the only proper place of sanctuary offered to
her son, a physical structure that could contain him.
A few days after admission, Mr M’s named nurse, whom his mother felt
was involved with his case and knew what was going on, went away for
a few days. When his mother next visited him, she found that he had stayed
in bed for the last two days. The bed was in a mess and the room didn’t
appear to have been cleaned. Her son didn’t appear to mind at all. He
talked of there being nothing left in life and he was preoccupied with
thoughts of hanging himself.
At the same time, he didn’t want his mother to speak to the nurses. It
seemed that this was as much because he did not want their attention drawn
to the state of his room as because of his suicidal risk. In fact, a few hours
later, he phoned his mother on her mobile to let her know that he was no
longer feeling suicidal and was feeling much better. The next day, he was
pleased to relate to his mother that the nurses had taken custody of his razor
and cigarette lighter, as if being designated ill had exempted him from any
responsibilities.
His mother had had anxiety dreams during the week of Mr M’s admis-
sion, indicative of the stress that she was carrying. One was of a fruit bowl
that was full to overflowing with too many items; all were items she needed
to attend to. The other dream was simply a picture of manicured nails, which
seemed to represent her attempts to keep her feelings to herself, in a
manicured state, until this became unbearable.

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Developing an exoskeleton

I have described these events in some detail in order to convey an

authentic picture of what it is like to be the parent of a young person
who has been overtaken by a schizophrenic illness. They have lost
the person that they once knew. The situation is a nightmare. There is
worry about potential suicide. There is a struggle to try to make sense
of the situation, as well as attempts to find temporary relief by blaming
oneself or the institution for its shortcomings.
I think that it would be misleading to blame the facilities available
or the degree of coordination between the professionals, as it inevit-
ably took time for the situation they were facing to unfold. Medica-
tion had been given and activity placements had been tried. Indeed, in
the early years of Mr M’s illness, he was regarded as too well to attend
a day centre for chronic states. I have learned over the years that it
is important when coping with protracted psychotic episodes to think
in terms of it being nobody’s fault but view the illness as having its
own autonomy. This helps to free us in our attitude to our work.
In Chapter 14 I discussed a patient with recurrent manic depressive
episodes whom I followed analytically in the health service over many
years, whose case also illustrates the need to think in this way.

Underlying dynamics

Tuning into the psychotic wavelength

To make sense of what has been happening with this patient we

must first tune in to the psychotic wavelength. We have be aware of
the dominance of the psychotic part of Mr M’s mind, which is
intolerant of frustration and uses the mind as a muscular organ to
evacuate the thinking undertaken by the non-psychotic part of the
mind. The psychotic part is driven by deadly anti-life forces. Having
evacuated the concerns arrived at by the non-psychotic part, the
psychotic part fills the gap with denial and rationalisations, and then
presents itself to the outside world as if very reasonable in attitude.

Who makes the diagnosis of a psychotic disorder?

In ordinary circumstances, patients take themselves to the doctor with

troublesome symptoms. The doctor makes a diagnosis, decides on the

239
Implications for management and education

severity of the condition and prescribes treatment. In major psychotic

disorders, the situation is the reverse of normal. The relative or partner
makes the diagnosis and goes to the professionals. It is then a question
of whether they are going to be believed.
This places an enormous strain on the relatives, here Mr M’s
mother in particular. She is the one who realises Mr M’s condition in
the first place and his later deterioration and she then has to alert and
convince the professionals to become involved.

Issues of confidentiality

Mr M had told his mother not to divulge to the nursing staff that he
was preoccupied with suicidal thoughts. She, of course, did tell the
staff. However, perhaps the ‘of course’ is not so obvious. Professionals
sometimes misguidedly maintain the same respect for patient con-
fidentiality when working with individuals with psychotic disorders
as they would with non-psychotic patients. Psychotherapists normally
regard their involvement with patients as private and sacrosanct, but if
a patient is exhibiting suicidal or homicidal features, it can become
important to share concerns.
The issue of confidentiality again raises the issue of needing to be
clear in one’s mind about whether one is working with a patient with
a neurosis or a psychosis. Mr M’s mother graphically described how,
for several years, at the onset of his illness, the professionals refused
to divulge information or listen properly to his parents’ concerns
because of his age, and did not accept that there should be a difference
of approach in relating to psychosis as opposed to neurosis. When
working with psychotic patients, issues of safety, whether for the
patient or the public, should always override issues of confidentiality.

The multidisciplinary approach

Clearly, if concerns about the management of patients in psychotic

states are to be shared, there has to be freedom of communication
between the responsible professionals. The South Devon Homicide
Inquiry into the murder of an occupational therapist concluded that
tragedies were less likely to happen, even if many cannot be prevented,
when there is a good supportive morale and when professionals from

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Developing an exoskeleton

different disciplines are able to communicate openly about their

concerns without misguided restraints over confidentiality (Blom-
Cooper et al. 1996).
Since patients in psychotic states tend to project their difficulties
and it is the relatives or professionals who first pick these pro-
jections up, it is important for the involved professionals and relatives
to get together. This means that a multidisciplinary approach where
every participant’s information is afforded equal respect is essential. It
is like putting together a jigsaw puzzle: we cannot know in advance
who may have the missing link that will enable us to clarify the
picture.
No piece of information should be regarded as sacrosanct. We have
to create an atmosphere that will enable us to share and discuss our
anxieties freely as a team, especially when faced with potentially sui-
cidal states of mind.

Addressing suicidal states of mind

When addressing suicidal states in psychosis, we have to consider

whether to try to understand the act using our ordinary empathic
feelings or whether we need to tune into a different wavelength. The
ordinary way of understanding such states of mind would be to say
that we can all become depressed at times, and we could understand
that someone in Mr M’s position might feel like ending it all. The
approach that would follow from understanding his case in this way
would be to contain the patient in hospital and give him antidepres-
sant medication until he started to feel better, as his psychiatrist
initially suggested to his mother. While this view of Mr M as in need
of treatment for depression is understandable, the question arises of
whether it is the only way to explain Mr M’s alarmingly fluctuating
suicidal state.
An alternative framework would be to understand Mr M’s suicidal-
ity in terms of a psychotic part of his personality that sometimes
threatens to attack or even murder the healthy part in order to prevent
exposure of its self-destructive behaviour.

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Implications for management and education

Approach to the hospitalised patient

We can now use the above considerations to guide our approach to a

patient like Mr M, a young man with schizophrenia who is expressing
suicidal ideation.
It seems to make intuitive sense to see Mr M as primarily going
through a depressive phase with difficulty getting up in the morning
that should respond to treatment with antidepressant medication.
However, this does not fit in with his mother’s report that it has been
hard to get him out of bed for years. She was not impressed with the
above formulation.
By thinking in terms of the psychodynamics underlying psychosis,
we arrive at a different perspective. When the patient does not get
out of bed in hospital and keeps his room in a mess, while his key
nurse is on leave, his mood is triumphant. He is enjoying himself
while he negates everything in life and contemplates ways to kill
himself.
There are two parts to his personality; the psychotic part had taken
over while his key nurse, who would support the life forces in him in
standing up to this part of his personality, was away. The psychotic
part triumphed over the life forces in the patient, reducing him to
staying in bed, neglecting to eat or care for himself and idealising self-
destructiveness. His fear of being on the receiving end of this manic
murderousness was projected so that it was his mother who was left to
carry the worry about his state, as indeed she had been prior to the
admission. The psychotic part of Mr M did not want its way of
behaving exposed, so tried to intimidate his mother by telling her not
to communicate with the nurses.
Later the patient tried to play down his behaviour as a passing
mood, rather than a persistent way of being, by ringing his mother on
her mobile to reassure her that he was now feeling better. However, by
now, his mother was not prepared to accept his rationalised explan-
ation of his behaviour. At this point it was important to confront the
patient with the operation of this powerful part of his personality
with its deadening ways which, fuelled by grandiosity and indis-
criminate envy, would rather murder himself to remove the evidence
of his behaviour than be exposed for questioning. The patient also
needed to be helped to realise that it was his parents who were left
to contain the frightened feelings of the projected healthy part of
himself that was on the receiving end of the threatened attack.

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Developing an exoskeleton

The psychotic part of Mr M derived a cruel enjoyment from

frightening his parents. Of course, the consequence of his behaviour
was that he remained in a dependent state and never had to face
growing up, as he had spelled out when he said that he wanted to
remain a little boy forever. Powerful forces are operating to maintain
this state of affairs.
For movement forward to occur, all the carers needed to respond to
the presenting situation, first by grasping the true state of affairs, and
then by planning a joint strategy with a logical coherence. The patient
then needed to be confronted with this plan. Mr M would need to be
repeatedly confronted with the negative ways in which a part of his
mind could work, undermining therapeutic initiatives, and how he
kept trying to seduce others into accepting his ways as reasonable,
for example on the ward where he initially succeeded in having his
occupational therapy (OT) programme arranged for the afternoon
because he couldn’t get up in the morning.
As Bion (1957a) described, in schizophrenia there is a never-
decided conflict between the life and death instincts. In working
with such patients one should not be thinking in terms of bringing
about a cure; rather, the professionals need to engage alongside the
patient’s family in a lifelong struggle against the powerful negating
forces at work in him, starting with the immediate worry of the
risk of suicide if the destructive forces were left unaddressed. An
ongoing concern in working with Mr M was that as soon as anything
positive was instigated, like the befriender’s group, it led to a frighten-
ing backlash from the psychotic part. This situation was understand-
ably too much for his parents to manage on their own. A whole team
needed to be involved, and in planning his care it was important
to consider whether he might benefit from placement in a well-
organised group home with in-built structured activities, if one was
available.
This may all sound terribly obvious, but when it comes to dealing
with psychosis, nothing is straightforward or can be taken for granted.
For example, it had been felt that the patient was too depressed to get
up and go to OT in the mornings. A few days later, when he was out
on leave with his parents for lunch in the local town, he suddenly
walked into the road in front of a car, so that his mother had to
pull him back. When she then chastised him, he had a paranoid out-
burst, got out of the car while it was moving, and made his own
way back to the hospital. A tranquilliser was added to his medication

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Implications for management and education

to calm him down. The next morning he got up and went to

OT, presumably afraid of what the staff’s reactions might be to his
destructive behaviour of the day before.

Living with unbearable anxieties

It is important to appreciate how difficult it is for the professionals as

well as the family to live with unbearable anxieties, when a patient
presents in an unpredictable acute psychotic state. We can give more
tranquillisers as an interim measure to make both ourselves and the
patient feel better. We can look for an ideal solution, for example by
pinning our hopes on clozapine, a drug that is prescribed for cases that
have proved refractory to other medication.
However, we must also remember to ask ourselves whether our
overwhelming need to find an answer does not represent a psychotic
reaction to unbearable pressure that leads us to play down the over-
all difficulties and concentrate on one aspect in the hope of finding
a definitive solution. This might take the form of advocating the
primacy of medication, a behavioural approach or psychoanalysis, or
one may be played off as superior to the other. We are then in danger
of developing a closed mind rather than achieving an integrated
approach.

Further developments

In time, Mr M’s mental state settled sufficiently to enable his return to the
community. He chose to immerse himself in the church. While there was
concern about his over-identification with religion as a substitute for his own
growth, at the same time the church community provided a warm, socially
supportive atmosphere for him. In time he found a partner, also somewhat
fragile with her own mental health problems, and they were accommodated
together in supportive accommodation. Mr M received supervised medica-
tion and ongoing monitoring from his parents and the professional staff,
so that an effective exoskeleton supporting him was now in place.

The establishment of this supportive exoskeleton took many years of

hard work, especially by his mother, who had to learn what it meant
to have his condition and find a way of communicating effectively

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Developing an exoskeleton

with the professionals. However, lifelong monitoring would need to

remain in place.
Finally it is interesting to consider the place of analysis in Mr M’s
case. Mr M’s mother had sought help from all possible sources, includ-
ing analytic help, especially early on. She found the advice of the non-
medical adolescent psychoanalyst at the time when Mr M first broke
down unhelpful. He needed admission, not a misguided attempt
to contain his psychosis by sitting with him twenty-four hours a
day. Later, still in the initial stages of his illness, Mr M underwent
several years of individual analysis. This was a very difficult time for
his mother, as he had to be driven a considerable distance to his
sessions and he would often have disturbed episodes in the car on the
way home.
As a supportive exoskeleton started to take shape in the local
community, together with logistical difficulties in managing to fit
in the travel to sessions while attending local activities, Mr M became
resistant to continuing with his analysis and his mother decided
that it was the right time for him to stop. Mr M’s analyst told her
that continued analysis was the only hope for his future. His mother
again required strength of character to not accept that this was
the case.
It is important to consider the place of psychoanalysis in the early
management of this patient’s schizophrenic illness. Early on in his
illness, his mother turned to analysis for help and support in address-
ing Mr M’s psychotic state and encouraging his capacity for think-
ing. The aim of individual analysis would be to contain fragmented
states of mind and strengthen the non-psychotic part’s capacity for
reflection. However, it would be a mistake to believe that individual
psychoanalysis was the only thing that mattered for progress. In the
early years of the illness, the most important thing is the gradual
establishment of an effective exoskeleton of local supportive services.
Applied analytic thinking has a place in considering what needs to be
built into the supportive framework, and in making sense of states of
relapse, but when working with psychosis one should not fall into the
trap of placing all one’s eggs in one basket, and becoming morally
judgemental about all other initiatives.

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Implications for management and education

Summary

The onset of a severe schizophrenic illness is a frightening state of

affairs, with unpredictable acting out behaviour. Typically it is the
parents who have to cope with this state of affairs emerging in their
late adolescent child and alert the professionals. It may take something
like five years for the patient’s mental state to settle down. During this
period, it is vital to build up a supportive exoskeleton, a team com-
posed of carers and professionals who are reliably available to contain
and respond to the patient’s needs. While medication, psychological
interventions and occupational activities are important, the priority
in the early years of the illness remains the recognition of the need to
build up an ongoing supportive network, for responding to situations
that the psychotic part of the mind cannot deal with if left to itself.
Later on, the patient may relapse if the supportive exoskeleton
breaks down. In these relapses the patient may produce delusions, with
the associated affect being projected into the carers. The need for the
carers to process their countertransference experiences in order to
make sense of the delusions is discussed in Chapters 12 and 13.

246
18
Destr uctive attacks on reality and the self

Introduction

The focus of this chapter is the destructive attacks on reality and the
self encountered in work with patients in everyday general psychiatry.
Psychoanalytic insight can help us to understand the underlying psy-
chopathology, and assist us as we try to understand and cope with the
tragedies that can result from these violent attacks. There are three
areas of particular concern: violence directed at the self (suicidal acts),
violence directed at others (murderous attacks) and the effect of such
incidents on staff morale.
We need a framework of understanding to help us cope when we
are presented with either potentially or actually destructive actions.
Constant risk assessment is required to work with patients with
unpredictably fluctuating states of mind (Lucas 2003b). This chapter
describes the author’s development of a framework of understanding
linked to clinical experiences, and contrasts this approach with the
more prescriptive approach to management through the use of risk
assessment forms.

The overall assessment of risk

Since the mid 1990s momentous changes have occurred within the
National Health Service in the UK, with the closure of the large
asylums and a shift of emphasis to community care in conjunction
with district hospitals. Subsequently tragedies have occurred, like
the Christopher Clunis case where a man with paranoid schizo-
phrenia and a history of past aggression was left unsupervised in the

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Implications for management and education

community and killed a stranger while he was in a deluded state. Such

tragedies have led to the creation of more medium secure units but
not more general psychiatric facilities.
Management’s anxiety over containing disturbed behaviour has
replaced asylum walls with ‘walls of paper’, namely the Care
Programme Approach (CPA) form and the risk assessment form. The
problem with forms can be that they encourage a psychotic belief
that everything would have been all right if only one had followed the
form. However, review and research articles continue to reinforce
the view that there is no foolproof way to prevent tragedies. Proulx
et al. (1997) conducted a study of 100 inpatient suicides and con-
cluded that ‘inpatient suicides remain a relatively rare phenomenon
difficult to predict, and that all the signs of a potentially impending
suicide can be identified more easily with the benefit of hindsight’
(Proulx et al. 1997: 250). If used retrospectively, suicide risk scales
tended to identify a large number of false positives. This study did
not find any specific item which would improve the specificity of
such scales.
However, the government-driven desire to achieve an anxiety-free
state about the risk of violence to self or others, has resulted in a trend
towards giving undue weight to risk assessment forms. The statistics
from Appleby’s National Confidential Inquiry into homicides and
suicides revealed that 24 per cent of suicide cases, some 1,200, had
had previous contact with mental health services. Half of these had
contact with mental health services in the week before their death,
but in 85 per cent of cases the risk was not perceived. Among the
recommendations for improvement was a thorough overhaul of the
CPA, and training in risk assessment (Appleby 1997; Thompson
1999). This preoccupation with forms seems illogical as the patients
were actually receiving medical attention at the time of suicide. The
proper conclusion is that when it comes to individual cases, we still
have to rely on our own sensitivities and clinical acumen, and learn
from experience.
The following serves as an example of what I would call a delu-
sional belief in the power of forms over feelings. It comes from a
monthly Trust review on violent incidents and the recommended
lessons to be learned. It is typical of many others.

Incident: Doctor kicked on the shin while assessing a patient in

the emergency reception centre.

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Destructive attacks on reality and the self

Recommendation: Training on risk assessment required.

Lessons learnt: Completion of risk assessment forms on all patients.

Forms do of course have their uses. It is always important to record

suicidal ideation in the medical or nursing notes. Perhaps the CPA’s
best feature is the requirement to designate a key worker responsible
for coordinating follow-up care. The risk assessment’s best feature is
an invitation to look through past psychiatric records to alert one to
previous alarming states of mind and acting out behaviour. However,
spending time filling out 120 boxes on a risk assessment form not
only is unnecessary bureaucracy, but also takes valuable time away
from the nurses’ contact with their patients. Forms will never be a
substitute for learning from actual clinical experience and acquiring
relevant frameworks of understanding is an ongoing individual learn-
ing curve for all of us.
As I have argued in earlier chapters, when relating to the destructive
attacks on reality associated with major psychiatric disorders, one
needs to think in terms of two separate parts to the personality, and
to bear in mind that that the psychotic part is the dominating force.
It is resistant to change and, at times when it feels under threat, can
produce a dangerous backlash. Since there is an intimate relationship
between the mind and the body, the non-psychotic part of the per-
sonality can be projected into the body and the body then attacked.
This situation, arising in major psychotic disorders, is to be distin-
guished from the self-harm characteristic of borderline states, where
a suffocating object might be projected into the body and temporary
relief of tension sought through cutting.

Violence to self

This psychoanalytic framework of understanding can help us to

comprehend suicidal states of mind and to manage both our own
anxieties, and those of staff, relatives and management. The following
two examples illustrate how experience gained from one suicide
helped to make sense of a subsequent suicide through the application
of this framework for understanding.

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Implications for management and education

Case 1: An inpatient suicide

Mrs N was a middle-aged woman with a ten-year history of unremitting

chronic severe psychotic depression. Many years ago, she had jumped on
a railway line and lost both legs. Since then, she had made further suicide
attempts by taking overdoses. Following the overdoses, she was admitted
into hospital on section. She would never discuss her suicide attempts. She
would just fixate me with a chillingly murderous stare. She would also have
screaming fits on the ward that were not amenable to discussion, but would
subside prior to discharge back into the community.
We spoke at length with her husband about her outlook, and the likeli-
hood that she would one day succeed in killing herself. We agreed we
could only do our best. While in hospital, the nursing staff and occupational
therapist found it hard to engage her in any activity. The only sign of life she
gave was her interest in playing games of Scrabble. My countertransfer-
ence feelings of being at the receiving end of her chilling stare led me to
think about the underlying dynamics in terms of a dominating murderous
psychotic part that had imprisoned another part of her, a part that did want
human contact, that is through the games of Scrabble.
In other words, it was important to think about Mrs N in terms of two
totally separate parts of her personality. The powerful psychotic part is
never to be contradicted. Fuelled by the death instinct, nothing is allowed
to change or develop. It is never to be challenged or criticised, and any
attempt to change this state of affairs will lead to a murderous backlash. The
psychotic part keeps another part of the personality imprisoned, the non-
psychotic part that longs for companionship and support for development
and freedom of expression. It was my countertransference experience at
the time that alerted me to this underlying dynamic of a powerful psychotic
part keeping the non-psychotic part in an imprisoned state.
When Mrs N returned home, she would lie downstairs with her elderly
mother in attendance until the next admission. I put to her that there was
an imprisoned part of her mind that wanted us to help bring some variety
into her life when out of hospital, and a tear trickled down her cheek. She
said that she would like to be taken swimming. We said that we would
make arrangements for a befriender to take her swimming when she was
settled enough to return home. The CPA programme was fully in place and
recorded.
Two weeks before her death, she was left behind while other patients went
on a day-trip by bus to the seaside because the bus could not accommodate

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Destructive attacks on reality and the self
her wheelchair. She appeared angry. Afterwards, when she was having a
bath, the nurse bathing her left her briefly to fetch a towel. The nurse
returned to find her submerged under water, giving the nurse a fright as she
pulled her up. This bathroom also contained the only toilet on the ward
wide enough to accommodate her wheelchair from which she could get
independently onto the toilet. Her mood settled over the next twenty-four
hours. She continued, as previously, to go independently to that toilet.
Within two weeks, it was felt that she was ready for a trial weekend at
home. But when her husband came to collect her on the Saturday morning,
she had gone to the toilet, turned on the bath and drowned herself.
The aftermath of this event is of particular interest. I had been away on
leave and returned to face an internal hospital inquiry to investigate and
look for any lessons to be learned. For example, was the CPA form com-
pleted and had it been reviewed recently? Did everyone know its content?
Did another nurse become the key worker if the key worker was not on duty?
Was there adequate interdisciplinary communication? Could the ward be
altered in design to enhance safety? However, with the anxiety engendered,
and pressures to produce a report with recommendations, there is a danger
of falling into the trap of believing that answering these sorts of questions
can furnish explanations for the tragedy. The nursing staff, who had cared
for the patient and were devastated by her death, gave flowers and went
to her funeral, inevitably then felt as though they were on the receiving end
of a clinical inquiry.

Freud (1920) thought that both self-preservative life forces and self-
destructive forces exist in all of us, the latter being linked with his
concept of an innate death instinct. Usually our emotional states con-
tain a mixture of positive and negative feelings. However, at times of
suicidal and violent acts, there is a diffusion of the two forces, with the
destructive force in the ascendant. It can also be helpful to think in
Bion’s terms of two separate parts of the personality, the psychotic
and non-psychotic parts (Bion 1957a). In some cases of suicide, one
might view the psychotic part of the mind as killing the non-psychotic
part in order to avoid having to account for its own destructiveness.
One might understand this case of inpatient suicide in these terms.
The more open, healthy state of mind that emerged with Mrs N’s
tears made her vulnerable to a deadly defensive backlash.
In his classic paper ‘Mourning and melancholia’, Freud (1917)
described how we all have to go through the work of mourning after
the loss of loved ones. We have to accept their death and through

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Implications for management and education

mourning we reinstate them inside us in our memory. However,

the finality of the suicide act can incline us to more melancholic
reactions, where we blame ourselves or others due to the unbearable
pain of the situation. The superego plays a leading role at every stage of
the process, from the patient’s illness and suicide to the consequences afterwards,
and for the participants at every level of involvement, the family, the consultant
and other professionals and the organisations involved.
As the consultant I saw my role as offering support to the nursing
staff by attempting to bring in a balanced perspective; namely that
while an inquiry must be made and any lessons learned, the tragedy
was nobody’s fault and could not have been prevented. It was interest-
ing to consider my superego or critical conscience, which I felt
answerable to in that situation, as the consultant. In my mind, the
arbitrator would be an understanding coroner.
Unfortunately, as both this case and the next one illustrate, it is
not always possible to enable the patient to reinstate the more benign
superego, and prevent the deadly attack on the ego. In this case, the
coroner represented the reinstatement of a more benign mature
reflective superego that tolerated the complexities of life, rather than
blaming the staff.
All suicides challenge our omnipotent belief that we can help
everyone and that tragedy is always preventable if we carry out correct
practice. Thus, cases of suicide expose those involved to accusations
from harsh superego representations. Suicides are particularly hard on
nursing staff, who have given loving care to a patient over many admis-
sions, and have to try to come to terms with a suicide at the same time
as answering an immediate internal inquiry centred on CPA and risk
assessment forms. Fortunately, in this case, the coroner proved to be
non-judgemental. He apportioned no blame or criticism, just sym-
pathy to all those affected by the tragedy. He approached me afterwards
and told me that he felt that the patient’s condition was untreatable.

Case 2: A suicide in the community

The lessons I learned from this experience helped me when I later

had to face an even more horrendous situation.

Mr P was 39 years old. His psychiatric notes described two brief admis-
sions in his early twenties in a paranoid state. He was diagnosed with

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Destructive attacks on reality and the self
schizophrenia and placed on depot medication, which he had taken ever
since. He had never worked. His father had died many years ago, and for
decades he lived with his mother. Recently there was a suggestion that he had
been experiencing mild mood swings, but there had been no admissions for
over fifteen years. He had no history of self-harm.
Mr P had a very supportive family of four sisters and a brother, and a
community mental health nurse (CMHN) monitoring the situation. He pre-
ferred to do his own thing rather than attend a day centre. When his mother
died, he moved into joint accommodation with his single brother, who went
to work. He would visit his sisters during the day and one married sister
was particularly supportive.
He moved into our catchment area and it was noted that he had
developed an agitated depression. His CMHN became concerned and felt
that he needed medical attention, and she referred him to me. I saw him in
the middle of a busy new patient clinic. He was clearly in an agitated and
preoccupied state. However, while he accepted antidepressant medication,
he refused an offer of admission. He also refused the offer of attending the
day hospital, saying that he would think about it. He denied any suicidal
feelings, but conveyed a distressed state and he was also informed of the
Emergency Reception Centre facility.
At the time I did not think that he was sectionable, or that his family would
have supported admission. I therefore arranged to review him at my next
outpatient clinic, and told him to bring a relative along. Although he was
clearly unwell, he refused all offers of help before I had to terminate the
interview.
On Monday morning I was informed that he had committed suicide on
the previous Friday afternoon. He had come to the hospital on Friday at
midday to collect his tablets and had bumped into his CMHN, who used
the opportunity to check on his mental state. He had not slept the night
before, but had then slept to midday. When asked he denied feeling sui-
cidal. The CMHN advised him to go round to his sister, until his brother
returned from work. His brother had also ascertained that Mr P had not
slept the night before, advised him to sleep to midday and then go round
to his sister. Again he denied suicidal feelings. When he returned from
work that afternoon, his brother found Mr P lying dead, with blood every-
where. He had cut his throat, wrists, body and legs, and had walked
round the flat until he died. There was an open empty medicine bottle on
the floor.
Mr P’s suicide was a severe shock to both relatives and professionals. His
eldest sister rang up saying that the family wanted help to understand and

253
Implications for management and education
make sense of it. They did not blame anyone. I was left trying to process this
on a typical very demanding NHS Monday morning. In the midst of my
many commitments, as the consultant, I had to cope with my own feelings of
guilt, with the immediate effect on the supporting staff, and attempt to pro-
cess and make sense of the tragedy for the meeting arranged with Mr P’s
family and CMHN.

I had to come to an understanding of what had happened that would

convince me and help Mr P’s relatives. In my formulation I drew on
my experience from the inpatient suicide and the love shown by the
nurses who had attended Mrs N’s funeral and sent flowers. My under-
standing was based on the idea that the suicidal patient splits mind and
body, equates the healthy part of their mind with the bad object and
projects it into their body. Their body becomes identified with the
bad object, which is then murderously attacked (Bell 2001). I felt that
there was a split between two parts of the patient’s mind, the healthy
part, which had responded to his family’s love and appreciated their
love and care, and the ill, very secretive part that had hidden his
suicidal intentions.
The suicide of a relative is beyond ordinary comprehension and
empathy alone was not enough. I had to help the relatives to under-
stand that the patient, on reaching mid-life and separated from his
mother, was having to face up to the destructiveness of the psychotic
part of his mind and how it had prevented him from living. When
internally brought to account, the psychotic part murderously attacked
the evidence by killing itself. When I shared these thoughts with his
sisters, one of them recalled the patient saying three months previ-
ously, ‘My body is tired of living’. I was then able to share with them
my own countertransference feelings of guilt and helplessness. These
understandings enabled the relatives to begin to express more ordin-
ary guilt feelings, such as ‘If only I’d done that’ and to understand
how he had been sick and why he appeared to have rejected all their
love and support.
On this occasion, unlike the previous clinical example of Mrs N,
the family and I had not been sufficiently aware of the patient’s under-
lying murderous state of mind before the tragedy. After I had seen
the patient, I was only left with a feeling of general unease, and
impatience over his having presented in a distressed state, while refus-
ing to accept my offers of help. Only after the suicide was I able to
recognise how destructive he had been and the compulsion to destroy

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Destructive attacks on reality and the self

that recognition. I then found myself able to draw on my experience

with Mrs N, with the two separate parts of the personality, to help
make sense of what had happened. The non-psychotic part had come
to me in search of help and protection from the destructive power of
the psychotic part. The struggle between the two forces had led to my
countertransference feeling of an impasse towards making any pro-
gress, when I tried to clarify his presenting state of mind. This time I
did not have such a clear picture of an imprisoned part of the patient’s
mind, as through projection I also felt imprisoned in the impasse.
Only after the tragedy, with wisdom of hindsight, was I able to fully
appreciate the experience that I had undergone.
This experience left me with feelings of gratitude to my psycho-
analytic thinking which, together with my previous experience, had
helped me to arrive at a formulation that proved helpful to the rela-
tives. I was of course still left with my own superego telling me that if
I had spent more time with the patient or had been more sympathetic,
the tragedy might not have happened.
It is not surprising to hear about burnout and early retirement from
general psychiatric posts, or psychiatrists opting for quieter specialities
with less demanding workloads. However, psychoanalytic thinking
can provide us with invaluable support and understanding as we con-
tinue to work in the ‘impossible profession’.

Violence to others: identifying the psychotic wavelength

Many interesting statistics have arisen from the National Confidential

Inquiry into Suicide and Homicide by People with Mental Illness
(Appleby 1997; Thompson 1999). Of the homicides, the majority had
personality disorders, often abetted by drug or alcohol abuse, fewer
had schizophrenia. Most victims were from within the family or the
patient’s circle of acquaintance. However, within the field of general
psychiatry, it is the patients with psychosis that present the challenge,
when trying to determine the risk of potential violence. The violent
act might be to a complete stranger. If persecutory or depressive
feelings become unbearable, in the psychotic state, the patient may
project the problem concretely into a stranger and then seek relief
by attacking the stranger. Leslie Sohn (1997) described the process
in detail with an analytic study of patients who attempted to push
strangers onto railway lines.

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Implications for management and education

While risk assessment takes place every time a patient with a his-
tory of psychosis is seen clinically, there are two particular settings
where this is the central feature of the proceedings. These are when
assessing the grounds for a formal hospital admission and when a
hospital tribunal is considering whether it is safe to lift a patient’s
restriction order.
Admission of a patient on a compulsory basis under the Mental
Health Act 1983 requires a recommendation from two doctors.
Ideally one should be the patient’s general practitioner, who knows
the patient well, and the other should be a specialist in psychiatry,
ideally the responsible consultant. After speaking with the nearest
relative and seeing the patient, the approved social worker then
decides whether to complete the section. In most cases, there must be
full agreement on the necessity for a formal admission. Only in cases
where problems have arisen can lessons be learned. The following
case serves as an illustration.

Case 3: The consequences of failure to listen to a relative

The mother of a patient with a previous record of admission in a violent

psychotic state noticed that her son seemed to be deteriorating. Mr R had
stopped complying with his medication. He would no longer allow her
access to his home and when she looked through his window, she noticed
broken dishes in his bedroom. His mother notified his community mental
health nurse (CMHN). Mr R threatened to harm the CMHN if she attempted
to visit.
The CMHN notified the GP and as the responsible psychiatric consultant,
I was asked to visit the patient at home. Mr R was clearly in a guarded and
paranoid state, allowing only a limited dialogue in the hallway. I completed
my part of a compulsory order. The GP did not visit, as the patient’s current
residence was some distance from his practice. The ASW came with another
doctor, who was approved under the Mental Health Act 1983 but unfamiliar
with the patient. The patient was still guarded in manner, refusing access to
his room and arguing that his privacy should be respected. He said that his
mother did not understand his needs, but agreed that he should not have
spoken threateningly to the CMHN.
Mr R assured the ASW that he would visit his GP that week to collect
further medication and that he would comply with outpatient attendance. In
this situation, it was felt that the order could not be completed. The ASW

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Destructive attacks on reality and the self
also suggested that the mother might need help to improve her understand-
ing of her son. However, the next day he was formally admitted after an
unprovoked violent attack on a stranger.
Mr R had thrown bleach in the face of a young woman who was waiting
to collect her young child from a school opposite to where he lived.
Fortunately his attack caused no permanent disfiguration or blindness, but
he said at the time that his aim had been to scar her. His action could be
understood in terms of the wish of the psychotic part of his personality to
avoid any reflection on his current mental state. Mr R envied the child, who
seemingly had no problems as he was going to be totally looked after by
his mother. The psychotic part of his personality wished to ensure that any
current self-criticisms were projected and disowned into the mother, so that
he could remain in an omnipotent state of mind.

This brief vignette raises several issues for consideration aside from
the immediate points that the GP who knew the patient was not able
to be part of the assessment team and that the ASW had not spoken
directly with the consultant before arriving at his decision.
Patients with psychotic disorders project and disown their prob-
lematic states of mind, especially when relapsing. As discussed in earlier
chapters, the commonest presenting symptom of psychosis is not hal-
lucinations or delusions but lack of insight presenting as denial and
rationalisation (Gelder et al. 1998). Bion’s theory provides an analytic
framework that can help us to understand this vignette. While the
non-psychotic part of the mind is capable of reflection, the psychotic
part, fuelled by envy and hatred of psychic reality, operates by evacuat-
ing troublesome feelings, thereby creating hallucinations and delu-
sions. The psychotic part then covers up its murderous activity, by
appearing calm and reasonable. Whenever we have to make an assess-
ment of a patient with a possible history of psychosis, we must consider
whether we are listening to a straightforward communication from
the non-psychotic part or a rationalisation from the psychotic part.
In physical illnesses it is the doctor who makes the diagnosis. With
relapse of psychosis, it is usually the relative who first makes the
diagnosis. Then it is a case of whether the professionals believe the
relatives or the patient’s denial of illness and rationalised explanations
for the reported disturbed behaviour. Without Bion’s model in mind,
one may be forced into a position, as in this case, of adopting a moral
stance where the relative is held to be in the wrong, and consequently
the degree of the patient’s potential violence is underestimated.

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Implications for management and education

The other situation where risk assessment in relation to potential

violence arises is at mental health tribunals where a patient appeals
against continuing detention in hospital. Tribunals can get into dread-
ful muddles if they lack the framework of understanding that will
enable them to recognise the operation of a separate psychotic part
of the patient’s mind, which is capable of disguise and rationalisation.

Case 4: The power of rationalisation

The parents of Mr S eventually had him admitted to hospital because he was

living as a recluse at home, refusing to collect his benefits, and his parents
had to do everything for him. His room was in such a state of neglect that
they had to remove the door and replace it with a curtain in order to gain
access to clean it. Mr S had the delusion that he was a film producer. He
would say that he had a team under him but would never be able to substan-
tiate this claim. In hospital he dressed soberly, wearing a sports jacket and
tie, and his assertions sounded convincing. When he appealed against his
section he insisted that his parents did not attend the tribunal. The tribunal
sat for five hours but could not make up their minds about whether or not
Mr S was a film producer as he claimed. They adjourned pending the
patient bringing in a film and asking for a professional film producer to
come and evaluate it.
I attended a second outside tribunal. This time his parents’ views were
heard, and the section was upheld.

This case illustrates the powerful persuasiveness of rationalisation and

highlights the need to obtain and carefully consider the relatives’
views in all cases of risk assessment relating to psychosis. The patient’s
very powerful projective identification of his madness into the listener
can result in the listener feeling that they must be mad because the
other person seems so rational. One is then left either having to
negate one’s doubts, or seek help from others who know more about
the person’s background and history.

Summary

Risk assessment requires more than completion of the appropriate

forms. Each presenting clinical case needs assessment in its own right.

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Destructive attacks on reality and the self

Psychoanalytic insights on the working of the mind have an important

contribution to make in the individual assessment of dangerous states
of mind. We have to rely on our own sensitivities and clinical acumen
and learn what we can from unforeseen tragedies like the cases
described above. A review of major inquiries concluded that most
tragedies were ‘inherently unpredictable’ (Blom-Cooper 1995).
Good practice relied on good morale. In other words, the manage-
ment and clinicians needed to support and respect each other and
work as a team. A good working relationship between the involved
members of the clinical team is the most important factor when
trying to reduce the risk of tragedies, although it is not always possible
to prevent them from happening. When tragedies occur, the team of
professionals needs to make sense of the situation, and support each
other and the relatives. Continued development of our own analytic
sensitivities and clinical skills remains the real challenge in the field
of risk assessment.

259
19
The role of psychotherapy in reducing the
r isk of suicide in affective disorder s
A case study

This chapter was originally published as a joint article with Caroline

Taylor-Thomas, who brought the patient for supervision.5 I am
grateful to Mrs Taylor-Thomas, an experienced psychoanalytic psy-
chotherapist, for permission to republish the article and for her
contribution. Material is presented from a patient with a diagnosis
of a recurrent affective disorder who exhibited resistance to engaging
in the work of therapy alongside the emergence of active suicidal
intent. The case shows how supervision can help in containing
intensely disturbing feelings in the therapist and aid in identifying
the underlying psychosis. Through exploration of their counter-
transference feelings, the therapist can become attuned to a playing
down of the psychosis by the patient and alert other involved profes-
sionals. Technically, the challenge remains one of how to make an
impact in the sessions by converting a psychotic monologue into a
dialogue. The case illustrates the role that psychoanalytic psycho-
therapy can play in helping to reduce suicide risk in a depressed
patient.

Introduction

As I have argued in previous chapters, in affective disorders, as distinct

from other causes of depressed states, there is a hidden psychosis. With
such cases, tuning into the psychotic wavelength is necessary in
order to make a significant impact. The case described in this chapter

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Psychotherapy and reducing the risk of suicide

illustrates some of the features that can obscure appreciation of this

underlying psychopathology.
For the psychotherapist working with a suicidally minded patient,
access to regular supervision can be crucial, not only in helping the
therapist to contain the intensely disturbing feelings that occur when
engaging with a patient whose life is at risk, but also in helping them
to process their own superego reactions.
The therapist needs support in moving from domination by a crit-
ical superego, instigated by the patient, to develop a more reflective
superego. This in turn helps the patient to move into a more reflective
rather than self-critical mode of functioning. Through this process,
the patient comes to be able to entertain the idea of being ill rather
than bad and this produces a palpable relief. The patient is gradually
less dominated by self-reproach, and the difficulties encountered
in making any real impact on the patient can start to be addressed.
Material taken from the psychotherapy and supervision of a 36-year-
old suicidal patient will be described, followed in the discussion sec-
tion by a review of some of the theoretical and clinical issues raised
by the material.

Background history

Mrs T was referred for psychotherapy through a low-fee clinic scheme, suf-
fering from depression. She was already under psychiatric care for her
ongoing affective disorder. The case described is not one where the risk of
suicide was only a theoretical consideration. Mrs T kept a rope in the loft
in her home, contemplating using it to hang herself.
During eight years in twice-weekly psychotherapy, she has taken two
overdoses and had three hospital admissions. There have been numerous
threats of suicide and episodes of cutting and burning herself. Over the
years Mrs T has also been on a variety of antidepressants and mood stabil-
isers, including lithium carbonate. At the time of writing the therapy was
ongoing and Mrs T had not been readmitted to hospital for more than
two years.
Mrs T is a married woman and mother of two young children. The
youngest of three children herself, in childhood she was brought up in
a household dominated by a recurrent physical illness of her mother
and also by adherence to fundamentalist religious convictions that had run
in the family for generations. Father was a ‘spare the rod, spoil the child’

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Implications for management and education
disciplinarian who would hit the children with a stick, which he kept behind
a cupboard by the stairs. The experience of growing up in this culture left
Mrs T feeling that she did not exist. Religious rules substituted for her devel-
oping a mind of her own. Mrs T went on to marry a man from a similar
religious background. After rising to departmental head within a caring
institutional setting, she was subsequently given early retirement as her
depressive illness took a grip on her.

The treatment

The treatment will be described in three phases linked to progressive

changes occurring in the therapy. In the first phase there seemed to be no
hope of making any meaningful contact with Mrs T, leading the therapist to
think that the therapy should be ended. In the second phase, the real nature
of Mrs T’s problems became apparent, first to the therapist and then to the
patient, with both then becoming interested and engaged with the under-
lying pathology. In the third phase Mrs T showed striking changes in her
thinking and a growing capacity to understand how her mind was working.
However, a central question remains for the therapist with such a patient
about whether any lasting purchase is gained on self- destructive aspects
and whether related insights are internalised rather than evacuated. This
issue will be considered further in the discussion.

The first phase

The first phase was characterised by an increasing conviction in the therap-

ist that there was nothing happening in the therapy and that it was going
nowhere. Mrs T seemed to show no interest in knowing about or attempting
to understand her mental state. It appeared that she wanted to cling to the
therapist and use the space provided by her sessions in order to evacuate
her mental contents rather than seek any meaning in them. This took the
form of monotonous and repetitious complaints about herself and her lack
of worthiness as a Christian, a wife, a mother and a patient. These self-
reproaches were interspersed with threats against herself, sometimes vague
and at other times more specific, which she would then quickly disown. Inter-
pretations made no impact, and her responses to any attempts to instigate
symbolic thinking were very concrete in quality.
There was uncertainty and confusion about the precise nature and

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Psychotherapy and reducing the risk of suicide
severity of Mrs T’s problems. On the one hand she presented as someone
oscillating between suicidal depression and ‘highs’ where she could look
after everybody and do everything in a perfect way. At the same time she
would confide in her therapist that she was over-dramatising her accounts of
her depression and suicidal thoughts in order to manipulate her GP and
psychiatrist, because of her need for respite through hospital admission.
She needed the respite because when she was God’s helper, it all became
too much for her. She would either become suicidal or long for a respite in
hospital.
This led to uncertainty in the therapist’s mind as to whether the patient
was providing a true or fictional version of her state in her sessions. It
also resulted in confusion, and sometimes exasperation, in all those treating
her, with the patient feeling that she got the attention she craved only by
fraudulently exaggerating her suffering.

The following clinical material from a session approximately two

years into the work is fairly typical of this early stage of the work.

Mrs T arrived a few minutes early, sat in the waiting room and when invited,
tentatively entered the consulting room, searching around with her eyes.
Her characteristically long opening silence gave the therapist the opportun-
ity to observe how her ubiquitous soft shapeless clothes folded around her
like baby’s clothes on a toddler. Her trainer-clad feet relaxed into their
pigeon-toed resting position, adding to the impression of a rather childlike
figure. Although she said nothing, she managed to convey, as she often did,
the impression of someone who was apprehensive but at the same time full
up and brimming over.
The therapist noticed with irritation that her eyes were drawn to the clock,
as they usually were at this point in the session. It confirmed as always, that
only a few minutes had passed. Once again, with irritation, she became
aware of a familiar predicament – one that she had spoken to the patient
about before. Should she break the silence with one of the interpretations
she had used so often before, and which had begun to sound so mechanical?
Or should she wait, feeling guilty that she was failing to rescue an anxious
patient from her suffering – something she had also voiced before.
As the silence wore on, the therapist became uncomfortable with thoughts
about whether Mrs T was dramatising her presentation. In a recent session
she had confided exaggerating her situation to her doctor in order to get
more sympathy and attention. She claimed that this was not something that
happened in her sessions. The therapist was not so sure. ‘It’s difficult to

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Implications for management and education
start,’ Mrs T said at last. Looking around the consulting room, she added
mournfully, as if it hurt her, ‘The flowers are beautiful.’
After a long pause, when it became clear there would be nothing more,
the therapist said that Mrs T expressed appreciation of her arrangements
here, but that she got the impression something pained her. She wondered if
the break since the last session left her feeling like a flower with severed
roots, making it difficult to reconnect with the therapist and start again.
Mrs T responded in a way that was characteristic:

‘I feel it’s my fault, that with coming here, and the doctors, I get so much help
that I should be better by now. I’m sure there are lots of people in a worse
state than me who would be able to use all this properly.’

The therapist observed that Mrs T had moved into castigating herself, as
she often did, and that she probably felt that the therapist was irritable
and angry with her. She said to Mrs T that she thought this might be prefer-
able to facing reproachful feelings towards her therapist and her doctors
for failing to remove her difficulties, but Mrs T was adamant: ‘I just feel
that I’m being selfish taking space here when other people are much worse
than me.’
The therapist said that Mrs T was inviting her to come in and reassure her
that it was legitimate for her to have therapy, but she did not think that such
reassurance would help. She said that she had the impression that Mrs T’s
self-reproaches were like a mantra she repeated over and over, designed to
keep her and her therapist away from any real thought about her and what
she was going through. After a pause Mrs T said:

‘I feel that everyone wants me to get better – you, Dr X [her GP] and my
family. But if I do, it just means that I’ll have to be a wife and mother and look
after the people at church and that I’ll have no help at all. I’d rather stay as
I am. At least I get some attention.’

Any further attempt to interest her in thinking about this situation proved
fruitless. She often attributed her depression to her shortcomings as a
Christian, saying that if she prayed harder or better, it would lift. Over time
Mrs T made it clear that she wanted peace rather than having to think.
Having a mind involved having dirty, messy and sinful thoughts and feelings.
‘We believe it’s bad to be angry, that if you’re a good Christian you
shouldn’t get angry’, she had told the therapist on a number of occasions.
Life without a mind and without feelings was felt to be preferable. Mrs T
made it clear that she had no intention of using the therapy space for reflec-
tion or the development of understanding. She just wanted someone to

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Psychotherapy and reducing the risk of suicide
make her difficult, depressed feelings go away. The atmosphere created
was of someone who exaggerated her state in a histrionic way in order to
obtain and secure the attention she craved. Once she had it, her ambition
was to hang on to it.
The therapist’s feelings of irritation and boredom mounted unbearably as
the therapy wore on. These feelings were attended by guilt over an absence
of empathy for Mrs T and the stuck nature of the work. The patient claimed
she suffered but her therapist did not really believe her. She felt disheart-
ened and began to question both her competence and abilities as a
psychotherapist.
The uncharacteristic intensity of the feelings the therapist experienced
towards the patient, particularly her wish to put an end to the therapy
and get rid of Mrs T, alerted her into recognising that she was having
difficulty distinguishing what belonged to her and what belonged to the
patient. This alarmed her and led her to seek more intensive supervision of
her work with Mrs T.

This move opened up the interesting, but at the same time frightening,
second phase of the work. It also generated new life in the sessions.

The second phase

As a result of the supervision, the therapist was able to think about the
situation from a different perspective, something she had previously been
unable to do with this patient. This involved exploring the meaning of
her negative feelings towards Mrs T and the extent to which Mrs T’s
punitive superego was impacting on her own vulnerabilities in this area. It
also involved questioning whether patient and therapist had been uncon-
sciously treating the wrong patient – seemingly a controlling, manipulative
histrionic – who stimulated a contagious primitive superego in them both.
With supervision, it became possible to tune into a different wavelength
and to recognise that Mrs T’s rather histrionic presentation served to
obscure a more serious and complex underlying situation, in which Mrs T
was in the grip of an affective disorder over which she had no control. It
became apparent over time that Mrs T preferred to see herself as someone
who manipulated and exaggerated her distress in order to maintain her
illusion that she was in control of the situation, as though she could stop
being ill if she chose to.
Once this shift in attitude had occurred within the therapist, it made a

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Implications for management and education
dramatic difference to the work, particularly in her emotional response to
the patient. As the therapist’s own superego modified as a result of her new
understanding, her countertransference changed from chilly disbelief and
impatience into interest, concern and sometimes alarm. As a result, the tone
of the sessions began to change as Mrs T and the therapist were able to
begin to face together the more disturbing underlying aspects that had been
disguised by her initial presentation.

The following material from this phase conveys something of Mrs T’s
manically driven state, and the impossibility of her preventing its
eventual inevitable collapse into depression.

‘Sometimes I feel I’m going up a sand dune and that as I get nearer to
the top I’m sliding back and getting more and more exhausted.’ Crying,
she went on to describe the punitive aspect within herself that she was
up against.

‘At the bottom of the sand hill there are lots of people saying that I should be
doing this or that, and that they’re in a worse state than me and they’re
not getting all the help that I get. I just feel that I’d be all right if I could get to
the top of the hill.’

The scale and power of what she was up against internally was vividly
conveyed by something she said just prior to her first hospital admission. ‘I
feel that I’ve got this war going on in my head – but I don’t know what it’s
about. It’s not like single bullets going off – it’s like I’m standing in front of
two tanks and I just want to get away.’ At this time Mrs T regarded death
as a friend, an idealised state defined by the presence of peace through
the absence of suffering. Although on this occasion Mrs T made no actual
attempt on her life, her suicidal thoughts increased, with plans for using the
rope in the attic, or getting drunk and overdosing on pills.
At the same time it became clear that Mrs T enjoyed a fantasy that she
would survive her death, a fantasy which was particularly dangerous since
she believed she would go to a heavenly better place and become at one
with a perfect object who would look after her forever. On one occasion
when the therapist had been talking about the ubiquitous conflict in Mrs T
between lively and self-destructive aspects, she responded, ‘When you talk
about it, self-destructive has a hostile sound to it. I’m not aware of feeling
anything like that. I see death as peaceful, with no stress. A sort of back to
the womb situation.’ She added: ‘It feels like something good and peaceful,
with a road stretching out from it.’

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Psychotherapy and reducing the risk of suicide
Later she talked about death as a sleepy, unconscious state where she
could remove herself from any thoughts, feelings or conflicts: ‘I suppose I see
it as a kind of Nirvana’. She often spoke about her fantasies of suicide in a
dissociated way:

‘I was thinking of trying something next week, but I thought it was a bit
close to our holidays, so I thought maybe when we get back from holidays
and when my daughter is away at camp, she gets very upset if anything
happens to me.’

Squaring her suicidal impulses with her religious convictions presented no

problems for Mrs T. She said, ‘I’ve given some thought to God’s attitude
towards people who take their own lives and I think probably that he’d
forgive one sin at the end’. Her family, she reasoned, would be better off
without her. However, following time in therapy, some evidence arose that
Mrs T was becoming frightened by what she was up against inside herself.
After a serious overdose that led to her second admission to hospital, Mrs T
spoke about her fear that she had succeeded in taking a fatal overdose
and how this had coincided with the realisation that she did not really
want to die.
Links between suicide attempts and revenge on an unresponsive object
emerged. After her release from hospital she told the therapist, ‘They have to
take notice of you if you try suicide.’ It transpired that before she took
the overdose, Mrs T had been unsuccessfully trying to see a key worker or
a doctor at the day hospital she attended in order to let them know how
depressed she was feeling. She was also clear about at least one function
of her self-mutilation, which involved cutting her arms and burning them
with cigarettes (she does not smoke). She said that she did not want to stop.
‘I suppose I don’t want to stop using my body to shout at people,’ she
explained.
Mrs T was profoundly shocked when a family friend succeeded in killing
herself, saying ‘I would have liked to put out my arms and held her.’ Never-
theless, she was fascinated by the event, particularly about what might have
actually tipped the woman into committing suicide.
During this second phase she began to articulate the burden she felt that
her children, her husband and the members of her church congregation
placed on her. On the one hand she perceived them as getting in the way of
ridding herself of her conflicts by killing herself, and on the other hand she
experienced them as greedily demanding that she give over everything
of herself to them. She spoke with contempt about the congregation’s
response to her admission of praying for her recovery, but at the same time

267
Implications for management and education
experienced this as a pressure on her to be well and felt that she was a
failure for not managing to respond to their prayers.
She was plagued by fear that she might improve or get better. In her
black and white state of mind, if she improved it meant that there was no
room to be a patient. This presented a problem, because if there was to
be no patient, there could be no help. She would be back alone in the grip
of aspects of a self that demanded she gave over everything to others. In
turn this meant that she had nothing for herself and that her life was not
worth living.
A dream just before she went into hospital, for the third and final reported
occasion, illustrated her black and white manic state. In the session she
said:

‘I’ve been having lots of dreams, but I can only remember one of them. It
was very frightening. I was being pushed into a plane. It was black and
white and looked very familiar – but I was aware that it went very fast and I
was frightened. A friend’s husband was the pilot. I think it was one of those
stealth planes that flies undetected and then dumps its deadly load.’

She awoke feeling very frightened. As the result of the dream, it was pos-
sible to explore with Mrs T both the fear and attraction of her driven state,
and the feelings of helplessness that accompanied it.
The theme of stealth, secrecy and trickiness was a strand that ran
throughout the therapy, with Mrs T covering up the extent of her disturb-
ance, in the same way she covered the gashes on her arm with the sleeve of
her shirt, leading people to believe she was exaggerating the seriousness of
her psychopathology. She would then feel burdened and hurt by what
she experienced as a lack of interest and unresponsiveness by the people
around her. They, she believed, confirmed her own view about herself,
namely that she should be able to get rid of her problems and be better.
Although there was evidence during this phase that Mrs T was becoming
more concerned about her state, she still regarded the ‘highs’ that she was
always trying to reach by being the provider to others as heroic and interest-
ing, and certainly preferable to the alternative of an impossibly messy
internal world. One vignette taken from her childhood well illustrates her
fear of making contact with the underlying messiness. Mrs T was about 7
when an incident occurred at school, which had a profound impact on her.
She had been carrying paint pots and someone had bumped into her. All
the paint went down the front of her uniform and her mother was called to
bring in a fresh one. The child Mrs T went to pieces, believing she had done
something terribly wrong.

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Psychotherapy and reducing the risk of suicide
An example of this messiness came into the work over the issue of fees
during Mrs T’s second admission to hospital. The therapist received a num-
ber of calls from Mrs T’s husband wanting to know if she would be charged
for sessions while she was in hospital. The therapist herself experienced a
variety of messy feelings about this, but she was helped in supervision
to recover some perspective. Thought was given to the desperation of the
husband, who must have concluded that since his wife was in hospital
again, the therapy was failing. From his perspective, something should be
done to make the patient well. If the therapy and the drugs failed to keep
Mrs T out of hospital, it meant that therapist and doctors were failing. At this
stage of the work neither the patient nor her family were at a point where
they could accept that Mrs T had a problem that would have to be managed
rather than eliminated.
Supervision helped to process some of the difficult feelings that the situ-
ation had stirred up in the therapist, mostly connected with feelings of guilt
and responsibility that her patient was in hospital again. She was enabled
to realise that the situation with Mrs T had been managed in a way that
provided her with the containment she needed in hospital and that this
represented an achievement, not a failure. The therapist came to recognise
and reflect on how she had got caught up in ‘thinking’ very similar to that of
Mrs T and her husband. A communication from the therapist that the fees
were not an issue at this time allowed the focus to return to Mrs T and to the
real nature of the problem.
The understanding gained in supervision of the kind of feelings Mrs T
stirred up in the people caring for her had already become a helpful tool
when it came to detecting signs of deterioration in Mrs T. They came to serve
as a useful warning indicator of relapse. The following incident illustrates
some of the dangerous confusions that can get stirred up in others by a
patient like Mrs T.
Just before Mrs T’s last hospital admission, material emerged in her ses-
sion that Mrs T believed that the doctors and nurses treating her had had
enough of her. It unfolded in this way. During the session, Mrs T reported
suicidal thoughts, feelings and plans, which, although not unusual, had a
quality that particularly concerned the therapist. The patient also expressed
a belief that the medical professionals involved in her care, her GP and staff
at the day hospital she attended were exasperated with her. With Mrs T’s
agreement, the therapist decided to speak to her GP about her state. When
she made contact with the GP she was shaken by the irritation and exasper-
ation towards the patient expressed by the usually sympathetic and support-
ive doctor – thoughts and feelings strikingly similar to those the therapist

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Implications for management and education
herself had experienced earlier in the work. She was alerted by these
responses to contact the psychiatric service about Mrs T’s relapse and pos-
sible need for admission. During that stay in hospital, Mrs T was able to
attend regularly for her sessions.
This second phase of the work was marked by a growing recognition
by both Mrs T and her therapist of the real nature of her problems. This
put them both in a position to detect and explore what was going on
beneath Mrs T’s apparently attention-seeking histrionic behaviour and to
appreciate the seriousness of her situation. The change in the therapist’s
countertransference during this second phase, resulting from the under-
standing gained in supervision, together with the growing recognition by
the patient of the extent and nature of her illness, generated new life in the
sessions.
During this second phase, Mrs T became more interested in the intrica-
cies of her mental state and more able to reflect on the work done in ses-
sions, in marked contrast to the earlier phase of the work. She experienced
a great deal of relief when she became able to recognise that she was ill
rather than ‘attention-seeking’ and ‘bad’. This relief was associated with the
gradual realisation that she would have to learn to manage the oscillations
in her moods and feelings rather than get rid of them.

The third phase

For the therapist, the changes that took place in the second phase of the
work raised the key question of whether anything she could do in the session
and any of the insights and understandings gained in the course of her work
with Mrs T could have any impact on the autonomy of the self-destructive
structures operating inside Mrs T.
Even though Mrs T appeared to respond well to the work in sessions, and
cooperated in strengthening more thoughtful, reflective aspects of herself,
there was an ever-present concern about whether there was a deadliness
in Mrs T so powerful that it would kill off all links with the therapist and also
with Mrs T’s own capacity to think. The therapist’s experience of Mrs T’s
acting out led her to remain concerned over an aspect of Mrs T that stood
apart from what was going on in her therapy and carried on with business
as usual, untouched by the work. However, through exploration of the ques-
tion of whether any purchase could be gained on this deadly system a new
third phase opened up in the work.
Gradually Mrs T was coming to be able to think about her object

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Psychotherapy and reducing the risk of suicide
relationships both internally and externally and was growing concerned
about what she might be handing on to her children. There was recognition
of the possibility of an ego-destructive system, gathering pace through gen-
erations if nothing changed. There was some evidence that Mrs T wanted
change. She now often talked about her efforts to bring her children up in a
different, more free, way. Recently she had even talked about wanting to
be more free herself. ‘Things that have been coming up in my therapy are
starting to make sense to me,’ she said recently. ‘I wonder why I am like this,
why I seem to hate myself so much?’
She showed signs of being more able to stand up to destructive aspects
of herself. Although the impulse to cut herself was often strong, she was
no longer doing this at present. There was also evidence of something less
cutting in her attitude towards herself and her limitations, linked to under-
standings of how sane, vulnerable aspects of her became lodged in her
body and then attacked. She said:
‘It’s not easy, but I’m trying very hard every time I feel that I have to do things
for other people to think about whether I can manage it or whether I’m
sabotaging myself again. I know I like looking after other people, but I also
realise it’s often very bad for me.’
Mrs T showed increasing interest in evaluating the family version of
Christianity, as well as thinking about the culture she experienced as a
child and the parenting she received. She was even able to ponder with
some humour her mother’s extensive capacity to judge and criticise others,
while at the same time seeing herself as an exemplary Christian. While
Mrs T remained a committed Christian, she rejected the idea that if she
prayed enough, or if the congregation of the church prayed enough, she
would be cured of her depression: ‘I think sometimes that I’d like to say
it’s all a lot of bloody bullshit and try and get on with my life and try to
manage my illness.’
During one recent session she talked about her suicide longings in a
different way: ‘I was thinking earlier that I don’t really want to kill myself, but
I want the kind of attention that suicide brings me, that people are able to
see how bad I feel sometimes.’ Following an interpretation about using her
body, and what she did to it in order to tell a story in such a way that the
therapist and others would listen, Mrs T added:
‘I’m also beginning to realise that it’s not bad to want attention – that per-
haps I need it now because for various reasons I didn’t get it in the past. It
doesn’t make me bad because I want attention, but before I always thought
it was selfish to want something for myself.’

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Implications for management and education
After a pause, she added, ‘It’s interesting, too, that if I allow myself to have
them, the longings, it doesn’t seem so important whether I actually get
them or not.’
However, even in this third phase of the work there were disconcerting
echoes of earlier themes. For example, on the therapist’s return from a
break, she found Mrs T distressed and exhausted. Mrs T told the therapist
that earlier that day a friend had congratulated her on her improved ability
to think about and understand herself. This had left Mrs T feeling terribly
alone and that she had no right to be feeling as exhausted and low as she
was. Initially the therapist was very active with this material, making links
to the break, to Mrs T’s difficulty in communicating her state and so forth.
However, when Mrs T said she wished her friend could see how bad she
was really feeling, the therapist realised her mistake.
Mrs T showed relief when the therapist said that she had fallen into the
mistaken belief that Mrs T was better than she was today, failing to take on
board how exhausted she was. This had left her feeling that her therapist
was as out of touch as her friend. In that session, and those following, it was
then possible for both patient and therapist to see how a muddle occurred
in Mrs T’s mind, in which she made an equation between her advances
in understanding and her being well. When she made this equation, it
exposed her to a destructive aspect of herself that exploited these advances
in order to make demands on her she could not meet. It came as a relief to
Mrs T to realise that, although she now understood herself and her situation
more than she had previously, which created a different state, that meant
different, not well.
In this third phase the transference and countertransference shifted from
the concrete into more of a relationship of interest and reflection. It became
possible to explore with Mrs T her attempts to make the therapist into an ego
ideal on whom she could depend. For example, the way that the environ-
ment must be perfect, with fresh flowers in the consulting room reflecting the
perfect arrangements the therapist made for her. The therapist must also
continue to wear a suit, in order that Mrs T could feel safe and depend on
everything going on in a uniform way.
The object relationship that Mrs T was seeking was to a God-like figure,
who would make everything all right for her. She felt that she had to be a
‘good’ patient, because if she did not fit in at all times, with the new religion
of therapy, she would be cast out and rejected. If the uniform perfection of
the therapist broke down, Mrs T feared she was with a frightening superego
figure who was bored, critical and angry with her.
If she was severely depressed or had to go into hospital, she would feel a

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conviction that someone had failed – that either the God-like therapist and
doctors were false gods who promised salvation but failed to deliver, or that
she had failed as a patient and wilfully squandered her opportunities. In this
state of mind, her desire was for identification with an ideal object; there
was no room for humanity, neither in her, nor in the therapist.
Over time Mrs T became more tolerant of a therapist who consistently
frustrated her efforts to turn her into a god-like figure and psychotherapy
into a new version of religion. She was the recipient of an experience with
a therapist whose own superego has managed, sometimes with great dif-
ficulty, to survive the ‘failures’ involved in treating Mrs T, and to go on being
interested and involved with her.
The clinical material illustrates how some of the therapist’s early difficult
countertransference experiences with Mrs T became modified and changed
over time. However, it is also important to underline the fact that Mrs T’s
capacity to stimulate such strong emotions in the therapist and other profes-
sionals working with her, feelings of anger, exasperation and boredom that
were often difficult to bear, also proved to be a vital factor informing the
work, alerting those involved in her care to her dangerous underlying
psychopathology.

Discussion

The case material raises several technical issues that should be con-
sidered when confronted with a patient with an affective disorder.

Attention-seeking

Often when patients are referred to as ‘attention-seeking’, this car-

ries a pejorative connotation, implying that the presenting symp-
toms are being used for secondary gain, that the patient is opting
for the ‘sick role’, and not making enough effort. However, this
diagnosis can be made when we do not understand what is going
on and such an attitude may cause a therapist to miss a hidden
diagnosis, by dismissively categorising the patient as ‘hysterical’
(Slater 1965).
It is interesting that in this case the patient herself holds the belief
that she should not need help, regarding herself as merely attention-
seeking because of her need for a respite. In the countertransference,

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Implications for management and education

Mrs T evoked a similar attitude of mind in both her therapist and GP,
which carried the danger of underrating the severity of the underlying
depressive psychopathology and attendant suicidal risk.
The lesson for us all as therapists is to be alert to the development
of a dismissive attitude towards a patient with depression, as one may
unwittingly have become the object of the patient’s projections,
which may lead one to underestimate the severity of the underlying
disorder.

Differentiating the countertransference in depression and borderline states

The patient showed no interest in doing any meaningful work in the

sessions or in paying for them. She merely evacuated material, leaving
the therapist dissatisfied that no meaningful intercourse was occurring
and feeling like terminating the treatment. It was this sense of hope-
lessness in the therapy, together with a passing reference to the rope in
the loft, that awoke the therapist to the underlying psychopathology
and led her to seek more intensive supervision.
The patient had a history of acting out, including taking overdoses
and cutting herself. Nowadays, such behaviour inevitably leads to a
diagnosis of a borderline state. The clue to the fact that Mrs T’s
condition was depressive, not borderline, lay in the countertransfer-
ence. With a borderline patient, the countertransference is directly
to the therapist, who is held to be entirely responsible for all the
patient’s problems, a very uncomfortable situation for the therapist
(Britton 1989).
Here, the countertransference experience was quite different with
the patient unwilling to make any emotional or physical payment,
engendering the feeling of an unrewarding situation for the therapist.
The therapist’s attitude changed, leading her interest in Mrs T to
return, only once she realised that the patient’s apparent lack of
interest was being orchestrated by an underlying psychosis.

Depression, the forgotten psychosis

Recognising an affective disorder as a psychotic state means that we

can no longer rely on our ordinary empathic experience for under-
standing. We need to tune into the psychotic wavelength and identify

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the dominating phantasies to make sense of what is happening in the

sessions.
The psychotic part here clearly has its own agenda. In the manic
phase the patient feels identified with a role of God’s servant, a
universal provider for others. In this state of mind her children are
seen as nothing but greedily demanding objects. Any respite from this
role as God’s provider, through attempts to gain admission, is felt to be
fraudulent, leading to the projected countertransference feeling that
she is exaggerating her needs. God’s provider is not supposed to have
needs of her own, as God attends to all, and no one else is felt to be
giving thought to her predicament. When she becomes exhausted
and depressed, this leads to thoughts of suicide as the only way out,
and statistically speaking about one in seven patients with bipolar
disorder do commit suicide (Angst and Sellaro 2000).
Once we are alerted to the underlying psychosis, we can then
give further consideration to differing aspects that contribute to the
patient’s suicidal states of mind.

Aspects of the suicidal state

Mrs T likened her striving to be at one with an ideal to trying to

climb a sand dune, like the myth of Sisyphus. Death is seen as a
welcome respite, like a peaceful return to the womb. The self-
destructiveness is not addressed but superficially rationalised as ‘God
will probably forgive one sin’.
Awareness that a self-destructive attack is about to take place is kept
at a distance through a dreamy, dissociated way of speaking. The
projected anxiety from the non-psychotic part that was on the receiv-
ing end of the attack was manifest in the therapist’s awakening to the
dangerousness of the suicidal state.
Later the patient also became alarmed by her realisation of the
dangerous dreamy dissociated state creeping up on her, as evidenced
by the dream of being taken over by a stealth plane that dumps its
deadly load, after which she woke in a fright.
The psychotic part of the personality may deny its murderous
intent, but the non-psychotic part on the receiving end may con-
vey frightened feelings, and awareness of the two distinct parts
becomes crucial to understanding suicidal acts in such cases (Lucas
2003b).

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Implications for management and education

Self-mutilation also occurs in this patient, in a different context, as

an act of revenge towards the idealised object that is experienced
as being totally unresponsive to needs through demanding perfect
obedience. The dynamics behind this self-mutilation is different from
that in a borderline state, where the patient attempts to make contact
with feelings through cutting.

The autonomy of the bipolar state and the attempt to create a dialogue

Behind the presenting facade of histrionic and attention-seeking

behaviour is an attempt to underplay the dominion of manic depres-
sive psychopathology that holds her in its grip.
In the manic phase, Mrs T is identified with God as his universal
provider. She goes on until she needs a rest, but she has to justify
this. It is an all or nothing state. In a collapsed state, hospital, however
disturbed the ward, is seen as a respite. Her anger at the relentless
demand by the ideal object is expressed in her bodily attack. Death is
seen as a preferred option to going on as previously.
Having ventilated her anger in self-mutilation and had a respite in
hospital, through manic reparation she forgives her God for having
been over-demanding and goes back to serving him. In time, with
therapy, a reflective part grows and sees this magical recovery for
what it is, hence her criticism of the congregation’s prayers for her
recovery as ‘bullshit’.
As the bipolar state seems to have an autonomy of its own, this
left the therapist with the question of how she could make a lasting
impact. She found that she could make salient interpretations that
Mrs T seemed to respond to intellectually, but she felt unconvinced
that these were having any lasting impact. Her concern remained that
dangerous suicidal states could recur.
With no interjection from a sane part, the manic depressive cycle is
expressed as an uninterrupted monologue. While the hidden psych-
otic part with its manic depressive agenda has been viewed as a
cohabitee to be understood and talked to in its own right (Sinason
1993), the challenge clinically remains how to make an impact on its
dominance. The way forward is to convert the monologue into a
dialogue.
The dialogue must first arise in the therapist through challenging
the assumption of the manic depressive transference by bringing in a

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different perspective. For example, the patient became disturbed when

the therapist changed from wearing her usual formal suit and blouse.
This black and white state was seen as a desired uniformity imposed
in the sessions, with the patient not having to think but simply to
follow the therapist’s dictates, re-enacting her internal relationship
with an idealised object.
For the patient to see this as a wish for an idealised uniformity in
preference to breaking free and developing a mind of her own, the
conflict had first to be experienced and realised within the therapist.
Then the patient could be helped to consider another way of relating,
a two-person intercourse rather than identification with the absolute.
Insight does not remove the autonomy and forcefulness of the manic
depressive cycle, and the need remains to support a reflective part
of the patient who may recognise at times when she has become
overwhelmed and exhausted and may need a further admission in her
own best interests (see also Chapter 14).
Technically speaking, the central challenge for all analytic therapists
in addressing patients with major depressive illness is furthering
the move in the sessions from a monologue to a dialogue. Herbert
Rosenfeld (1987) was fond of interpreting in a style that articulated
different aspects of the patient’s thoughts to them when addressing an
impasse. Such an approach may help to stimulate dialogue, like an
internal argument on how to respond to feelings, within the patient’s
mind, thereby moving them away from a total domination by a rela-
tionship with an ego-destructive superego.

The concept of birth trauma in relation to depression

When we think in general terms about the purpose of a psycho-

analysis, we may think of a central dynamic, in ego development, of
reclaiming for the ego what has been taken by the superego. For
example, in the special circumstances of training as analytic therapists
there is tension between the need to learn from those who are more
experienced, one’s teachers, and the danger of overidentification
with overvalued ideas at the expense of developing one’s own mind
(Britton 2003). We also talk of life beginning at 40. We all have a
long gestation period before we can emerge with our own individual
analytic identities and views.
In patients with major depression the presenting problem is very

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Implications for management and education

different. The difficulty is not only one of prolonged labour pains

linked to the ego separating from a mature parental superego, but also
that the patient did not come into the world as a separate being. It
is as if the patient has been born into the world totally identified
with an idealised ego-destructive superego, which remains tyrannic-
ally in control. In these terms, one might say that the patient has never
been born as a separately formed individual.
There is a pull to remain in identification with the absolute in
order to avoid all the confusing mixed feelings towards the ideal that
result from starting to experience separateness, like Mrs T’s wish to
avoid ‘messiness’. While Melanie Klein described the concept of the
manic defence against depressive or persecutory guilt (Segal 1981d),
here the defence is against the experience of an underlying mixture
of inchoate feelings, from an ego never formed as a whole. The
experience of separation from the ideal, with its attendant release of
primitive emotions, accounts for the clinical presentation in puerperal
psychosis (Lucas 1994; see also Chapter 14).
This accounts for the very disturbing countertransference feelings
that the therapist was left with. She felt in the patient no sense of a
whole person underneath with whom she could relate, only a series
of reactions to events and interpretations. The therapist needs to be
able to tolerate living with this state in the patient, since it might take
a long period of time for a sense of a more integrated ego to develop.
If this underlying chaotic state is not recognised in supervision, the
supervisee may be left feeling uneasy because of being obliged to
carry these feelings alone.

Summary

This case illustrates that, for the therapist, relating to affective disorders
presents many clinical problems, with an overriding need to develop
a framework of understanding that can enable one to keep one’s
bearings. The psychosis underlying a hysterical facade that invites one
to underrate the patient’s psychopathology needs to be appreciated.
It is important to be aware of the autonomous manic depressive
part with its own agenda with the attendant risk of suicide. Working
with a patient such as Mrs T faces us with the technical challenge of
how to convert a psychotic monologue into a dialogue, and how to
strengthen the presence of the non-psychotic part of the patient.

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If progress is made, evidence of an underlying separate self may not

present as a coherent ego but more in terms of a series of uncon-
nected emotional reactions. In supervision it is important to realise
that the supervisee is experiencing no coherent ego in the patient
and that this is a very disturbing experience to stay with in therapy.
Depression is the forgotten psychosis and, as in all psychotic disorders,
projective mechanisms predominate. As illustrated in the clinical
material, it is therefore only through close attention to the counter-
transference experience that understanding can arise.

279
20
Education in psychosis

Introduction

This chapter considers the need to provide educational settings where

clinicians can learn about the applications of psychoanalytic thinking
to understanding and relating to psychotic disorders. There is no
substitute for direct clinical experience through contact with patients,
followed by a setting for supervised discussion. This can take several
forms. For individuals registered for an analytic psychotherapy train-
ing course, a six-month psychiatric placement attending ward reviews,
ideally with a chance to clerk patients and discuss their formulation,
is advocated for those without previous psychiatric experience.
For nurses and related professionals, the provision of courses to
examine their reactions and responses to the demands made on them
in their work is important for deepening their understanding, and
capacities for containment and self-reflection. If ward managers can
attend such courses, then what they gain can be filtered down to staff
under them, enhancing an interest in a therapeutic attitude on the
wards. Unfortunately such courses are in scarce supply, though there
is an increasing awareness of the need for them (Evans 2006).
In this chapter, I am going to concentrate on three contrasting
supervisory settings linked to the experience of the participants. First,
for junior doctors starting in psychiatry, weekly informal psychosis
workshops provide a setting for shared learning, and an example is
provided (Garelick and Lucas 1996). Second, at specialist registrar
level, a lot can be gained from the experience of seeing a patient with
schizophrenia individually.
Third, material is provided from a highly experienced analytic
psychotherapist, where the issues arising are different, namely how

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Education in psychosis

should psychotherapy departments respond when community mental

health centres refer patients in psychotic states to them for individual
psychotherapy.

The role of the psychosis workshop

Case 1: Deciphering a somersault!

At an informal weekly psychosis workshop, a problem was presented of a

young man whose behaviour was very hard to manage. The young man, in
his early twenties, had first presented two years previously with a psychotic
episode and had predominantly been in hospital since then. His father had
committed suicide, through hanging, five months before his first breakdown.
He had been living with his mother and younger sister. When he first became
unwell he had taken cannabis but not since then.
Prior to admission he had stood outside the house with a knife and
declared his intention to kill his mother. There was observed ‘high expressed
emotion’ between them and the family had been referred for psychotherapy
but had never engaged.
His mother was angry, scared and very critical of the patient and it was
noticed that she avoided looking at him when attending a tribunal hearing.
His sister’s reaction was very different. She had herself received psycho-
therapy, in relation to a past paranoid episode. She wrote a very polite
letter to the doctors expressing the hope that her brother might receive psy-
chotherapy but only when the doctors felt it was the right time.
Some months ago he had been moved from an admission ward to the
acute rehabilitation ward. The nurses were worried because he kept turning
somersaults. He would get down on his knees as if praying, move forwards,
turn over in a somersault, and then get up again. At times he would also
throw his food on the floor and walk into the shower with his clothes on,
but these acting-out behaviours did not have such a disturbing effect on the
nursing staff.
He was completely inaccessible to attempts to discuss his behaviour.
When he went to occupational therapy he was sent back prematurely as
his somersaults were disruptive to the group activity. When he returned to
the ward, the senior house officer (SHO) asked him if he had wanted to go
to OT and he tersely said ‘No’, but when he was asked if he had wanted
to return to the ward early, he also said ‘No’.
His only sign of activity on the ward was that he was reading a book

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Implications for management and education
called The Watcher, but as soon as anyone started to speak to him to try
to engage him in conversation, he conveyed that he was bored with them.

The problem presented to the workshop was how to understand his

behaviour and the other members in the workshop then started to
ask questions in order to try to make sense of it all.
The question was raised of whether this was attention-seeking
behaviour as he did the somersaults in the nursing office as well
as elsewhere. The nursing staff were worried that if he was left
unobserved he might do it on the stairs and injure himself. They also
worried that if they did not intervene, he might go up to his bedroom
and do it there on his own.
His behaviour was also considered in moral terms. While one view
was concern over his behaviour, others wondered what was wrong
with him doing it. The doctors and nurses were split in their reactions
to his behaviour. The nurses felt concerned and wanted the doctors
to do something about it, while the doctors were left wondering
why the excessive fuss and concern. Some of the nursing staff also
wanted to ignore the somersaults.
Attempts to involve the patient himself in discussing his activities
received only a terse response. He had sat through a manager’s hearing
without saying anything, even when the discussion related to very
sensitive matters about his state of mental health and diagnosis.
The nursing staff were now suggesting that he be sent back to the
acute admission ward because of his disturbed behaviour, yet he was
not smashing the place up or being aggressive.
The presenting junior doctor then recalled that before developing
his illness, the patient had been going around with a Chinese gang,
like the Triad, who carried machetes with them, and had the thought
that he could have had his head cut off!
The junior doctor was also reminded of another a patient who he
felt was like the patient but not psychotic. This patient was an ado-
lescent who was not going to school but was not bad enough to
be admitted and his parents were at their wits’ end. The link in the
doctor’s mind was that, in both cases, they were very stuck. So the
problem being presented was of the nurses’ anxieties and the doctor
feeling very stuck.
Other members of the workshop now started to associate to the
somersault. One member thought of the somersault as an acrobatic
act linked to an identification with a Chinese circus. This led onto the

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Education in psychosis

theme of aggressiveness linked to the Triad. The presenting doctor

then recalled that he had talked about the case with a fellow colleague
who had taken apart the word somersault into ‘some assault’. This
led to a consideration of the possibility that the assault in question
was an assault on people’s thinking; no one could make sense of
it or find a way of talking with the patient about his disruptive
behaviour.
The group then began to consider the question of why the somer-
saults were more disturbing than other behaviour, such as his repeat-
edly throwing his food on the floor. One idea was that this was
because the somersault was not as readily understandable as throwing
food on the floor. Mother’s reaction to what she found unbearable
was to cut herself off and demand it went away.
The question was then how to link the history and the group’s
associations in order to arrive at a meaningful psychodynamic formu-
lation that would be helpful to the doctors and nursing staff. Within
this context the following issues needed to be considered.

The diagnosis
In the given history there were no diagnostic first rank symptoms,
but the length of stay in hospital in a disturbed paranoid and socially
withdrawn state, in the absence of an affective disorder, suggested the
diagnosis of a schizophrenic illness. Indeed the length of time without
remission suggested that we were dealing with a severe condition
that would require long term professional involvement.

The role of medication

While medication had an important role to play in this patient’s
treatment, medication alone was only part of the wider picture in his
management. He was already on clozapine, the drug of choice in
resistant cases of schizophrenia, augmented by fish oil and amisul-
pride, and still remained in a disturbed state.

Recognising the onset of a severe and enduring illness

The onset of a severe and enduring schizophrenic illness is a frighten-
ing and bewildering situation for the patient, his relatives and the
involved staff. The patient desperately tried to cope by identifying

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Implications for management and education

with the Chinese gang and distancing himself from his feelings by
taking cannabis. The loss of his father around the time of the eruption
of his illness exacerbated the situation. In her anxiety for him to
become well again, his mother came to represent a non-understanding
figure demanding that he conformed to standards he could not meet,
resulting in his hostility towards her. She needed help in coming to
terms with his condition so that she was not left to feel guilty and
consequently blame herself, the patient or professional staff.
Nowadays, due to the shortage of beds, there is pressure to move
patients to community care as soon as possible. However, every now
and then, one may come up against a patient where in the early stages
of the illness only a hospital setting can provide for his needs.

Negative symptoms
If we are dealing with the emergence of an enduring psychotic dis-
order, we can expect to face much resistance to treatment, the negative
symptoms of schizophrenia linked with strong anti-life forces. We can
readily appreciate this in the patient’s negative reaction to occupational
therapy, his obliviousness to the tribunal proceedings and his terse
bored reaction to any attempts to engage him in conversation.

Countertransference experiences
The workshop was able to reflect on their own associations from a
slightly distanced position, making it easier for them to think than the
professionals at the coalface. They could appreciate the staff feeling
stuck and the mother feeling frightened and angry. Some nursing
staff wanted to return the patient to the acute ward, for a variety of
reasons. His behaviour with the repeated somersaults was not under-
standable and they had no way to influence it. There was a fear that
he might come to real harm if he happened to do the somersaults on
the stairs out of sight. If they ignored the somersaults leaving him to
do them in his bedroom they became concerned that he might with-
draw into a totally inaccessible state. Through their associations the
members of the workshop were able to understand that the somer-
saults had an aggressive component that disrupted any attempt to
involve the patient in communication and that they represented an
attack on thinking, i.e. really ‘some assault’.

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Education in psychosis

Deciphering the meaning to the somersaults

The somersault can be seen as an ideo-motor activity, an attempt
to both relieve and communicate feelings. The patient’s hostility to
examination of his non-verbal communication led to his abrupt ter-
mination of any conversation on the grounds that it was boring. As a
projected activity, we had to do the thinking for the patient. Through
the countertransference experience we could start to understand
aspects of his communication – his failure to solve his problems by
acrobatic identification with the Chinese gang, his feeling of being
stuck and going round in circles, his attempts to sort things out by
himself by living in a world of his own making, and his fear that he
might stay forever in an inaccessible state. All these were thoughts
of the staff in contact with him and they had difficulty containing
them. The challenge now was to find a way to enable the staff to
feel more confident in relating to the problem and addressing the
patient.

The psychotic and non-psychotic parts

The non-psychotic part of the patient is capable of thoughts and
concerns over his breakdown and his inability to influence the situ-
ation. However, this part is under the domination of the psychotic
part, which aims to eliminate all insight gained by the work of the
non-psychotic part. The non-psychotic part is not allowed to speak
and its content is evacuated by the psychotic part through projection.
Bion (1957a) referred to this as the evacuation of the accretions of
mental stimuli in ideo-motor activity. To make any sense of the
patient’s actions the workshop had to provide all the associations in
order to bring out the different components making up the activity.
Having done this work, it might begin to be possible to talk with
the patient about the plight that he finds himself in: how he feels
unable to cope alone with the demands of life and how we need to
provide a continuing support for him in hospital until he is ready to
try the alternative of an outside supportive placement. His somersaults
can be understood both as a means by which the psychotic part tries
to relieve itself of feelings and an attempt by the non-psychotic part
to communicate his needs to the staff.
The staff need to feel confident that they know what is going on
and can safely contain and manage the situation of the early years of a

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Implications for management and education

severe psychosis in their own ward setting. Once they are orientated
to what it means to have to contain the early stages of a marked
schizophrenic illness, the staff may feel freer to help the patient’s
mother and daughter to begin to understand their relative’s illness
and to enable his mother gradually to feel less persecuted by it. If
the staff convey their willingness to make a long-term commitment
to the patient, then gradually a relationship can be built up between
patient and staff.

Case 2: An anorexic patient

Background history
At a weekly psychosis workshop, in an informal setting, an SHO who was
working on the eating disorder unit presented the case of a 19-year-old girl
with a history of severe anorexia since the age of 15. She had spent eighteen
months in a non-specialist hospital and had then been transferred for a year
to an inpatient adolescent unit. After discharge, she started primary school
teaching, but required readmission within a year. She had been on the
eating disorder unit for two months at the time of the presentation.
We were told that although she was prepared to talk, she would neither
eat nor drink. Under the Mental Health Act 1983 she was having to be
forcibly fed twice a day through a naso-gastric tube. She kept pulling out
the tube and it took six nurses to hold her down, while she screamed and
resisted the tube being reinserted.
This young woman came from a Catholic background. She was the fifth
of seven children. There was no family history of mental illness. She had
always been shy, which was regarded as indicative of her being very
determined or very stubborn, depending on how one looked at it.
She had been diagnosed as having a psychotic depression as well as
anorexia nervosa, because she experienced visual hallucinations and kept
saying that she wanted to die. The visual hallucinations involved seeing
people who were dead. In the past, these visions of dead people had
frightened her, but now she had started to say that she didn’t mind if she
joined them. Other people could stab her or give her an overdose, she
said, but she would not do this; she could only try do die by starvation. As
part of her treatment on the eating disorder unit she was seeing a psycho-
therapist for individual sessions, but this person was not present at the
workshop.

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Education in psychosis

Discussion
In the ensuing discussion, the following issues emerged. First, in his
countertransference experience, the presenting SHO felt her illness
was like a bulldozer. He also complained of a monologue, mainly in
the form of a controlling silence by the patient. There was no dialogue
and only rarely did the patient seem near to tears.
Second, the SHO also wondered if her religious background played
a part as she had initially asked to see the visiting Catholic priest. He
was described as a warm and homely person. However, she now no
longer wished to see him.
Third, another SHO at the workshop recalled a time when he had
been on duty and had to be involved in her naso-gastric feeding. At
first he had felt sad for her, then frustrated and angry with her resist-
ance to intubation, which was extremely difficult for him to do. When
at last he succeeded with the intubation, he felt as though he was
raping her.
Fourth, another doctor felt that we were stuck at the physical level
of intubating her in response to her actions, and that we had no other
way of relating to her.
Fifth, apart from my SHO, all the other SHOs thought of the
hallucinations solely in phenomenological terms as part of the picture
of a psychotic depression. My SHO had been with me for several
months and, unlike the other SHOs, was a GP in training, rather than
a psychiatrist in training. He was not weighed down by phenomen-
ology training for exam purposes. He expressed a different view,
saying that he thought the hallucinations indicated a worrying shift in
the balance of forces within her, since at first she had been frightened
of an identification with dead people, but now she was not.

Teaching points
1 The psychotic wavelength
If anorexia nervosa and depression can be thought of as psych-
otic disorders, this means that we cannot rely solely on our
ordinary sensitivities to make sense of what is happening. We
have to tune into and relate to the specific psychopathology.
2 The psychotic and non-psychotic parts
In our work with patients with psychotic disorders, as Bion
said, we need to think in terms of two separate parts, not one

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Implications for management and education

person, and we have to deal with the psychotic part first (Bion
1957a). In anorexia nervosa, the psychotic anorexic part has a
fundamental hatred of appetite and is murderous towards any
sign of its presence in the non-anorexic part (Sohn 1985a). This
way of thinking can help the SHOs to understand why the
patient would not stab herself or take an overdose. In her mad-
ness, this behaviour would imply an appetite for something
and thus represent a need, however destructive this was. Thus
others would have to do these things to her; she could only kill
herself passively through starvation.
3 The limitations of the phenomenological approach
While the phenomenological approach is important for diag-
nostic purposes, a different approach is needed in a dynamic
clinical situation. The differing thoughts in the group about
how to approach the visual hallucinations illustrate the possi-
bility of viewing the patient’s hallucinations from different
perspectives.
4 From monologue to dialogue
The psychotic part of the patient repeatedly evacuates the
insight arrived at by the work of the non-psychotic part, in
the never-ending conflict between the life and death instincts.
Hence the non-psychotic part had a need for a warm priest as a
supportive figure. The psychotic part disowned these feelings,
through projection, into the priest and then did not want to
see him anymore. If one thought of the patient’s behaviour in
a more conventional way, one might simply have concluded
that she had just showed ambivalent feelings towards religion.

The SHOs’ basic problem, which applies to all cases presented at

psychosis workshops, is how to find a way of talking to the patient
meaningfully: how can we convert the psychotic monologue into
a dialogue?
Her mental conflict has been reduced, through projection, to a
physical battle around feeding. The conflict has to be reinstated as a
mental problem while, at the physical level, the anorexic part is being
made to realise that the non-anorexic part is being given equally
powerful support, when it is having to survive during a dominating
anorexic episode.
Over many years, with the aid of psychotherapy, the non-anorexic
part may be helped to grow in reflective strength. However, at this

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Education in psychosis

moment in time the SHO needs a meaningful framework to orientate

him and enable him to find a way of talking to the patient about the
battle of the two parts, and help the staff to support the dominated
tearful part that wants to live and train as a teacher, but is currently
being held in a suppressed state. Only once this has been spelled out
to the patient can periods of non-naso-gastric feeding be tried out in
the context of an attempted mental dialogue, even if for long spells
all sanity remains projected into the staff and the anorexic behaviour
remains predominant.
In all psychotic disorders, staff may have to endure stages of
seemingly never-ending intransigence, such as those that occur with
protracted episodes of depression in hospitalised cases, where it is
necessary to wait for the episode to relent. During these periods, it
is important to keep a live dialogue going, even if at times it feels as
though this is confined solely to the staff and carers.
The clinical situations encountered in general psychiatry may
sometimes feel as though they have little relevance to the world of
an everyday analytic psychotherapy practice, although they can help
one to feel for analysands who may have had to cope with living with
a parent with a major psychotic disorder in their childhood. However,
if the analytic concepts introduced are pertinent to the presenting
problem, they can be extremely helpful for the SHOs.
For a time, the SHOs are freed from the restrictions of purely
phenomenological thinking and enabled to take an interest in their
own responsiveness to the material. Through the introduction of the
analytic framework, they are provided with the means to begin to
develop confidence in speaking to their patients, and to move the
relationship from a monologue to a dialogue, even if at first this takes
place only in their minds. It is hoped that those SHOs most receptive
to these ideas, and I have found this already to be the case in practice,
will form the basis for the next generation of medically trained
psychoanalysts, fulfilling Freud’s wish that a psychoanalytic presence
remains in the field of general psychiatry.

A specialist registrar’s experience of being with a patient

with schizophrenia

I am grateful to Dr Sally Davies for permission and encouragement

to use the following material for educational purposes.

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Implications for management and education

The patient was a young man aged 27 with a diagnosis of schizo-

phrenia. He was seeing a consultant general psychiatrist in his out-
patient clinic and was on conventional antipsychotic medication. He
had taken illicit drugs in the past, but not recently. He had expressed
a wish for individual help and was referred by the consultant to the
psychotherapy department for this.
The following material includes a précis from three sessions illus-
trating the experience of direct contact with the mind of someone
functioning in a predominantly psychotic way. He was being seen
weekly. The specialist registrar, understandably, had great difficulty in
following and recording the gist of the sessions, but they are presented
as experienced.

First session

The patient came in full of paranoid thoughts. He said, ‘They know what
he is thinking’. ‘They look at him’. He stares at someone, and it is someone
to check out feelings by the way he reads their response. He cannot mastur-
bate at home. Perhaps this is why he has a homosexual relationship –
mindless – with a friend. Then he feels ashamed of this, and becomes con-
cerned over his mother’s attitude and her disapproval of this behaviour. The
therapist says so she, the mother, becomes the concerned one. The patient
says that he brightens up when he plays tennis.

Second session (two weeks later)

He misses the next week’s session. He had a charity gig last week and
completely forgot about the session that he had missed. Mother was away
in Devon. They (he and his sister) found that they had run out of money and
had no food. So they decided to have a party (as if this would be a way
to get food).
As well as having problems with girls (meaning coping with the way they
looked at him), he related another problem. He was picked for jury service.
He was the foreman in a rape case. He was told not to discuss the facts of the
case outside. He found it very difficult not to do this. There was not enough
evidence to convict the person. He was worried that he was influencing
other members of the jury. What if he was guilty? He was worried that other
members of the family of the rape victim would find him and beat him up.

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Education in psychosis
He had written a song called ‘Sex Offenders’. People liked his song. A
long time after playing it in gigs, a girl made a comment, which he took to
indicate that she knew that he had written the song and he wondered how
she knew this. He was worried over sexual feelings. A man had given him
a massage. He said to the receptionist, ‘Maybe you are a paedophile?’
The receptionist said that it was him who was the paedophile (he had
recounted this story before).

Third session (a week later)

He had not slept very well. He worries that if he doesn’t sleep and it con-
tinues, it means that he is becoming very unwell. It preceded breakdowns.
Then he slept OK so it was all right. He said that the session last week had
been very useful as he had spoken about the jury service.
He is working with a friend in the recording studio. He didn’t sleep, then
the friend didn’t sleep (as if it was then the friend’s turn not to sleep). He
gets very emotional over music and can reach people (with it).
He says that there is a small room in the house where he sits with his
mother and they don’t use it very much. It is worse since the abortion of a
girlfriend, also with cocaine. He gave up everything to be a musician, gave
up normal jobs.
He feels responsible as a musician and has to keep doing it. He doesn’t
stop this when ill; there is a feeling with it that he can do anything.
There was some sadness around and the therapist said that the patient
was sad that he still couldn’t do everything.
He then talked of the effect of cutting his hair. He feels more free if it is
longer and then creative. With medication, his hair is thinner, so he cuts it
and feels like a schoolboy.
The specialist registrar noted in her mind that father was very distant
compared to mother, and linked this with the patient’s thought about
mother’s anger about the sex with the boyfriend, but she did not say this to
the patient.

The specialist registrar’s countertransference reactions

The doctor felt that she had to act as the patient’s ego function,
without frightening him by doing this, but she felt that she should be
realistic in her advice and response. She also had a fear of becoming an

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Implications for management and education

ideal object for him, with him becoming dependent on her for
answers, as if she would be responsible for creating this unhelpful
dependent problem for him. She felt that with borderline patients
there was a theoretical framework for diagnosis and approach, but not
with psychosis. She felt it was a different experience, but one which
all senior doctors should have as part of their training.

Discussion points

The doctor raises the question of whether there is a theoretical

framework of approach to psychosis that differs from the approach
with borderline states. Bion would say that there are two separate
parts of the personality, the psychotic and non-psychotic and, in
schizophrenia, one always has to deal with the problem presented by
the psychotic part first.
A basic problem and one that led the patient to seek therapy is that
the psychotic part needs someone to think for him, as he is incapable
of doing this. However, since he attacks any separate person because
they represent a threat to an omnipotent state, he gets into dreadfully
confused states with his objects.
We can follow this theme in the material presented above. If he
projects out into people, they immediately know his feelings and this
is a disturbing experience. He has no container for his masturbatory
phantasies, i.e. no container breast/mother. This contributes to the
countertransference feeling that, unlike the situation with borderline
patients, where the primary complaint by the patient is lack of under-
standing containment from mother and a premature ejection into
the real world, here there is felt to be no containing framework
whatsoever.
The patient is aware that his view of mother’s reaction to the
homosexual relationship is linked to his attack on the mother or
maternal breast. He doesn’t really feel that he has an established adult
homosexual orientation, and sees the homosexual relationship as
mindless, the aim being to obliterate difference. He feels that the
mother linked to an adult mind and sanity would not approve of this
behaviour.
The need for some firm intervention, which is not occurring, may
account for the therapist’s thought about the patient’s distant father.
The patient brightens up by physically distancing himself from his

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Education in psychosis

conflicting feelings about the nature of his homosexual behaviour,

by playing tennis. He then misses a session.
He then gets caught up in the excited mood of the charity gig, his
own idealisation of his music (idealised masturbatory triumph over
his conflicts) and he completely forgets the next session. The therapist
is felt to have gone away, like his mother who is on holiday in Devon.
He has turned the situation around so that it is the therapist that has
left him rather than the other way round, with him missing the session.
He then runs into trouble, with no food being provided by the
therapist mother, so resorts to manic states with idealisation and
attacks on awareness. This is manifest in the material about influ-
encing others’ minds, the rape case and his idea of persuading the jury
that the accused is not guilty, idealising his song on ‘sex offenders’,
and worry that others will see through his behaviour and see his
sexualised excited destructiveness, in the reference to the paedophile.
In the final session there seems to be an attempt to put his critical
thoughts to sleep by becoming more manically excited over the
power of his music, which gives him power over all others and enables
him to become the universal provider, triumphing over the mother
therapist. By projection of disturbing insight into others he distances
himself from awareness and reduces the risk of a more extreme manic
breakdown leading to hospitalisation.
The attack on the container is returned to in the reference to the
abortion, use of cocaine, and his renunciation of life to be the omni-
potent musician, leading to his comment on the very little used small
shared room for him and the mother/therapist.
The therapist is subjected to the experience of a non-stop mono-
logue, with very little room for the development of any shared
reflection on the functioning of the patient’s mind.
The patient’s wish to actualise a state of total omnipotence where
he could help everyone through his music was linked to his masturba-
tory phantasy that he could renounce the real world in which he
needed a relationship in order to develop his thinking. The therapist
articulated his sadness over his failure to achieve this. Perhaps taking
on his feelings and becoming like a friend sharing his musical record-
ing made him feel better because he had found someone to take his
projections. This is suggested by his comment that he felt better after
he recounted the jury service story to the therapist.
However, the wish to achieve some magical ideal state either by
being the ideal provider, or alternatively by the therapist assuming this

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Implications for management and education

role, leads to the therapist’s countertransference concern that she has

allowed herself to be treated as an ideal and that this was not helpful
for the patient.
Rey (1994a) described what he termed the claustrophobic-
agoraphobic dilemma as a dominating feature in schizophrenia. The
patient wants to distance himself in order to be free from awareness.
He does this by projecting into the therapist and then missing the next
session. However, he then finds himself without a needed mother/
therapist so he returns to his sessions and the cycle of distancing
through projection repeats itself.
The therapist, who has allowed herself to be open to receiving the
patient’s powerful projections, is left trying to process her feelings.
The non-psychotic part of the patient’s mind feels frightened of being
taken over by the manic state of mind, while the manic state of mind
does not take kindly to being scrutinised. So the feeling that the
therapist is left with is that she needs to act as an ego function, to do
the thinking for the patient, but without frightening him by exposing
him to the full awareness of his state of mind.
One can appreciate that the issues to be considered here are very
different from those in the case of a non-psychotic patient. For a
specialist registrar an experience like this may help them to develop a
deeper feel for the way that the mind works in psychosis. They will
then be able to use the experience gained in other encounters within
general psychiatry.
A common feeling that results from involvement with a patient in a
psychotic state is of being left with a headache if one doesn’t impose
some rationality on the material. This is a reaction to the wish of the
psychotic part of the patient to attack thinking and the therapist’s
mind. The case material illustrates this.
It is always easier to be in the role of the supervisor. The therapist
brings the couple, the patient and themselves, to supervision. In super-
vision one has the opportunity to make slow action replays, as I have
done here, to try to make sense of material that is produced with
bewildering speed in the sessions. The trainee needs the opportunity
to work with an experienced supervisor in order to enable them
gradually to develop a framework of approach to the patient and begin
to gain the confidence to make potent interpretations.
In an ideal world all specialist registrars would have the opportun-
ity to gain one-to-one clinical experience with a psychotic patient.
A period of personal therapy also helps enormously in gaining

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Education in psychosis

confidence in relating to the inner world, and is to be encouraged in

all trainees who seek to learn to do this, not merely in those who
wish to pursue formal analytic psychotherapy training.

Referral of patients with schizophrenia: identifying the role

for the psychotherapist

Introduction

I am grateful to Marcus Evans for his permission to use this clinical

material, shared in a supervisory setting. He presents from the position
of an experienced analytic psychotherapist, involved in relational work
between an NHS psychotherapy clinic and local psychiatric services
(Evans 2006). He often found that his view of the patient’s needs
differed significantly from that of the referring psychiatric team.

Background history

The patient was a 30-year-old man referred with a diagnosis of paranoid

schizophrenia, although this was now disputed by his team. He had been
seen in weekly psychotherapy for six months. Mr Evans took him on the
condition that he continued to be seen by a psychiatric team for ongoing
medication and psychiatric care.
The patient’s parents separated when he was 3 years old. He was angry
with his father because he did not take any interest in his upbringing, and
angry with his mother because she remarried when he was 15 years old
and no longer gave him her undivided attention. He successfully completed
several O Level exams, but then started smoking ‘skunk’ (a strong form of
marijuana) with a group of school friends and dropped out of the sixth form.
The patient became obsessed with stalking his mother, and this resulted in
her taking out a restraining order, for him not to visit.
When he was first admitted to hospital, the patient said that he was
gathering evidence that he was the son of God. He expressed a belief that
he would die when he reached 33, the age that Christ died. When the
patient was put on antipsychotic medication, his mental state improved
quite quickly. He then asked for someone to talk with and was referred for
psychotherapy.
A week prior to the first of the sessions described below, the patient had

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Implications for management and education
stopped taking his medication and his therapist had told his CPN of his
concern about this.

First session

The patient began by expressing regret about the way he had treated his
parents, saying that he should have had more control over his feelings and
that he had been ‘drugging’ himself with the notion that his parents were
to blame for his problems.
However, he agreed with the therapist that while he was expressing his
wish to control his own thoughts, he also felt at times that he was being
mocked like Christ, the son of God. He said that he was bored with those
thoughts, but then added that he did not like to be seen on the way to his
sessions. The therapist linked this to his humiliated feelings about his depen-
dency needs, similar to his saying that he couldn’t blame everything on
his parents.
The patient then described powerful feelings of despair, ‘I feel lost’.
Towards the end of the session he reported paranoid delusions of being
watched in his flat in the evening, which resulted in him going round to his
mother in the middle of the night and repeatedly banging on her door until
she called the police.
In the intervening week the therapist phoned the CPN and said that he
was worried about the patient, and that he understood that he had stopped
taking his medication. The CPN was again alerted to the therapist’s concern
over his mental state and said that he would phone the patient, but he
was then not in his flat at the time of the arranged visit. The CPN told the
therapist that he would try again, although the tone in his voice indicated
that he thought the therapist was being rather anxious and overly protective
of the patient.

Second session

The patient admitted that he had received notification from the CPN of his
visit but said that he had to leave the flat as people were following him. At
the same time, he denied that he was in a paranoid state or that he was
Jesus, but said that he was conducting his own studies on hieroglyphics
and the meaning of numbers.
His therapist pointed out that while his feelings of need were indicated by

296
Education in psychosis
his attempt to see his mother again, at the same time he was denying that
there was anything wrong and claiming that he did not need help from the
CPN. He recalled how the patient had on one recent occasion gone round
to his father and tried to jump off the balcony. The patient said that it was a
drug-related problem that had made him paranoid. In this way the psychotic
part continually tried to minimise the extent of his illness.
A week later his CPN reported that he had seen the patient, could find
no evidence of psychosis, and was planning to discharge him. This was
despite contradictory feedback from his therapist, who then contacted the
consultant psychiatrist, who felt that the patient had improved with therapy.
The psychiatrist agreed that the patient was a vulnerable man and needed
medication, but he did not have direct authority over the community health
team’s caseload. The consultant was not sure about the patient’s diagnosis
and thought that he might be suffering from a drug induced psychosis rather
than schizophrenia, despite the psychotherapist’s statement that the delu-
sional system appeared pretty fixed and that the patient had not taken illicit
drugs for several years.

Third session

The patient came to this session in a very different mood – oscillating

between feelings of pain, humiliation and mania. He had seen his consult-
ant who had put him on some new antipsychotic medication. He had also
been to court as a result of breaking his restriction order, and the judge
had warned him that he would be sent to prison if he broke it again. He said
that he felt very humiliated and was worried that he would be put in prison.
At this point he felt in touch with the seriousness of his situation, but then
he started to talk about a situation in which he was with someone who
smashed up a snooker hall. He described putting numbers together in a
way which revealed hidden meanings and elaborated on his understanding
of hieroglyphics.
He did not turn up for his next appointment as he had been remanded
in custody after another attempt to break into his mother’s house. He sub-
sequently received a lengthy prison sentence. His probation officer, who
had interviewed him the day before the incident, felt guilty as she had asked
him a lot of probing questions. He had become more and more bizarre as
the interview went on and she worried that he could not cope with insight.
His therapist was left asking himself similar questions. He wondered
whether the psychotherapy was making the patient worse as insight seemed

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Implications for management and education
to provoke a vicious counter-reaction and wish to ‘smash up’ his mind. Also
when the patient talked in an insightful way, there was a question about the
function of this talk: to what extent was the patient sharing a problem he
wanted help with and to what extent was he was getting rid of the insight
into his therapist?

Discussion

Psychotherapy departments in the UK exist in a changing world

where they will be expected to become more involved with psychotic
disorders within the Community Mental Health Centres. Psycho-
therapists will need a different theoretical framework to the one they
are accustomed to work with when approaching problems presented
by non-psychotic disorders.
The first issue is to establish agreement with the general psychiatric
team as to what the patient’s needs are. In this case, the team disagreed
on this patient’s diagnosis as, for short periods, he was able to rational-
ise his paranoid states as the result of his previous drug related
psychosis.
Evans observed that what appeared to be insight was in fact an
evacuation by the psychotic part of awareness arrived at by the work
of the non-psychotic part of the patient (Meltzer 1966), similar to the
function served by dreams in psychotic disorders (see Chapter 12).
The experience within the sessions indicated the patient’s very limited
ability to stay with psychic pain rather than evacuate and return to
delusional solutions. The primary issue was not that insight made
him worse, but rather that contact through the sessions and interview
allowed him to begin to appreciate the fragile state of his mind.
From his work with the patient, it quickly became evident to Evans
that the appropriate diagnosis was of a longstanding paranoid schizo-
phrenic illness, with all the management implications attendant on
such a diagnosis.
A diagnosis of longstanding severe paranoid schizophrenia means
that a dedicated psychiatric team needs to be in place on an open-
ended basis, with a designated key worker monitoring the patient’s
medication, and working gradually to establish an effective exoskel-
eton (see Chapter 17), consisting of supervised residence and day
placement activity. The team working with the patient had not
accepted his diagnosis and they were unable to respond appropriately

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Education in psychosis

to his relapsing state. In fact he should have been admitted to hospital

on a formal basis and should not have ended up with a prison sen-
tence, as it was clear that he was in a psychotic state when he broke
the restriction order to visit his mother.
It was due to his background clinical experience that Evans was
able to identify the lack of clarity and firmness within the team’s
approach and he did his utmost to try to ensure that it was addressed.
This became his central role as the involved psychotherapist.
Psychotherapists are now being asked to provide a meaningful
presence within general psychiatry, while still wishing to retain space
and time for their own work with less disturbed patients. Becoming
aware of how the issues presented in psychotic disorders differ from
those in neurotic and borderline states can help psychotherapists to
prioritise a review of the state of the support being provided by
the responsible psychiatric team, rather than feeling that their role is
confined to providing individual therapy for all patients on request.

Overall summary

In this chapter I have considered the importance of education for those

involved in the area of psychosis, highlighting the fact that the worker’s
needs will differ depending on their stage of training. Non-medical
psychotherapy trainees need six months of psychiatric experience at
minimum. For senior nurses, postgraduate analytically based clinical
courses can deepen their individual capacities for self-containment.
For junior doctors new to psychiatry, a psychosis workshop can serve
as an important space for reflection. For those who are more advanced
in training, seeing an individual case with supervision can be an
enlightening experience. Finally, for experienced psychotherapists the
challenge will be to find a way of relating effectively to the increasing
demands from the local psychiatric services.

299
21
Conclusion
Psychoanalytic attitudes to general
psychiatr y and psychosis

Freud did not share the oft-expressed view that general psychiatry
and psychosis are an arid area for analytic exploration.
In 1916, writing on the subject of ‘Psycho-analysis and psychiatry’
as part of his Introductory Lectures on Psychoanalysis, Freud commented,
‘There is nothing in the nature of psychiatric work which could
be opposed to psycho-analytic research. What is opposed to psycho-
analysis is not psychiatry but psychiatrists’ (Freud 1916–1917b, p. 254).
This would make for a lively debate at the AGM of the Royal College
of Psychiatrists!
In a later paper in the Introductory Lecture Series on ‘The libido
theory and narcissism’, Freud goes further in support of the need for
an analytic presence in general psychiatry. He writes:

There are difficulties that hold up our advance. The narcissistic

disorders and the psychoses related to them can only be deciphered
by observers who have been trained through the analytic study of
the transference neuroses. But our psychiatrists are not students of
psycho-analysis and we psycho-analysts see too few psychiatric
cases. A race of psychiatrists must first grow who have passed
through the school of psycho-analysis as a preparatory science.
(Freud 1916–1917a, p. 423)

Ernest Jones, the founder of the British Psychoanalytical Society,

added his view in a paper entitled ‘Psycho-analysis and psychiatry’
(Jones 1930). He observed that the so-called normal individual, the

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Conclusion

neurotic, and the psychotic have reacted differently to the same

fundamental difficulties of human development, and commented:

Parenthetically, I wish to express here my conviction that the stra-

tegic point in the relationship between the three fields is occupied
by the psychoneuroses. So-called normality represents a much
more devious and obscure way of dealing with the fundamentals of
life than the neuroses do, and it is correspondingly a much more
difficult route to trace. The psychoses, on the other hand, present
solutions so recondite and remote that it is very hard for the obser-
ver to develop a truly empathic attitude towards them, and unless
this can be done, any knowledge remains intellectualistic, external,
and unfruitful.
(Jones 1930, pp. 487–488)

This book has argued that in order to develop what Jones (1930)
described as ‘a truly empathic attitude’, we need to tune into the
psychotic wavelength; ordinary empathy, applied to non-psychotic
disorders, is insufficient.
Over the years psychoanalysts have sometimes attempted to impose
their own views to explain the behaviour of psychotic patients.
Reacting to the inhumanity of the early physical interventions,
leucotomy and insulin coma, Laing and the anti-psychiatry move-
ment blamed schizophrenia on society’s intolerance of eccentricity
(Lucas 1998). The exponents of this approach later became dis-
enchanted when the psychosis did not go away with their laissez-faire
attitude. In the United States, at Chestnut Lodge, the roots of
psychosis were attributed to infantile trauma, following Fromm-
Reichmann’s (1950) concept of the ‘schizophrenogenic’ mother. In
the UK during the 1960s, emerging Kleinian theory was applied to
the mind in psychosis and led to an enthusiasm for treating individual
cases of schizophrenia through psychoanalysis. Many seminal insights
resulted from this work (H. A. Rosenfeld 1965; Segal 1950; Sohn
1985b). The prevailing climate of optimism also led to the creation
of specialist analytic units in the NHS at the Shenley and Maudsley
Hospitals (Jackson 2001a). However, the enthusiasm faded and the
specialist centres eventually closed, perhaps partly in consequence
of the dawning realisation of the intransigent nature of chronic
psychoses.
Following on from the work of Klein, and based on his individual

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Implications for management and education

analytic case studies, Bion introduced a completely new perspective

to psychosis, with his consideration of a psychotic part of the person-
ality which develops and functions completely differently from the
non-psychotic part (Bion 1957a). Bion urges us to keep these two
separate parts in mind and, in all major psychotic disorders, always
to address the needs of the psychotic part first and foremost. It has
been left to those few analysts still working in the field to add Bion’s
insights to preceding theories, in order to assemble a framework that
is both relevant to the task of relating to patients with psychosis and
can aid junior doctors in their work.
In modern-day psychiatry, with its emphasis on evidence-based
approaches, everything that is undertaken is expected to be open to
objective measurement. At present, this does not include evidence
arising from a consideration of the individual clinician’s countertrans-
ference experience. Such evidence would be regarded as too subject-
ive and unscientific, and yet it is vital in enabling us to decipher the
meaning of experiences with psychotic states. I have found it essential
to provide space in psychosis workshops to support the SHOs in the
exploration and valuing of their individual emotional experiences,
helping them to learn not to dismiss these as idiosyncratic.
In the introduction to his book, Sex, Death and the Superego, Ron
Britton (2003) compares the current emphasis on an ‘evidence-based’
approach in medical research to what he terms an ‘experience-based’
one. He points out that, in contrast to learning new medical skills, it
takes decades to gain experience in psychoanalysis. In the mean time
the young doctor has to rely on information gleaned from papers and
from the supervision of others who have already gained such experi-
ence. He warns, however, that we all carry ‘overvalued ideas’ that we
tend to treat as if they were ‘selected facts’ (Britton 2003). This means
that we must always retain our own critical faculties when listening
to others, no matter how experienced they may be in the field.
This idea is very relevant for the SHOs starting in psychiatry who,
when presenting at workshops, need to be encouraged to retain their
own critical faculties and individual sensitivities. Using Winnicott’s
terminology, we need to foster a ‘facilitating environment’ for the
development of the next generation of psychoanalytically orientated
psychiatrists (Winnicott 1965).
Despite a psychoanalytic training and seven years at the Maudsley
Hospital, including the privilege of working under Henri Rey in
the psychotherapy department seeing borderline patients, and on the

302
Conclusion

specialist psychosis inpatient unit run initially by John Steiner and

then Murray Jackson, nothing prepared me for arriving at Claybury
Hospital in 1978. The setting was a busy asylum, with responsibility
for 28 acute beds, 125 long-stay beds, a day hospital, outpatient clinics
and forensic visits. This was very different from the small caseload and
academic atmosphere I had encountered at the Maudsley.
I found that I had to act as a scavenger, gleaning any useful analytic
contributions on psychosis from wherever I could find them, while at
the same time being wary of any overvalued ideas, in myself or others.
In this way I began building up a framework with which to relate
to patients and their psychopathology. This has been a difficult and
demanding experience, but in the end it was a gratifying one through
which I have been able to offer help to new psychiatrists starting on
their own voyages of discovery.

Developing a model of the mind applicable to psychosis

As a psychoanalyst who works in general psychiatry, and carries clin-

ical responsibility for patients who are very ill and require protracted
admissions, my perspective is very different from that adopted by the
analytic psychotherapist in other areas of clinical work. The theory
I work with is one which must take into account the following issues.

The usefulness and limitations of the medical model

The medical model, as applied within psychiatry, is very limited in

flexibility. While it helps to clarify that we are dealing with a major
psychotic disorder, it provides only a snapshot, and cannot take into
account dynamic movement, since this requires introduction of an
analytic model. Without a psychoanalytically based teaching, SHOs
will not be introduced to this perspective.

The role of medication

Antipsychotic medication may help to act as a container and ease

the pathway in relating to the patient. Antidepressant medication
can sometimes be a helpful adjunct to facilitate the continuation of

303
Implications for management and education

analysis in severe cases of depression where, for example, the patient is

finding it difficult to get up for morning sessions. The fundamental
point is that when we are dealing with psychosis, we have to relin-
quish the omnipotent views (whether analytic or organic) that only
one pathway should prevail. In other words, we need to be prepared
to introduce flexibility into our thinking.

The notion of cure

Over the years many optimistic attempts have been made to cure
schizophrenia, from both the organic and analytic perspectives. This
illness does not fit into our familiar preconceptions. When the
asylums closed in the mid 1990s, it was believed that chronic schizo-
phrenia was the result of institutionalisation. In theory effective
community care should have obviated the need for inpatient
beds. In fact the closure of the asylums led to an acute shortage of
beds in the district hospitals. During the alarming early years of
schizophrenia, with potential for suicidal acts, the danger is that
we may focus too much on an attitude of trying to achieve a cure.
The consequence of this therapeutic zeal may be that we lose sight
of the importance of providing support for the patient to come to
terms with the condition, by working to assemble a containing
environment or exoskeleton.

Theories of infantile trauma

Most analytic models of the mind place a central emphasis on infant-

ile trauma to explain development of psychopathology. However,
over-reliance on this approach may lead us into difficulties when
relating to patients with schizophrenia. What is needed is an open
mind in each individual case.

The need to differentiate psychotic processes from major psychiatric disorders

It is important to differentiate severe borderline states from schizo-

phrenia, since each has different implications for modes of manage-
ment and prognosis. Borderline patients can teach us a lot about

304
Conclusion

psychotic processes (Rey 1994a), and they can be treated using an

analytic approach. The transference has a particular intensity directed
to the therapist, while the patient may well be very committed
to the therapy.

A view on the death instinct

Nothing in Freud’s theorising has generated more controversy

among his followers than his introduction of the notion of an
inherent destructive force, the death instinct or death drive. Freud
introduced the concept to his metapsychology belatedly in order to
complement his notion of the life instinct. As Laplanche and Pontalis
(1973) pointed out in a detailed review of the death instinct, a
dualistic tendency is fundamental to Freudian thought. At first Freud
was tentative about the notion, but ended up strongly endorsing it.
He wrote:

To begin with, it was only tentatively that I put forward the

views that I have developed here, but in the course of time they
have gained such a hold on me that I can no longer think in any
other way.
(Freud 1930, p. 119)

Klein viewed envy as the external manifestation of the death instinct.

The question often arises, why not just view aggressiveness as a
positive reaction to frustration, without the need to invoke such a
draconian measure as the death instinct? When this point arose some
time ago in a discussion at a scientific meeting of the British Psycho-
analytical Society, I recall Hanna Segal saying that the best way she
could describe its manifestation in everyday life was ‘human bloody
mindedness’ – something that we can all recognise. This certainly
resonates with my own clinical experience when relating to patients
with major psychotic disorders.

Tuning into the ‘psychotic wavelength’

Identifying the dominating psychopathology, while still retaining an

overall empathy for patients in their struggles to cope with crises with

305
Implications for management and education

their limited mental capacities, is a central issue in teaching SHOs

to regard their patients as human beings rather than objectifying them
as ‘the psychotic’.

A patient who came into hospital because he was unable to cope with a
financial crisis had changed his name by deed poll to Jesus Christ, but he
complained that he was angry with God. He was unable to cope in
his present state, so in his psychotic way he had hoped that, if he changed
his name, God would help him out. Unfortunately for him, changing his
name had not resolved his financial troubles. We can feel sympathy for
his attempts to cope within his limited mental resources, rather than just
considering the presenting material in phenomenological terms.

The importance of the countertransference experience

Since patients in psychotic states make extensive use of projec-

tive mechanisms, our countertransference experiences are of crucial
importance when striving towards an overall understanding. For
example, since there are two separate parts operating simultaneously
in psychosis, we frequently find that we ask ourselves whether we
are being fair in doubting the veracity of a patient’s account. Is what
the patient is saying evidence of psychosis or is it the truth? If we
experience this doubting countertransference, it usually indicates
that we are in the realm of psychosis.
For the leader and participants of a psychosis workshop, it is a
common experience to feel that one will have nothing to contribute
when one hears florid psychotic material that makes no sense. It is
only with time that we come to recognise that we have been on the
receiving end of powerful projections from the psychotic part of
the patient. This part is engaged in evacuating and negating thoughts
that have been arrived at through the work of the non-psychotic
part. It is as if the psychotic part has a contemptuous murderous
reaction, a ‘so what!’ response to any thinking that might take place.
As the workshop proceeds, it begins to come to life as we hear
everyone’s associations to the projected material. This enables the
initial aridity to turn into a workshop that becomes creative and
fruitful.

306
Conclusion

The deciphering of ideographs and the relationship between hallucinations

and delusions

Bion (1958) described how the psychotic part of the mind is

incapable of thinking; it can only act as a muscular organ. It stores
memories, termed ideographs, formed through the work of the
non-psychotic part, in which it projects feelings, for the purpose of
evacuation or communication. Our task in everyday psychiatry is
to decipher the meaning of these ideographs. This is comparable
to solving crossword puzzle clues and is helped by the simultaneous
use of our countertransference experiences (Bion 1958). Such work,
importantly, introduces humour and interest into the team’s involve-
ment in work which might otherwise threaten to become arid,
demanding and soul-destroying.

A patient in a manic state complained that he had contracted avian flu. If

we think of this delusion as an attempt by the psychotic part to evacuate
his sanity, the symptom becomes alive and interesting, rather than just a
dry phenomenological description of a delusion requiring medication.
I described the avian flu that the patient had caught from chickens as his
attempt to fly away from his need to cooperate with our treatment for him.
I said that he was chickening out of attending the day hospital and receiving
full community support, rather than facing up to his problems with our help.
Interpreting in this way made the patient smile and helped the care team feel
less disabled by the patient’s mania.

The psychotic and non-psychotic parts of the mind

Most importantly of all, I have learned to think always in terms of two

separately functioning parts of the mind, rather than one person,
when relating to individuals with such major psychotic disorders
as schizophrenia, bipolar affective disorders, and major depressive
episodes. I would also include anorexia nervosa, as in the case briefly
described in Chapter 20.
As a general psychiatrist, whenever I am asked to consider section-
ing a patient under the Mental Health Act 1983, I have to determine
whether I am relating to a sane part of the patient, or to a mad
part masquerading as normal. Denial and rationalisation, rather than
hallucinations and delusions, are the commonest presenting symptoms

307
Implications for management and education

in psychosis. The patient’s denial and rationalisations can frequently

fool us into underestimating the severity of the disturbance in their
underlying state of mind. A common occurrence of this dynamic in
everyday analytic practice is in severe depression, where we might
think we are relating to a non-psychotic part which is seeking insight,
whereas the dominating psychotic part is not in the least interested in
understanding, since all it wants is fusion with an idealised object.
Psychoanalysts who are not familiar with working in general
psychiatry may still feel uncomfortable with the notion of the two
separate parts, rather than thinking in terms of split-off parts of the
personality requiring reintegration. Reintegration of split-off parts,
though a fundamental way of thinking in relation to the analytic
process, properly belongs to the workings of the non-psychotic part
of the personality. For myself, I find the concept of two separate
parts of the personality enormously helpful when I am trying to
orientate myself to the presenting psychosis. For example, if a patient
says that he or she is feeling fine, yet the nearest relative has alerted the
professionals to an alarming relapse, who are we to believe? It is
crucial, in my view, that approved social workers carry this model of
the two parts in mind when they are conducting assessments under
the Mental Health Act 1983, otherwise they can be left with the view
that asserts that the patient is fine and the problem lies solely with the
nearest relative.

308
Notes

1 Recently, on the initiative of the President of the British Psychoanalyt-

ical Society, Roger Kennedy, an NHS Liaison Committee was formed
to rectify this.
2 Bion’s complex interpretation of the ideograph, based on his knowledge
of the patient, was as follows:
The glasses contained a hint of the baby’s bottle. They were two
glasses, or bottles, thus resembling the breast. They were dark because
frowning and angry. They were of glass to pay him out for trying to
see through them when they were breasts. They were dark because he
needs darkness to spy on his parents in intercourse. They were dark
because he had taken the bottle not to get milk but to see what the
parents did. They were dark because he had swallowed them, and not
simply the milk they had contained. And they were dark because
the clear good objects had been made black and smelly inside them.
All these attributes must have been achieved through the operation of
the non-psychotic part of the personality. Added to these character-
istics were those I have described as appertaining to them as part of
the ego that has been expelled by projective identification, namely
their hatred of him as part of himself he had rejected.
However, in what Bion actually said to the patient in the session he
describes, he concentrated on the psychotic problem, that is, the need to
repair the ego. He said: ‘Your sight has come back into you but splits
your head; you feel it is very bad sight because of what you have done to
it’ (Bion 1957a, p. 58).
3 For a full appreciation of the breadth of his contributions, see Clifford
Yorke’s obituary of Tom Freeman in The Times (31 May 2002).
4 A version of this chapter was originally published as Lucas, R. (1998).

309
Notes
Why the cycle in a cyclical psychosis? An analytic contribution to the
understanding of recurrent manic depressive psychosis. Psychoanalytic
Psychotherapy, 12, 193–212.
5 A version of this chapter was originally published as Taylor-Thomas, C.
and Lucas, R. (2006). Consideration of the role of psychotherapy in
reducing the risk of suicide in affective disorders: A case study. Psycho-
analytic Psychotherapy, 20, 218–234.

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Index

Abenheimer, Karl 118 attention-seeking 273–4

Abraham, K. 197–8, 215, 216, 224 auditory hallucinations 21
affective disorders: psychotherapy role
in reducing suicide risk in 260–79; Barnes, Mary 120
psychotic wavelength in see Bateson, G. 120
depression management; manic Beck, A. T. 27
depression; puerperal psychoses beliefs: Britton 41–2, 81; and psychic
aggressiveness 55, 305; aggressive reality 81; see also delusions
phantasies 63; depressive anxiety and Bentall, R. P. 25–7
64–5; murderous assaults on strangers Berke, Joseph 120
76, 255 beta-elements (Bion) 99
agitated depression 225 Bion, W. R. 7, 29, 49, 243; agitation and
agitation 99–100, 214, 223, 225 the maternal container 225; alpha-
agoraphobia 225–6; claustrophobic- and beta-elements 99; bizarre objects
agoraphobic dilemma 77–8, 130, 85, 87–8, 90, 95; denial of projective
294 identification 133; differentiation of
Alanen, Y. O. 34–5 psychotic from non-psychotic
alpha-elements (Bion) 99 personalities 85–93, 134, 161, 200,
amisulpride 283 257, 285, 287–8, 302; dreams 161;
anaclitic mode (Freud) 105 hallucination 93–6; ideographs 90–1,
analyst-centred interpretation 80, 133 307, 309n2; Laing and 121–2; ‘On
Anna O (Bertha Pappenheim) 81 arrogance’ 132–3; pathological
annihilation dread 86 projective identification 67; superego
anorexia 307; anorexic states of mind 230, 231; theory of thinking 90–1,
75; psychosis workshop 286–9 96–100
antipsychotic drugs 22, 110, 111, 244, bipolar state autonomy 276
283 birth trauma 277–8
anxiety: castration 65; depressive 64–5; bizarre objects 85, 87–8, 90, 95, 131, 172
earliest psychotic anxieties (Klein) Black, D. M. 56
66–7; persecutory 63, 64, 67 Bleuler, E. 102, 203
appersonation 102 borderline psychopathology: clinical
ASWs (approved social workers) 7, 8–9, aspects of borderline states 126–9;
256–7 countertransference 137–9, 274;

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borderline psychopathology – Contd. clozapine 244, 283
differentiating countertransference in Clunis, Christopher 247–8
depression and 274; differentiating cognitive analytic therapy (CAT) 41
psychotic processes from psychotic cognitive-behavioural therapy approach
disorders 125–41, 304–5; Rey 76–8; to delusions 37–43
theoretical aspects of borderline states Cohen, M. B. et al. 201
129–35; treatment parameters for Coltart, N. 120
borderline states and psychotic communication: confidentiality and
disorders 139–40 140, 240–1; conversion of psychotic
Bourne, S. et al. 215 monologue into a dialogue 276–7,
breast: attack on maternal breast 292; 288–9; delusions as 163–4;
envy directed towards the breast 56; differentiation of psychotic from
the good and bad breast 63, 168; non-psychotic 146–8, 156, 257 see
‘greedy vagina-like breast’ (Bion) 99; also tuning into the psychotic
intolerance of frustration and the wavelength; making contact with and
absent breast 97–8; and the magical apparently inaccessible state of mind
penis 131, 199; narcissistic fusion 152–4; and the sense of truth 100;
with feeding breast 197; part-object understanding in countertransference
relationships to the breast 62, 78, 284–5, 306
199; repair to the breast 131, 199; concreteness: in borderline states 130–1,
see also maternal containment 132; concrete projection 65; concrete
Britton, R. 41–2, 56, 57, 113, 200; belief symbolisation 130–1
and psychic reality 81; borderline condensation, Freud 48, 158
primary relationship problem 133–4; confidentiality 140, 240–1
ego and superego 82; ‘evidence- confusional states (Rosenfeld) 71
based’ vs. ‘experience-based’ research container: analyst’s provision of an
302; humour 178; Oedipal illusions understanding container 128; attack
81–2 on 292, 293; maternal see maternal
bulimic states of mind 75 containment; medication as 303;
Bullard, Dexter 108 parents as 235; in schizophrenia and
Bullard, Ernest 107–8 borderline states 77, 131–2
Cooper, David 120
Care Programme Approach (CPA) countertransference: in borderline vs.
248–9 psychotic patients 137–9; danger of
case reviews 9 underrating severity of depressive
castration anxiety 65 psychopathology in 273–4;
CAT (cognitive analytic therapy) 41 delusional countertransference
CBT (cognitive-behavioural therapy) experiences 128; in depression 229,
approach to delusions 37–43 273–4; differentiation in depression
censorship 53 and borderline states 274; disturbing
Chestnut Lodge 29, 51, 107–14, 168, feelings in suicidal cases 254–5,
188, 301 260–79; doubt in 176–8; effects on
classification in psychosis 16–19 therapeutic alliance 43; humour,
claustrophobic-agoraphobic dilemma humanity and perseverance in
77–8, 130, 294 178–82, 183; importance of the
Clay, J. 121 experience 306; and modification of
Claybury Hospital 33, 144, 303 therapist’s superego 265–6;

326
Index
monitoring changing experience of depression: agitated 225; birth trauma
171–3; paralysis in 173–6; presence and 277–8; borderline personality
throughout hospital setting 6; disorders and 140;
specialist registrar’s reactions with countertransference in 229, 273–4;
schizophrenic patient 291–2; tuning danger of underrating severity of
sensitivities in see tuning into the depressive psychopathology in 273–4,
psychotic wavelength; understanding 308; the depressive position (Klein)
communications through 284–5, 306; 63, 64, 68–9; differentiating
understanding delusions through 6, countertransference in borderline
33; utilisation in psychosis 166–83 states and 274; dreams and the
Cox, J. et al. 216 depressive position (Bion) 95; grief
CPA (Care Programme Approach) reactions 222 see also mourning;
248–9 identification with idealised parental
curiosity 133, 134, 225 figure 42–3; management see
depression management; manic see
Davies, Sally 289 manic depression; melancholia see
day hospitals 36 melancholia; nameless dread and
death instinct 55–8, 103–4, 105, 251, 99–100; neurotic/reactive 204, 215,
305; anxiety and 64–5; in conflict 218, 221–2; normal 221; post-natal
with life instinct in schizophrenia 204 see also puerperal psychoses;
243; envy as earliest externalisation of psychoanalytic understanding of
63, 105, 305 223–6; psychotic 52, 64, 215–16,
defence mechanisms: Freud 54–5; 222–3, 274–5 see also puerperal
hallucinations as 110; manic 67–8, psychoses; superego in 220, 229–32;
199; projection see projection transference in 228
delusions: analytic understanding of depression management 220–32;
cognitive approach 41–3; as attempts medication 205, 227–8, 241, 303–4;
at recovery (Freud) 47, 49, 95; ‘bizarre moving from monologue to dialogue
objects’ as delusional formations 85; 276–7; psychotherapy role in
CBT approach 37–43; delusional reducing suicide risk 260–79;
countertransference experiences 128; puerperal psychoses 205, 217–19
dreams and 157–65; emotional depressive anxiety 64–5
meaning 6; grandiose, in puerperal depressive equivalents 227
psychosis 206–7; hallucinations and derealisation 223, 226
their relationship to 307; medical destructiveness: destructive attacks on
model 36–7; narcissistic 224–5 see also reality and the self 247–59;
narcissism; Pao 109–10; persecutory destructive impulses 86; destructive
168; in phenomenological approach narcissism 72; ego-destructive
to psychosis 20–1; projection and 49 superego 56–7, 80–1, 82, 230–1, 278;
see also projection; psychoanalytic and envy as destructive projective process
CBT approaches 40–1; restorative 63; Freeman 104; innate 52, 57, 105
(Steiner) 79; understanding 6, 33, see also death instinct; murderous
163–4 assaults on strangers 76, 255; suicidal
dementia praecox 19 see suicide
denial 7–8, 30; countertransference and displacement 159, 208; Freud 48, 158
138–9; Freud 49, 54 dissociation 94, 158, 275; dissociated
depersonalisation 223, 226 way of speaking 266–7, 275

327
Index
dread, nameless 99–100 Evans, M. 295, 298–9
dreams: as guidelines 157–8; in context existential birth (Laing) 117
of psychosis 94–5; in context of existentialism, psychoanalysis and
psychotic disorders 160–2; delusions (Laing) 118–20
and 157–65; importance as indicators
of progress in therapy 158–60; Fairbairn, R. 29, 105
puerperal psychosis patient 213, false self 117, 118
214 fantasies see phantasies/fantasies
drugs see medication Fenichel, O. 188
first-rank symptoms, Schneiderian 21
ECT (electrocompulsive therapy) 115, Fonagy, P. and Bateman, A. W. 125
189, 205 Freeman, T. 24, 101–6
Edgar, David 120 Freud, A. 102
education: in counselling skills for Freud, S.: anaclitic mode 105; analytic
community workers 215; family 22; study of psychoses 5–6; co-existence
of patients’ partners 228; psychosis of the psychotic and non-psychotic
workshop: ‘an anorexic patient’ 161; countertransference 170; death
286–9; psychosis workshop: instinct 55–8, 105, 251, 305; defence
‘deciphering a somersault!’ 281–6; mechanisms 54–5; delusions as
psychotherapist role and referrals in attempts at recovery 47, 49, 95;
schizophrenia 295–9; relating to depression 223–5; displacement 48,
psychotic disorders 280–99, 302–3, 158; dreams 157, 158–9; ego 65;
306; a specialist registrar’s experience instinctual dualism of forces 72;
of being with a patient with mania 197; melancholia 52, 53,
schizophrenia 289–95 216–17, 222, 224, 230; mourning
ego: bodily (Freud) 65; death instinct 222, 251–2; narcissism 47, 50–2, 53,
and 56–7; defence mechanisms 54–5 216–17, 224–5; Nirvana Principle
see also defence mechanisms; ego loss 103–4; pleasure principle 52, 53, 103;
224; Freud’s structural model 53; projection 47, 49, 54; psychoanalysis
introjective identification 66; mania and psychiatry 58–9, 300; Schreber
and the ego 197; relationship to case 47–9, 50; structural model and
superego (Britton) 82 psychosis 52–3, 54–5; superego 64,
electrocompulsive therapy (ECT) 115, 229–30; symbolisation 48, 158;
189, 205 thinking 88–90; topographical model
emotions: emotional meaning of 52–3, 103; transference 51, 53, 167–8;
delusions 6; and relapses in Turkington on the Schreber case
schizophrenia 22 39–40; underlying psychopathology
empathy 33; ‘truly empathic attitude’ 215
301 see also tuning into the psychotic Freudian perspective of T. Freeman on
wavelength psychosis 101–6
envy: death instinct and 63, 105, 305; Fromm-Reichmann, F. 108, 110, 142–3
ignored 145; indiscriminate 242; frustration tolerance/intolerance 97–8,
paranoid-schizoid position 63; 200
towards the breast 56 fusion fantasies 127
Esterson, Aaron 120
evacuation of insight 136, 162, 165, 288, Gelder, M., Harrison, P. and Cowen, P.
293 37

328
Index
Gelder, M., Mayou, R. and Cowen, P. insecurity 99–100, 225; ontological 117,
18 118, 119
Giovacchini, Peter 143 intensive psychotherapy 51, 108, 109,
gratitude 63 110, 111–12
Greenberg, J. 108 internal worlds 34, 226; Freud 48;
grief reactions 222; mourning 198, 222, getting in touch with 130; Klein
226, 251–2 61–2; and manic reparation 69
guilt 63, 68, 95, 131 internalisation 53; of reciprocal role
Guntrip, H. 29 procedures 41
interpretation, transference 10, 32–3, 93,
hallucinations: auditory 21; Bion 93–6; 127, 133–6, 167–8
as defence mechanisms 110; delusions introjection 168
and their relationship to 307; dreams introjective identification 66
in the context of psychosis 94–5; as Isaacs, S. 119
evacuations 95–6; frequency 96;
genesis 93; Pao 110; psychotic and Jackson, M. 41, 188
hysterical 94 Jacobson, E. 221
hatred 104; of reality 86, 122 James, W. 118
Heimann, P. 170 Jones, E. 300–1
Higgs, Roger 31–2 Joseph, B. 72–3, 170
Hinshelwood, R. D. 69 Jung, Carl 170
homosexuality: case example of a Katan, M. 105
schizophrenic patient 290–3; fears of Kendell, R. E. et al. 205
130; homosexual object relationships Kierkegaard, S. 118
50; unconscious homosexual Kingdon, D. G. and Turkington, D. 26
conflicts 48, 49 Kingsley Hall 120
hot cognition 39, 42 Klein, H. S. 199
humour 178–80, 183 Klein, M. 29, 105; death instinct 56, 57,
hysterical hallucinations (Bion) 94 63; the depressive position 63, 64;
envy 63, 305; gratitude 63; insecurity
id 53 and depression 225; internal world
identification: with the aggressor 54; 61–2; manic depressive states 198; the
conflict and 217; depression and paranoid-schizoid position 62, 63–4,
223–4; with God 88, 276; with 67; primitive superego 53, 57, 64, 198,
idealised parental figure 42–3; 230; projective and introjective
introjective 66; narcissistic identification 65–7; reparation and
identificate (Sohn) 74; with manic reparation 68–9
omnipotent internal mother figure Klerman, G. L. 111
200, 212–15; overidentification Kotowicz, Z. 119, 121
277; projective see projective Kraepelin, E. 19, 117, 187, 203
identification
ideographs 90–1, 172, 307, 309n2 Laing, A. 116, 118, 121
infanticide risk 205, 209–11, 217 Laing, R. D. 301; background 115–16;
infantile trauma theories 304 Bateson’s influence 120; The Divided
inference chaining 38–9 Self 115, 116–18; existentialism and
innate destructiveness 52, 57, 105; psychoanalysis 118–20; Kingsley Hall
see also death instinct 120; laissez-faire attitude to

329
Index
Laing, R. D. – Contd. Michels, R. 28, 29, 30–1, 32–4
schizophrenia 112, 120, 301; legacy Milner, Marion 118
121–2 Mitchell, J. 119–20
Laplanche, J. and Pontalis, J.-B. 55–6, mother: identification with omnipotent
166–7, 305 internal mother figure 200, 212–15;
learning from experience 98 maternal alpha-function (Bion) 99;
Lewin, B. D. 197 maternal breast see breast; maternal
Lieberman, J. A. and First, M. B. 28 containment see maternal
life instinct 199, 243 containment; maternal reverie 99
mourning 198, 222, 226, 251–2
McGlashan, T. 111–12 multidisciplinary approach to psychotic
Macquarrie, John 118 states 240–1
manic defences 67–8, 199 murderous assaults on strangers 76, 255
manic depression: case example 188–97; Murray, L. et al. 204
cycle of psychosis 187–202;
depressive phases (case example) nameless dread 99–100
191–2; dreams 160–2; manic phases narcissism: anaclitic and narcissistic
(case example) 193–4, 195–6; modes 105; conflict and narcissistic
puerperal psychosis and 205 identification 217; depression and
manic reparation 68–9, 131, 198–9, 276 224–5; destructive (Rosenfeld) 72;
Martindale, B. V. 35, 40–1 Freud 47, 50–2, 53, 105, 216–17,
masturbation 48, 70; masturbatory 224–5; narcissistic fusion with
phantasies 292, 293 feeding breast 197; narcissistic
maternal alpha-function (Bion) 99 identificate (Sohn) 74; narcissistic
maternal containment 225; borderline object relations 105, 225; oral 224
patients’ need for 132; failure 133, National Confidential Inquiry into
292; see also breast Suicide and Homicide by People
medical model of psychosis: Bentall’s with Mental Illness 255
criticisms 27; clinical implications negation 54
22–3; delusions 36–7; diagnosing neurosis 92, 105, 119
schizophrenia 19–20; incorporating neurotic depression 204, 215, 218,
an analytic perspective 23–4; mental 221–2
state examination 21–2; Nirvana Principle 103–4
phenomenology 20–1; rationale non-psychotic personality parts
behind classification 16–19; see psychotic/non-psychotic
usefulness and limitations 303 differentiation
medication: antidepressant and normalisation 42
anxiolytic 205, 227–8, 241, 303–4;
antipsychotic 22, 110, 111, 244, 283, object loss 105, 197, 222, 224, 226
303; role of 303–4 object relations: demand of the ideal
melancholia 52, 53, 216–17, 222, 224, object 275, 276; to a godlike figure
230 228; narcissistic 105, 225; object
memories, visual see ideographs related phantasies 50; in Oedipus
Mental Health Act 1983 see sectioning complex 133–4; part-object
under Mental Health Act (1983) relationships 62, 78, 132, 198–9;
mental health tribunals 7, 176, 256, 258 premature and precipitate formation
mental state examination 21–3 86; therapeutic support of 202

330
Index
Oedipus complex 53, 64, 119, 133–4; projection: of ‘aliveness’ 199; analyst’s
Oedipal illusions (Britton) 81–2 acceptance of unbearable projections
omniscience, sense of 98 128–9; ‘bizarre objects’ and 85, 95
ontological insecurity 117, 118, 119 see also bizarre objects; into the body
organic psychiatry 23–4 65, 227, 254; in claustrophobic-
organic psychoses 17, 102 agoraphobic dilemma 77–8, 130, 294;
O’Shaughnessy, E. 66–7, 80–1, 84, evacuation of disturbing insight 136,
231 162, 165, 288, 293; felt as depressive
overidentification 277 equivalents 227; Freud 47, 49, 54;
maternal reverie and the infant’s
Pao, P.-N. 109 projections 99; onto relatives 229; in
Pappenheim, Bertha (Anna O) 81 paranoid-schizoid position 62, 64;
paranoid-schizoid position 62, 63–4, 67, and reversal 7–8; as substitute for
168; borderline reversion to 132; thinking 200; see also
paranoid anxiety 64 countertransference; transference
part-objects 62, 78, 132, 199 projective identification 65–7; bizarre
patient-centred interpretation 133, objects and 87; destructive denial of
135–6 133; pathological 67, 87
penis: castration anxiety 65; idealised Proulx, F. et al. 248
151; magical 131, 199; manic 78, psychic retreats 79
199; as object of reparation 65, 78, psychoanalysis: Chestnut Lodge and the
199; as part-object 62 psychoanalytic treatment of
peripheral questioning 38 schizophrenia 107–14; existentialism
persecutory anxiety 63, 64, 67 and (Laing) 118–20; intensive
persecutory delusions 37, 78, 168 analytic psychotherapy 51, 108, 109,
phantasies/fantasies: aggressive 63, 65; 110; and psychiatry (Freeman) 101–6;
borderline patients 130, 131, 132; and psychiatry (Freud) 58–9, 300;
delusions as pre-existing fantasies psychoanalytic attitudes to general
109; fusion 127; identification of 274; psychiatry and psychosis 300–8;
internal phantasy world 69 see also psychoanalytic framework for
internal worlds; in manic depression understanding suicide 249–55;
78; manic reparation and 131, 199 see psychoanalytic understanding of
also manic reparation; masturbatory depression 223–6; relevance to
292, 293; narcissism and object- schizophrenia 28–34, 110, 111–14,
related phantasies 50; of paranoid- 245; see also psychotherapy
schizoid position 63; projection of 65, psychosis: in anorexia nervosa 286–9;
70, 87 see also bizarre objects; Bion see Bion, W. R.; classification
projection; of size 130; of suicide rationale 16–19; denial and
266–7; of surviving death 266; rationalisation in 7–8, 138–9, 156
unconscious 61–2, 65, 81 see also denial; rationalisation;
phenomenological approach to developmental perspective (Freeman)
psychosis 20–1 102–6; differentiation and stigma
Piaget, J. 131–2 25–8; dreams in context of 94–5;
pleasure principle 52, 53, 103 education in 280–99; Freud see Freud,
postpartum psychosis see puerperal S.; infantile trauma theories 304;
psychoses Klein see Klein, M.; Laing 119–20;
primitive catastrophe 133 manic depressive see manic

331
Index
psychosis – Contd. psychotic wavelength; Bion 85–93,
depression; medical model see 134, 161, 200, 257, 285, 287–8, 302;
medical model of psychosis; mind borderline states and psychotic
model applicable to 303–8; neurosis disorders 125–41; divergence
and 105, 119–20; and the non- between parts 92–3; Freeman 105;
psychotic part see psychotic/ functioning of the non-psychotic
non-psychotic differentiation; part 88; functioning of the psychotic
phenomenological approach 20–1; part 91–2; importance of 307–8;
post-Kleinian contributions 69–82; psychosis workshop reflections
psychoanalytic perspective on 3–9, 285–6; in resistance to change
16–44; psychotic organisations 200; in schizophrenia 29–30, 33,
(Steiner) 79–80; puerperal see 85–93, 156, 239, 242–4, 292; in
puerperal psychoses; schizophrenia suicidal cases 274–5
see schizophrenia; utilisation of psychotic transference 71, 167–8
countertransference in 166–83; psychotic wavelength tuning see tuning
workshops 281–9, 302, 306 into the psychotic wavelength
psychotherapy: demand on NHS psychotropic drugs 22, 110, 111
psychtherapy departments 298–9; puerperal psychoses 203–6, 215–19,
intensive 51, 108, 109, 110, 111–12; 278; case study: general psychiatric
and medication in the management perspectives (Mrs K) 206–9, 218;
of depression 220–32; role in case study: risk of infanticide (Mrs J)
reducing suicide risk in affective 209–11; case study: tip of an
disorders 260–79; see also iceberg? (Mrs L) 211–15, 216;
psychoanalysis identification with idealised parental
psychotic disorders: case reviews 9; figure 42–3
countertransference in borderline puerperal sepsis 204
and 137–9; diagnosis difficulties 8–9,
240; differentiating psychotic Rado, S. 197
processes from 125–41, 304–5; rationalisation 7–8, 30;
dreams in context of 160–2; countertransference and 138–9; and
multidisciplinary approach to 240–1; differentiation of psychotic from
organic psychoses 17, 102; psychotic non-psychotic communications
depression 52, 64, 215–16, 222–3, 146–8, 156, 257 see also tuning into
274–5 see also manic depression; the psychotic wavelength; disguise
puerperal psychoses; puerperal and 258; by hospital management
psychoses see puerperal psychoses; 145; powerful persuasiveness of
treatment parameters for borderline 258
states and 139–40; tuning into reactive (neurotic) depression 204, 215,
see tuning into the psychotic 218, 221–2
wavelength reality principle 53
psychotic hallucinations (Bion) 94 reciprocal role procedures (RRPs) 41
psychotic/non-psychotic regression: to narcissism 50, 224; to
differentiation: anorexia nervosa paranoid-schizoid position 63–4, 168;
287–9, 307; and approach to regressive therapeutic experience
hospitalised patient expressing 120; topographical 102, 103
suicidal ideation 242–4; awareness reintegration, of split-off parts 7, 87,
cultivation of see tuning into the 152, 308

332
Index
relapses: accepting risk of 140; and dissolution and regression (Freeman)
emotions in schizophrenia 22; 102, 103; dreams and 160–2;
prevention 40 education 289–99; Freeman 102–6;
relatives 140, 229; consequences of and the internal world 61–2; intrinsic
failure to listen to a relative (case developmental features 86–7; Laing
example) 256–8; diagnosis by 8, 240, 112, 116–18; management see
257; family education, in schizophrenia management;
schizophrenia 22; provision of narcissism 50–1, 74; and the
supportive ‘exoskeleton’ 235–46; risk neurotic/psychotic distinction 105;
assessment and 256–8; in suicide cases Pao 109–10; pathological projective
253–5 identification 67; relapses 22, 40;
religion, psychotic use of 88 ‘schizophrenogenic’ mother 301;
repair 78, 131 Searles 108, 168–9; stigma 28;
reparation 68–9, 78, 131; manic 68–9, treatment see schizophrenia
131, 199, 276; penis as object of 65, treatment; see also paranoid-schizoid
78, 199 position
repression 53, 54, 158 schizophrenia management: approach
resentment 196, 202 to the hospitalised patient 242–4;
resistance to change 162, 200 confidentiality 240–1; developing
reversal into the opposite 8, 49, 54 supportive ‘exoskeleton’ for
Rey, J. H. 76–8, 129, 130–2, 199–200, adolescents 235–46; in early years of
294 illness (family case history) 235–9;
Richards, J. 200 lifelong monitoring 87, 245; living
Rillie, Jack 118 with unbearable anxieties and 244;
risk assessment: NHS and 247–9, 256–8; multidisciplinary approach 240–1;
of suicide in schizophrenia patient psychotherapist role and referrals
154–5; suicide risk scales 248; 295–9; role for hospital-based
see also infanticide risk services within an integrated
Robbins, M. 34 approach 34–6; specialist registrar’s
Rosenfeld, D. 51, 169 experience 289–95; suicide risk
Rosenfeld, H. A. 29, 51, 169; evaluation 154–5; treatment see
confusional states 71; destructive schizophrenia treatment; underlying
narcissism 72; the psychotic dynamics 239–41
transference 71, 167–8 schizophrenia treatment: addressing
Rycroft, Charles 118–19 suicidal states of mind 241; Chestnut
Ryle, Anthony, cognitive analytic Lodge and psychoanalytic treatment
therapy 41 107–14; deciphering delusions
163–4, 165; differentiating/working
schema level work 39, 40 with psychotic and non-psychotic
schizoid/borderline states see borderline parts in 29–30, 33, 85–93, 156, 239,
psychopathology 242–4, 292 see also tuning into the
schizophrenia: borderline states and 131; psychotic wavelength; through
claustrophobic-agoraphobic medication 22, 110, 111, 241, 244;
dilemma 77–8, 130, 294; concrete notion of cure 304; psychoanalysis in
projection 65; confusional states 71; 28–34, 110, 111–14, 245; transference
denial and rationalisation in 7–8, 30; 51, 167–9; see also schizophrenia
diagnosis 19–20, 239–40; as management

333
Index
Schneider, K. 21 understanding 249–55;
Schneiderian first-rank symptoms 21 psychotherapy role in reducing risk
Schorstein, Joe 115, 118 in affective disorders 260–79; relatives
Schreber, D. P. (the ‘Schreber case’) 51; in suicide cases 253–5; risk evaluation
Freud 47–9, 50; Steiner 79; in schizophrenia patient 154–5; risk
Turkington 39–40 in puerperal psychosis 205; risk scales
Schwartz, J. 56 248
Searles, H. F. 108, 168–9 Sullivan, H. S. 108, 109
sectioning under Mental Health Act superego 53, 64, 105, 167–8; in
(1983) 7, 9, 147–8, 236, 256, 307–8; depression 220, 229–32; ego-
tribunals see tribunals destructive 56–7, 80–1, 82, 230–1,
Segal, H. 61, 64, 67, 158–9, 169–70; 278; godlike 225, 227; mature, benign
aggressiveness 305; manic defence and reflective 231–2; modification of
and reparation 199; symbolism and therapist’s superego 261, 265;
symbolic equation 70–1 primitive 53, 57, 64, 198, 225, 230;
Segal, H. and Bell, D. 51–2 projection as defence against 199; and
self-berating 224, 225, 228, 229; suicide the suicide process 252
reaction of self-blame 252 supervision 261, 269, 294
self-mutilation 275–6 Sutherland, Jock 118
self, sense of 132 symbolisation: concrete 130–1; Freud
Silver, A.-L. 107 48, 158; symbolism and symbolic
Sinason, M. 200 equation (Segal) 70–1, 172
Smith, Ronald Gregor 118
Socratic questioning 38 Tausk, Victor 57
Sohn, L. 73–6, 255 Taylor-Thomas, C. 260
spectrum psychosis 205 thinking: Bion’s theory of 96–100;
Spielrein, Sabina 170 development of thoughts 97;
splitting: bizarre objects and 87; ideographs and origins of 90–1;
borderline patients 130–1; of the ego intolerance of frustration and 97–8;
57; Freud 48; hostile projective 71; of and learning from experience 98;
mind and body in suicidal patients putting thoughts into words 88–90;
254; paranoid-schizoid position role of maternal reverie 99; see also
(Klein) 62; reintegration of split-off communication
parts 7, 87, 152, 308; superego and third position 82
198 topographical model (Freud) 52–3, 103
Steiner, J. 79–80, 133, 134, 135–6, 161 transference: borderline patients 127–9;
stigma, in psychosis differentiation 25–8 in CBT approach 42; in depression
suicide 226, 227–8; addressing suicidal 228; effects on therapeutic alliance
states of mind 241; approach to 43; Freud 51, 53, 167–8;
hospitalised patient expressing interpretation 10, 32–3, 93, 127,
suicidal ideation 242–4; aspects of the 133–6, 167–8; narcissism and 51;
suicidal state 275–6; attempts, in premature/precipitate formation of
neurotic depression 222; case object relations and 86; presence
examples 250–5; in the community throughout hospital setting 6;
(case example) 252–5; family worry psychotic (Rosenfeld) 71, 167–8;
over potential 238–9; inpatient 248, schizophrenia and 51, 167–9; ‘total
250–2; psychoanalytic framework for transference situation’ 73

334
Index
transivitism 102 Turkington, D. 39–40, 43
tribunals 7, 176, 256, 258 Turkington, D. and Siddel, R. 38, 39
Trilling, L. 118 Turkington, D., John, C. H. et al.
tuning into the psychotic wavelength 6, 37–8
142–55, 239, 305–6; addressing
suicidal states of mind 241; case undifferentiated state 105
example: ‘a patient for the day
hospital’ 148–52; case example: ‘a tale violence: murderous assaults on
of a wig’ 146–8; case example: strangers 76, 255; to others:
‘evaluation of suicide risk in a woman identifying the psychotic wavelength
with longstanding schizophrenia’ 255–9; risk assessment see risk
154–5; case example: ‘making contact assessment; to self 249–55, 275–6
with and apparently inaccessible state see also suicide; see also aggressiveness;
of mind’ 152–4; case example: destructiveness
‘planning for reprovision’ 143–6;
differentiating psychotic processes Welldon, E. V. 219
from psychotic disorders 125–41; Wernicke, C. 102
dreams, illusions and 157–65; in Willick, M. S. 28–9
potentially suicidal cases of affective Winnicott, D. W. 29, 118, 119
disorder 260–79; professional wish-fulfilment 104
criticism and 180–2; and the Woolf, Virginia 26, 27
utilisation of the countertransference
166–83 Zachary, A. 218

335