Dissociations and derealistic associations of the mind in psychosis
St Petersburg, March 2002
Summary: The author discusses the concept of splitting (Spaltung) as it is described in classical psychiatric writings such as those of Bleuler, as well as by psychoanalysts from Freud and Jung onwards. Drawing on clinical illustrations from three psychotic patients, he shows how splitting affects not only the ego and the object but also the transference itself. Dissociation as between different realities, ordinary and delusional, is a defence against unbearable anxiety, persecutory feelings, and catastrophic experiences; the self breaks down into bits and pieces, often with bizarre associations that give rise to a delusional construction of the universe. This demands both a phenomenological and a psychoanalytic understanding. Ideally, different approaches psychotherapeutic, pharmacological and institutional can be undertaken in a complementary fashion as long as staff members work truly together.
Samuel began his analysis with me in 1997. He was 25 years old when I first met him, a good-looking young man, but detached, aloof and very tense. In my consulting room, he remained silent. He stood in front of me and looked all around, as though he were living inside a dream and trying to envelop me in his dream-mantle; indeed, I felt as though I too were being drawn inside a dream-world, in which hallucinating would be a normal way of life. He moved his lips as though talking to someone. In fact Samuel was hallucinating all the time, apparently addressing some ghostly beings or other standing all around him. When I said to him that I had the feeling we were not alone, he said nothing at first, then, after a few moments, he smiled and declared: "There are soldiers all around us, Charlemagne's soldiers". Then he mentioned a "dead horseman". Given that his manner of speaking was not very lively, I said to him that perhaps he was saying something about himself something about not being very lively / alive. Still in a monotonous voice, he said: "the soldier died in a battle". I understood that Samuel had experienced a tremendous battle inside himself, an unbearable experience that, in order to survive, had to be pushed far back in time, somewhere in the Middle Ages. However, in sending the dead part of himself so far away, he lost the lively / alive part. His body was a container for tremendous grief and a bloody / bleeding mourning process that he could not face up to alone. In some of his early drawings, he appeared as someone wearing a bandage round his head or, as I would say, round his mind.
In the climate of this first session, I felt that we were involved in a dream-world. There was a split (Spaltung) between present time and the Middle Ages, and an additional split between two realities, a waking space and a dreaming one. In the counter-transference I felt myself being drawn inside the climate of this double split in space and time. It was as though I myself needed to wake up from this cloudy, dream-like world in order to help the patient (and myself) to face the dissociative transference field; I myself was being taken away from present time back into the Middle Ages.
I learned from his parents, whom I first saw alone Samuel had not wanted to come out of his "shelter" (as he used to call his home) that his illness began more or less when he started his university studies in political science. At that time, he found it difficult to concentrate on his studies; ever since his childhood, he had been a very gentle, passive and introverted boy. While he was a student in another town far from his parents, one of his close friends became very worried because Samuel would neither answer the phone nor open the door to anyone. His parents went to visit him. He did not answer their call they began to think he was dead, had committed suicide or had run away . His father asked the emergency services to break down the door but they required proper bureaucratic procedures. As the parents insisted, the door suddenly opened, and in a very cold manner Samuel said "hello", then promptly disappeared, in much the same way as a ghost vanishes. Other friends said later they had seen him in Rome, dressed in rags and living like a drop-out, sleeping rough
Several months afterwards, he decided to phone home because he had run out of money. He was split between his delusional wandering world and a reality feeling that he did after all need to have money if he were to survive (and perhaps see a doctor
). He then consulted several psychiatrists, who prescribed medication and psychotherapy. But he barely responded to these initial attempts at treatment. I learned from my early experiences with psychotic and dissociative states that there is always a part of the personality that is preserved from the delusions, and therefore still in touch with reality. If we manage not to fall asleep with the patient seduced by the dream-like atmosphere of the psychotic world and stay awake, then we can face up to the splitting of the transference.
It was as if I were under the influence of some narcotic drug or other in Samuels mind. In one of our most recent sessions, he said: My life is split between sugar and cocaine. But I distrust people who appear to be too sweet with others. I understood that there was something very bitter in his experience of life. Yes, he said, but I need to calm my distress with cocaine. Perhaps, in fact, it could calm the distress of everyone. And to calm me, so that I wont be taken up inside your distress with the cocaine of your mind? As I said the word mind, I asked him about his thinking. He said his thoughts were almost dead, or at least sleep-walking or flying away into some foreign country Perhaps toMexico, he added, where ancient pyramids take care of famous dead people. Like the Egyptian ones? I asked. He went on: At the beginning of my illness I was transformed into a jaguar not the car, the animal! (His family business has to do with very select cars.) I became a blue jaguar looking for revenge for what people did to me in Europe. I will come back from Mexico one day and I will be the Pope in Rome, or something like that. I will see that justice is introduced into people. In another session, he decided to lie on the couch and began to associate. Then he stopped, because, he said, the Popes nose was coming between him and me. That was a maternal transference situation in which he wanted me to take care of him as his mother had looked after him at his birth they had then become an ideal couple; it was only when he was three years of age that his mother married a man who took on the responsibilities of the father. I know that he was a good father to Samuel as he is to this day: he brought Samuel to me for analysis. The father figure who takes on the true responsibilities as such does not want mother and child in such a fusional relationship, they have to be weaned from each other. The nose of the paternal superego was smelling that something seductive and hypnotic (like cocaine) was taking place between mother and child some gap (separation) had to be created, hence the Popes nose. This was a way of creating a place a space in which to relate, building a gap between mother and child, thus allowing the paternal function of organization to intervene (rules and laws): the proper and just constructive Spaltung, implying both differentiation and the need for a link
Bleuler used the term Spaltung in his book on the schizophrenias. This partly recalls Pierre Janets concept of splitting of the mind (1909: 342) in hysteria. Janet speaks of the dissociation of functions, suggesting that there is a double language a conscious one and a sub-conscious one. At that time, he was fascinated, as Charcot was, by hypnotism; in somnambulism, there is a split in functions between the action of the body, dramatising a dream-world, and wakeful life. When the sleeper wakes up, he is puzzled by what he has just done. Perhaps there is a level of dissociation in hysteria of a psychotic kind (folie hystérique), as Breuer found in the case of Anna O. Breuer and Freud regarded it as splitting of the mind (Bewusstseinspaltung). Around that time, Morton Prince published his book on The Dissociation of Personality (1905), in which he writes of cases of double personality (Miss Beauchamp and Sally). People were fascinated at that time by the double life of split personalities, and the world of theatre and cinema was greatly inspired by such uncanny yet attractive phenomena.
Freud himself, following Breuer, speaks of splitting of the ego (Ichspaltung) to designate a phenomenon found in psychosis and in fetishism. How can someone be normal up to a point, yet still be attached erotically to a fetishistic object? There is a conflict between conscious and unconscious, between opposite feelings in the same mind or between mind and body. Splitting of the ego is a defence mechanism, when the patient cannot have a global concept of himself and the world (Freud (1940a) 1938). In another unfinished paper of 1938 (Freud (1940e (1938)), he again speaks of splitting of the ego as a need, a process of defence against a real danger. There is a tendency to disavow reality, with the patient then able to believe there is no reason to be afraid. In a way, this is an attempt to avoid the conflict between facing reality and denying or rejecting it. One of the defences is to hallucinate a desire to compensate for a loss - in Freuds example, castration anxiety in a three-year-old boy. The boy had been seduced by an older girl, then energetically criticized and punished by his nurse. Freud developed the concept of castration anxiety the nurse threatened to cut off the boys penis as punishment. Freud made a parallel between the compensating fantasy and psychosis, when a hallucinated belief is implied. According to Freud, the little boy regressed to the oral phase in which he was afraid of being eaten by his father. This delusional belief is related to Kronos, the old Father god of Greek mythology, who devoured his children.
I find Freuds ideas very interesting, since just a few days ago I saw a patient called Fabien, who is an old child of 53 years of age. He has been ill for the past twenty-seven years, with remissions from time to time. He came to his session accompanied by a nurse from the day hospital who was very eager to co-operate in the treatment. Fabien looked at me in a fixed, penetrating way, and said: I am a psychoanalyst, you know (the nurse shook his head), and I have extraordinary powers. For instance, I can incinerate you with my gaze. Then he added, Or I could eat you up. After a pause, I said to him: Where am I? In my stomach, he replied, with a smile. But you are quite safe; Im taking care of you.
Then he said: I have a great need of psychoanalysis. It was as though he were giving up his psychoanalytic identity (identification with the aggressor) and returned to that of being a patient, albeit a greedy one. My understanding was that, as in Freuds example of the little boy, he was identified with a frightening Kronos-like father figure, eating all his children. I have always felt that the Greek myth of Kronos has to do with eating up the passing of time, before being devoured oneself by the rapid passage of greedy time
In fact, in his incinerating gaze, Fabien was auto-plastically (Ferenczi) dramatising some powerful character like Zeus who, with his rays (Fabiens own omnipotent and magic powers), could either save him or turn him into ashes.
He was aware of how chronically ill he was, and he feared to remain an old child and chronic patient. He left the session with the nurse, saying that he would like to see me again. A few minutes later, the nurse came back, saying that he (the nurse) had forgotten his back-pack. Some hours later, I noticed a hat in my consulting room and thought that Fabien had forgotten to take it away with him. In fact, it was the woman patient I had seen immediately before Fabien who had left the hat behind. (It was a Russian-style brimless hat or chapka a mans hat; the patient, an artist, had been given it by her son.) For some reason I had thought it belonged to Fabien he is of Russian-Jewish origin, like myself and I was almost sure I saw him wearing the hat! This transference confusion between his life and mine showed me how emotionally intensive were our reciprocal projections
or hallucinations. It was as though he had left his head with me, so that I could go on working with him, and that, in exchange, he had taken my head-hat in order to go on working with me. The boundaries in the psychotic transference are sometimes very difficult to determine clearly. The psychotic transference is part of an atmosphere in which the analyst can experience the fact of losing his own boundaries, or losing them and then finding them again: plasticity of the ego in the analyst or psychiatrist of psychotic patients is an essential factor.
In the next session, I apologised to him about my confusion. (I had phoned his nurse about the hat.) Fabien was very pleased to see me, and felt that I was very much involved with his delusion; he began talking like a young child. He said: Im thinking about yo-yo and toto. As he made a movement with his hand, I realized that he was indeed referring to the wheel-on-a-string toy and that reminded me of Freuds famous Fort-da game. For some reason, Fabien then spoke of a child inside a prison, who was trying to ask for help through the bars of the cell. The nurse then said that in prison parlance, yoyo has to do with taking something from and giving something to prisoners in their cells. I felt that Fabien was speaking about us in the transference how to get in touch with each other, when we were no longer under the protection of our hat / head, how to make contact with the mind of someone else and yet be able to get back inside ones own mind when we had to. Experience over the years has taught me that one of the problems of the counter-transference is the inability to tolerate psychotic anxiety as though by giving an interpretation that pushes something into the patient or prescribing excessive medication, the doctor is trying to run away from his own anxiety as awakened by the delusional transference. There is a time when the patient is analysing the analyst, just as the analyst is trying to understand him. The patient may become frightened if the analyst becomes confused with him, or if the analyst invites the patient to open up his protective autistic prison too quickly.
Fabien said that he liked the subtle way in which I addressed him I was taking care of his identity as well as my own, yet still trying to come together and perhaps to play together. After a while, he repeated in a childlike way yoyo toto. I answered: Yoyo, toto, boubou. Then he smiled and asked: Do you work with young children? Of course, I replied. There is a little boy inside you and inside me too, little boys who have not forgotten how to play. I remember Herbert Rosenfeld (from seminars and from my long analysis with him) saying that one cannot get in touch with the delusional world if the analyst and the psychotic patient do not develop a playful transference together.
The split (Spalt) between infantile and delusional reality is an important meeting-point where some therapeutic experience can develop.
In this situation, we are dealing not only with splitting of the ego (Ichspaltung) but also with splitting of the object (Objektspaltung). Melanie Klein developed this latter concept, especially with respect to the paranoid-schizoid position and its relationship to part-objects. Here, there was in addition a splitting between different realities autistic, persecutory (being in prison), delusional and infantile. I look forward to my future sessions with Fabien, because we will be less confused and more able to understand what is going on between us.
Another very schizophrenic patient of mine from the 1960s, David, after a long interruption of his analysis because of my departure from London to spend four months in Buenos Aires on family matters, had left me feeling very worried. When I saw him again, he was unusually calm and relaxed. I asked him how he was feeling. Very well, was his reply. I was able to see you every day on the wall of my room; it turned into a sort of screen, and your image was on it whenever I looked at it. Sometimes you even came out of the screen and visited me in order to play chess. As I write this paper now, I can see myself as a protagonist of Woody Allens film The Purple Rose of Cairo in which one of the characters comes out from the screen, dressed as an explorer. The analyst was Davids explorer, one he had always at his beck and call. Here there was a split between two realities: in the one, I was absent, in the other in the hallucinatory transference relationship I was constantly present for the patient. This corresponds to Freuds view in his paper on the splitting of the ego as a defence against grief and unbearable mourning for loss in a patient who was as attached to me as I was to him.
In Bleulers description, a patient like David could become withdrawn from an distressing reality (after the loss, even temporary, of important object relations) and return to an introverted and derealistic (autistic) world. But in fact his hallucinatory construction helped protect him from castration anxiety (the transference being cut off in an unbearably traumatic way). It was as though a good positive transference or loving feelings and need for reparation were able to restore, by projecting them on to the screen-wall, a living film of our transference relationship through two-dimensional images that changed for a short time into three-dimensional and realistic ones when he managed to make me leave the screen, come up to him and play a game of chess
As a matter of fact, from the beginning of his analysis (this took place in the third year at five sessions per week) he used to blink his eyes constantly (opening and closing them like a shutter), and he associated this to a photographers (still) camera. In this way, he could take photos of me as soon as he came into the room! He could take me away with him in his camera-eyes and visual space, just as Fabien took me away with him inside his stomach. This helps me now to understand that David was at one point able to change his photographic eye into a cinema camera, thereby giving me movement and making me come alive in his theatrical transference. I was pleased by this, because I felt that we were taking part in the same play. It was therefore very important to link the delusional transference with the infantile one, in which the child in him was able to deal with grief and the mourning process, perhaps through denial of separation, but also through a capacity for play that kept our relationship alive and preserved its play-ful character.
Herbert Rosenfeld presented a very interesting paper on the delusional transference to the British Psycho-Analytical Institute in 1964, describing the different transference situations with psychotic patients. An early infantile good relationship with mother and father enables patient and analyst to deal with the delusional transference, in which there are erotic and perverse aspects.
Concerning the erotic transference, in one of his sessions, David said to me as he lay on the couch: I am very excited, Dr Resnik. What is exciting you? I asked. He replied: It excites me when I see inside your mind, how your thoughts copulate amongst themselves when you think about me. Then he added: My penis is excited, and, a few moments later, I have indigestion. I pointed out that the sexualization of my thoughts and words (nourishment) were giving him a pain in his stomach. According to Melanie Klein and Herbert Rosenfeld, excessive eroticization of the nipple during a feed would seem to be a cause of future serious psychosomatic disorder (Resnik 2001: 212).
I remember the first description David gave me of his breakdown. One evening at home, when he was alone, he went to the refrigerator for milk. There was only cold milk
As he took it out, his father arrived, annoyed by the noise David was making. When he saw his father had found him out in his greedy object relationship with his mothers breast, David became afraid that he would be punished. With his powerful blinking eyes, he paralysed his father and changed him into a photo
The fact that Samuel, Fabien and David were so deluded did not affect their capacity to safeguard the good aspects of the transference. In time they were able to transform the splitting of the ego and the splitting of the object and transference situation into reparation; thus patient and analyst could find a way to negotiate the split-off parts of the personality of the patient and their old struggle between their divided selves. In The Divided Self, Ronald Laing writes (1960 (1965: 17)): The term schizoid refers to an individual, the totality of whose experience is split in two main ways: in the first place, there is a rent in his relation with his world and, in the second, there is a disruption in his relationship with himself. Such a person is not able to experience himself together with others or at home in the world, but, on the contrary, he experiences himself in despairing aloneness and isolation; moreover, he does not experience himself as a complete person but rather as split in various ways, perhaps as a mind more or less tenuously linked to a body, as two or more selves, and so on. Later, he says: The mad things said and done by the schizophrenic will remain essentially a closed book if one does not understand their existential context.
Splitting of the mind and catastrophic experience:
Wilfred Bion, whose seminars and personal supervision I attended for several years, read an interesting lecture in 1963 at the International Congress of Psycho-Analysis, held that year in London. He said that schizophrenic language is used as an active way of splitting the object. One example would be the tendency to attack linking between thoughts that, when they come together, turn into unbearable visions and persecutory experiences. In 1959, Bion wrote a paper on Attacks on Linking, describing how the patient cannot tolerate certain ways of thinking, either in others or in himself. There is not only splitting of the ego, of the object, and of the mind in general but also in the acute catastrophic experience as described years ago by Kurt Goldstein, there is a real breaking-up (or breaking-down) of the mind, of the ego and of the object. A particular way of getting rid of minute fragmentation is to put it outside the self, into the outer world. This mélange of fragments of the self, of nature, of other people, and of reality gives rise to an uncanny vision of the world, inhabited by bizarre associations and strange objects. This is the starting point for a new language made up of bizarre associations that become a real langu age for the psychotic patient. The task of the inspired analyst is to become a research worker in the linguistics of the unconscious in order to understand the meaning of the new delusional idiomatics employed by the deluded patient. This language is composed of fragments of the object, ego parts, and broken links. Sometimes the result of such a catastrophic experience in the mind can turn almost the entire thinking process into debris. This debris is sometimes equated with to degraded matter such as urine and faeces that drive the patient crazy, and is experienced as part of the material elements rejected by the patient and pushed into the analyst. This is part of the analysts normal and pathological counter-transference, and his capacity for reverie (Bion 1992: 53), allowing him to cope successfully with such situations.
The pathological transformation of the world is to be differentiated from what Bion (1965) calls normal transformation (any perception brings about an inevitable change in the object into a new representation), and from poetic creative imagination. A writer such as Thomas de Quincey, in a kind of experimental psychosis produced by opium, was able to change the appearance of a whole city (London)
. In his drugged state, walking along Oxford Street, he saw wonderful Chinese pagodas and his idealized love-object, Anne, changed into a beautiful lady.
It is from those strange or delusional worlds and links that the new language and world-vision comes into the mind and therefore into the open. In Bions experience (as well as for Herbert Rosenfeld and for me) a non-delusional part of the personality remains as does an infantile part of the self, together with fragments of realistic or syntonic contact. A child who is paralysed by fear or frozen or incinerated
. can come back to life in the transference, like Fabien and David. Thus delusional and non-delusional reality can be addressed together at a particular moment in the transference, when patient and analyst become aware of something new (or old repressed or denied). This corresponds to Bions catastrophic change (not to be confused with Goldsteins catastrophic reaction).
Some practitioners can offer patients lengthy analysis, others may just have to do what they can in a short time (perhaps because there are no other possibilities at hand or the case-load in the institutional setting is so heavy). The question always is how can the psychiatrist trained analytically and intuitively, help the patient to turn the contradictions in his different perceptions of reality and different ideologies (a delusion is also a system of ideas) into useful possibilities for psychic conflict?
Perhaps the art of a good analytical approach is to prepare, with the patient, a setting in which the transference is able to cope with these contradictions, addressing them without necessarily coming to an incinerating and nihilistic end
To change something into nothing, to make something that is full of meaning into something meaningless is part of the omnipotent aspect of pathological destructive narcissism (H. Rosenfeld). I believe that the analytical process, including its applied aspects in psychiatry, has to do with being able to confront the split-off aspects or fragments of the mind in a setting in which working-through at last becomes possible. I mean by this a confrontation in which conflict (between contradictory feelings and thoughts) can be negotiated. Otherwise, if patient and analyst are not prepared for such a delicate meeting of minds, the patients destructive narcissism may again break up any possible understanding; for a patient at the infantile level of paranoia, for example, laden with demands of all sorts, it is more important to be right than to be helped to become alive. This has political and religious implications for a disturbed paranoid world; this is what I try to discuss in one of my papers called Being in a persecutory world, published in English just a few years ago.
One of the main dimensions in psychoanalysis and in life in general is the pathological narcissistic side of the personality. Some respect and love for oneself is part of normal narcissism, the protective kind an acceptable protective prison / body, sometimes equated in Greek with the grave; it depends to what extent one is alive within ones body. Destructive narcissism, described by Herbert Rosenfeld, is related to an exaggerated state of what we usually call narcissistic wounds and arrogance (Bion 1967). Not being understood by others is a disappointment, but sometimes it stimulates the child who wants always to be right in his greedy demands and complaints. To be understood, for the strong narcissistic personality, may be unacceptable; the transference is experienced as a very painful attack.
Psychotic challenging of reality goes together with attacking the links to the outer world and parts of the inner world that disagree with the delusional political position. The theme of Bions paper Attacks on Linking (1959) is the phobic destructive attitude towards all links, mainly the primitive ones those related to archaic models of object relations. In my view, the link stands for the father figure as a symbol of order: introducing a hiatus between mother and child (reciprocal weaning), the father figure makes for real communication and dialogue between mother and child, and therefore normal development with the world. Enrique Pichon-Rivière, my first teacher in the field of psychoanalytical psychiatry, wrote some very interesting papers on normal and pathological links, and on the constructive aspect of good links in the transference situation and in normal development.
Between narcissism and socialism (to follow Bions formula), how are we to help the psychotic patient through this dilemma so that he may deal constructively with a disturbing paranoid world? What happens in society at large appears in the transference in the shape of a personal ideology that has to confront other ideologies. Psychoanalysis is also part of an ideology, as is psychiatry, as is politics, religion, etc. The person who is inspired to work with regressed and dangerous aspects of our culture must have the right training and the proper personality in order to do this difficult job. Just as the famous Italian poet Cesare Pavese wrote about the craft of living (il mestiere de vivere), we should speak in terms of the craft of being an analyst and of being a patient; not an easy profession, whether from the analysts point of view or from the patients. Through analysis and the development of the personality, some of us may be able to help split personalities and very disturbed patients in a very disturbed world and we do this from child to child, from person to person
 Bleuler (1923: 34; 1950: 67) speaks of dereistische (or autistische) Denken. This kind of thinking lies outside formal linear reality ; the autistic person is enclosed in his own world, he thinks in symbols, analogies, fragmentary concepts and possibly via accidental connections.
 We could say, in fact that he had indeed in a certain sense run away - he was often distracted from everyday reality. One of the characteristics of the psychotic Weltanschauung is to be often and in chronic states all the time distracted or split-off from a wirklich (realistic) world. According to Kant, there is a difference between wirklich (factual) reality, the essence of which we can never attain, and Wirklichkeit (perceptual, ordinary reality).
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