finding a space to think and a way to talk
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Finding a space to think and a way totalkAntony Garelick aa Consultant Psychiatrist and Psychotherapist , Tavistock Clinic ,London, UKPublished online: 10 Mar 2011.
To cite this article: Antony Garelick (2011) Finding a space to think and a way to talk,Psychoanalytic Psychotherapy, 25:01, 3-12, DOI: 10.1080/02668734.2011.542908
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Finding a space to think and a way to talk
Antony Garelick*
Consultant Psychiatrist and Psychotherapist, Tavistock Clinic, London, UK
Mental mechanisms and issues of psychoanalytic technique in the treatmentof psychotic states are explored and illustrated with clinical vignettes.The value of establishing a psychosis workshop to facilitate understandingand an appropriate language to communicate with the patient drawing on thework of Dr Richard Lucas and the author is described.
Keywords: psychotic states; psychoanalytic technique; container; primitivedefences
My interest in psychotic states of mind was stimulated by my experience as a
trainee psychiatrist at the Maudsley Hospital. It was there that I met Richard
Lucas and we became close working colleagues for the next 30 years.
The crucible for our experience was Ward 1 at the Maudsley: a psychiatric
in-patient unit run on therapeutic lines. My boss at that time was Dr John Steiner,
and he was succeeded by Dr Murray Jackson.
Richard Lucas was slightly ahead ofme in the training and hewent off to take up
a consultant psychiatrist post at Claybury Hospital. At that time I think he was the
only psychoanalyst running an acute admissions unit for a catchment area, and that
area was a deprived part of East London. He encouraged me to follow him to
Claybury and I duly took up the post of consultant psychotherapist there; it was
subsequent to this that we set up a psychosis workshop to facilitate our attempts to
understand psychotic states in patientswho had a formal diagnosis of psychosis such
as schizophrenia.
Finding the right home for the workshop is of significance: we started
meeting on the ward, his ward, then in adjacent offices to the ward, then we
moved to the doctor’s residence – all of these being in the main hospital. None
of them felt right. Eventually we moved to my unit at Forest House, a villa in
the grounds of Claybury, approximately 200 yards from the main hospital. This
became the settled location and there we found a space where we could think.
One of our early observations was that thinking can best take place at
some distance from the patient. Dr Henry Rey – one of my other bosses at the
Maudsley – told me about a young schizophrenic man whom he had interviewed.
This man spent hours looking through a telescope. It emerged that he was keeping
ISSN 0266-8734 print/ISSN 1474-9734 online
q 2011 The Association for Psychoanalytic Psychotherapy in the NHS
DOI: 10.1080/02668734.2011.542908
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*Email: [email protected]
Psychoanalytic Psychotherapy
Vol. 25, No. 1, March 2011, 3–12
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in contact with aspects of his mind that he had projected into space. Rey suggested
that there was a direct correlation between the degree of mental disturbance and the
distance the projected part of the mind had to be relocated to in order to be able to
survive (Dr H. Rey, personal communication, 1978).We in the workshop needed to
have an appropriate distance from the patient in order to facilitate thinking.
I will now draw on fragments of clinical material to illustrate some of the
clinical challenges that arise when working with these types of patients. Their
details have been changed to preserve anonymity.
Case 1
The first patient was a young woman presenting with obsessional problems
including cleaning rituals, fear of leaving parts of her body on things she touched,
fear of loss of control, problemswith her body, feeling detached and living in aworld
of her own. Her diagnosis was initially obsessional neurosis. She entered into
analysis using the couch and her latent disturbance rapidly emerged. This included
more overt signs of psychosis, the most prominent being thought disorder.
In this complex case I will focus on fragmentation of thinking and body
image and issues of separation. The predominant mode of communication for this
patient in the early phase of the work was action language. This fits in very well
with Piaget’s developmental schema, the sensory motor schema (Beard, 1969).
Her verbal communication was fragmented, very difficult to make sense of and
there was some suspicion that she was also experiencing auditory hallucinations.
In her case it was difficult to identify the location of the sane part of the mind.
It clearly existed: the patient arrived to the sessions on time, at the right place, and
she left and survived in between sessions. In the early phases of the work the
only evidence of its existence seemed to be the boundaries of the session where,
reluctantly, there was an acknowledgement of the external world and the need to
leave the consulting room. Any disturbance in the analytic setting had a profound
impact but was also an opportunity to engage with the sane part of the mind.
Holidays were a striking example. Attempts to engage the patient to think
about this seemed to be futile, words from the therapist just hit a brick wall.
However, work was possible after the break when the analysis resumed. The
patient had an uncanny capacity to choreograph the sessions after a break at both
the body and verbal level. She gave a running commentary about bodily aspects
of the therapist, for example when the therapist was going to breathe, whether it
was through the mouth or nose, comments about any type of movement, so it was
as though the therapist was a puppet, magically controlled by the patient.
Similarly the dialogue of the therapist was controlled by the patient, the
therapist finding that the things she said seemed to be scripted by the patient.
However, if the therapist deviated from this script the patient became disturbed
and would block out the therapist’s words by covering her ears or singing,
sometimes shouting. This could be understood as her defence against the rupture
in the setting: she transformed this painful reality by utilizing concrete
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omnipotent control and fusion with the therapist, thus ablating an experience of
separateness. This was something that could be worked on with a focus on a break
and its meaning, and by developing the capacity to experience separation and
tolerate the recognition of patient and therapist as two separate people.
Further work in this area led to it becoming apparent that the breaks and
separations were filled-in by the patient creating a continuous dialogue with the
therapist, some of which was hallucinatory in character. The experience of
separateness, and the associated capacity to challenge the omnipotent creation of
her own world, centred around disruptions of this sort in the analytic set up, and it
was around these types of issues that more meaningful verbal interchange
became possible. It should be remembered that speech requires the transmission
of sound, which in turn requires that objects are separated by air, this being the
medium for sound transmission.
The issue of separateness and integrity of the body manifested itself in an
additional way: that of the patient merging into the couch. At the end of the session
the therapist witnessed what appeared to be the patient tearing herself away from
the couch. Witnessing this process was excruciatingly painful for the therapist,
there was no sense of her skin acting as a boundary to her body. The ripping apart
revealed the sense of exposed flesh, like a gaping wound, experienced by the
patient as a cruel action which had been perpetrated by the therapist.
It is important to state at this point an inherent difficulty in writing a paper on
psychotic states of mind: in writing one endeavours to be coherent, but this
minimizes the reality of the difficulty of the work when faced in the room with
fragmented thinking and the action language of the patient. This type of patient is
basically in some primitive form of confusional state and our familiar concepts
that we use in thinking about our work are difficult to apply, and are therefore for
a lot of the time of limited help. Mechanisms such as transference and projective
identification – even splitting – are not easy to utilize because they assume a
level of coherence in the mental organization. Even at the part object level there
is separation between two elements.
This was not very evident in the early phases of the work in this case.
Rey wrote:
The whole of the therapeutic exchange can be summarised by answering thequestion: what part of the subject, situated where in time, is doing what to theobject, where in time and space, with what consequences for the subject and object(Rey, 1994).
In the early phases of the work with this patient it was not possible to map out the
mind in this type of way, although clearly it was the guiding principle at one level
of the work.
The main area of the work was re-establishing a container with the capacity
initially for the psychoanalyst to learn the language and experience of the patient,
and then to allow the psychoanalyst to employ a form of language that the patient
could make use of. While one is trying to navigate in these uncharted territories,
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an organizing principle is Bion’s notion of the psychotic and non-psychotic part
of the mind (Bion, 1957). The therapist in this type of clinical situation acts as an
auxiliary ego, a container, endeavouring to contain the very powerful phenomena
of fragmentation, confusion and identity dissolution.
This is a formidably difficult task and it is quite understandable when it comes
to containment why patients with a psychotic breakdown need to have an
admission to a mental hospital. There is the need for a physical container to deal
with the power of the fragmentation and projective processes that take place,
as well as their expression in the behaviour of the patient. Rey used to call the
mental hospital ‘the brick mother’ (Rey, personal communication, 1978) and
I think this is a very apt description that captures the need to be robust enough to
cope with such a demanding clinical situation. Part of the work we are doing is to
maintain the human element and relationship with our patients in the face of
very powerful challenges. This is graphically described in Richard Lucas’s book,
The psychotic wavelength (Lucas, 2009) which emphasizes tuning in at the right
level to the patient’s communication.
Returning to the patient, and jumping ahead to a later stage in the analysis,
the patient felt more integrated and was able to describe the changes in her as
follows: she felt that she had been like a large suitcase where everything had been
screwed up and thrown in at random, then the suitcase was closed the wrong way
round so the two halves with the contents were pointing outwards, and the outside
part of the case was inside. Now she was feeling the right way around.
This was a very valuable description and highlights the importance of
learning the language and subjective experience of the patient. It made the
experience of the couch, and tearing herself off it, comprehensible, as it did her
symptoms of losing part of herself when she touched things. It also helped to
explain the thought disorder and the problems with her mental apparatus that
produced her difficulties in thinking. She had a confused fragmented body, or
more accurately body ego, where things were put together in a haphazard way;
where the inside had become the outside and the outside had become the inside.
If we think about normal body image we are in effect like a doughnut or bagel.On the outside we have our skin: the boundary which holds the body contents inside,houses the perceptual sensory system, and is also a stimulus barrier for regulatingour contact with the environment. The hole in the middle is our gastro-intestinalsystem, our bowel, which again communicates with the outside; it is after all simplya long tube from mouth to anus. Bion made reference to psychotic states of mindworking rather like the bowel, evacuating and expelling things (Bion, 1957, p. 274).
I think this metaphor and his theory of thinking – the transformation of these
elements, the ‘beta elements’ or precursors, through alpha function into thoughts –
is a very useful description (Bion, 1962).
I found this helpful in thinking about this case: when in her psychotic state,
her bowel was in effect the external skin in a tube-like form, and there was
no possibility for physical or mental digestion. Instead things would go straight
through the tube. The normal bowel is derived from a similar type of cells to the
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skin but its structure enables digestion, absorption and metabolism of contents:
processes which mirror those required in order to think. Digestion also requires
the capacity to hold things for a sufficient time, to contain them, in order for the
process to operate, and this is again true of the mind: one has to be able to contain
mental events for sufficient time to process them. In the work that we do there is
the added need to contain them sufficiently to enable them to become conscious
and therefore verbally communicated. The alternative, acting out, is a
communication that takes place via the body, it bypasses the mind and therefore
bypasses consciousness.
I found that thiswayof thinking enabledme to conceptualize the problemsof this
patient in terms of her disordered body ego. Hermental digestion was compromised
because her external skin metaphorically formed her bowel. The capacity of the
patient to feelmore integrated, inmy view, is linked to her capacity to internalize the
functioning container which was a consequence of this work.
Before turning to the next case I would like to make a brief comment about
technique. I have not found it therapeutically useful to focus on attacks on thinking
and issues of aggression in the early phases of the work; in my experience
premature interpretation of aggression, and challenges to narcissistic defences, are
likely to lead to problems in the work. I think this fits in with Rosenfeld’s advice on
technique in his book, Impasse and interpretation (Rosenfeld, 1987).
Struggling with this type of patient in a psychoanalytic set-up is rather
like using an electron microscope. You are observing things at very high
magnification and this has both advantages and disadvantages. The advantages
are that you can get a more detailed understanding of certain phenomena.
The disadvantages, as with the microscope, are that the greater the magnification
the smaller the field you can observe: you do not see the pattern or larger picture.
Supervision and a workshop are essential in supporting this type of work in order
to preserve the view of the larger picture.
Case 2
I will now describe another case with similar symptomatology but being treated
in quite a different way. The patient was a young woman, 20-years-old, who had
a very deprived and abusive background – in particular an abusive mother.
The patient had spent most of the last 10 years in one form or another of
institutionalized care. Her primary diagnosis was intractable obsessive
compulsive disorder (OCD) with numerous rituals, problems sleeping,
particularly sleeping on a bed, and fear of touching things, again associated
with a fear of losing parts of herself. She was treated as an in-patient with an
intensive cognitive behavioural therapy (CBT) programme.
The patient was presented at a clinical work seminar because she was
deteriorating as the treatment programme progressed, with increased self-
destructive acting out. The focus of the work was on symptom removal. In effect,
removing the defences which, in my opinion, the patient had constructed in order
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to try to preserve both her body ego and her sense of self. This patient was presented
at a much lower level of magnification – a case presentation – so the patterns are
much easier to see. However the detailed knowledge, gained from the analytic work
with the first patient I have just presented, enabled me to understand the therapeutic
dilemma. The staff who were trying their best were experienced by the patient as
driving her mad. This mirrored the experience she had had with her mother. There
was an unconscious re-enactment taking place, with the staff being experienced by
the patient transferentially as the disturbed mother.
An ability to explain this to the staff, and to show that the patient’s defences
were critical at this junction in enabling the patient to preserve her bodily
integrity and avert dissolution of the self, enabled the clinical team to understand
why the patient was becoming more disturbed. They then became receptive to
reformulating both their treatment programme and the diagnosis, so that although
phenomenologically it was true that she had OCD, the larger picture was that this
was a defence against a fragmented and more psychotic internal state.
Case 3
I will now discuss a third case which, although unique in the presentation,
demonstrates very different aspects of psychosis. The main characteristics were
delusional beliefs and concrete psychotic identifications. I have chosen this case
to demonstrate the range of psychosis and to remind readers that the current
psychiatric diagnostic classification lacks precision, and it is more accurate to
talk of psychoses or schizophrenias.
The presentation was not of fragmentation or confusion, but rather the
opposite: a very rigid coherent belief system – a defensive symptom often
formidably difficult to penetrate. The patient in question was a late adolescent,
still at school, who was directed by the court to undergo psychological treatment.
The index offence was the disembowelling of two sheep. Attempting to establish
a therapeutic alliance in this type of circumstance is formidably difficult. The
whole structure of the therapeutic set-up in this case fitted in with the patient’s
paranoid anxieties that I would be a judge who would savagely attack him if he
made even the hint of a transgression. The direction by the court in the external
world corresponds to his internal world where a primitive punitive super-ego
resides. The main characteristics of the therapist–patient interaction were the
incredible stillness of the patient, his laser-like gaze and silence. The therapist felt
transfixed and was devoid of any associations and had an absence of thought.
This psychotic emptiness can be reproduced in clinicians outside the room:
one of the characteristics of the psychosis workshop that Richard Lucas and
I facilitated was a pattern of initial silence and lack of thoughts or associations
when a psychotic patient had been presented. It took quite some time for ideas
and for some more lively interchange to emerge. The initial comments tended to
be about the medication, its type and dose, about the phenomenology of the
mental state, and about the diagnosis. This broke the ice and slowly, the responses
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broadened and moved away from the conventional medical model to the
psychological domain and, when the workshop was working well, free
association. The workshop in effect acts as the auxiliary container where the
free associations of the workshop participants, which in part reflect different
fragments of the patient’s mind, can be held and processed. Reactions to the
material can generate diametrically opposite reactions in the participants of the
workshop; the notion of conflict in the mind of the patient only becomes more
tangible when the therapeutic work generated by the workshop results in a
diminution of splitting and projective processes. In primary process thinking
there are no contradictions.
Returning to the patient, his preoccupation when he did speak was to ask what
the therapist would do if the patient did not attend, would he report the patient
either to the court or to the police? The therapist had the difficult task of conveying
that he was there to help the patient but was also bound by the court directive.
There were long silences which the therapist often broke, trying to find something
to say or ask which would diffuse the persecutory tension in the sessions.
Slowly over time the tension eased and the patient asked if he could bring
something to show the therapist. The therapist said yes and the patient brought in
a large framed picture which he carefully unwrapped. It was a portrait of a falcon
that he had obsessionally and meticulously painted. It filled the entire canvas.
The speaking phase of the therapy now began: the patient described falcons in
meticulous detail. He explained that they were not aggressive – they only killed
to eat – and that they were very territorial, they would either face off or fight an
intruder as necessary. He also said that he was trying to breed falcons but had so
far been unsuccessful. It emerged that when he had free time, particularly at the
weekends, he would sit at the top of the highest point of a tree and would stay up
there all day – he was a boarder at a boarding school and lived in the country.
One could now begin to make sense of the episode with the sheep and
the early phases of the therapy. He was psychotically identified with a falcon.
The whole therapeutic set up, the entire room, was his territory and the therapist
was the intruder. Only when the threat substantially diminished could verbal
communication start. During these initial months no interpretations were offered
to the patient. It emerged that the index offence was preceded by a homosexual
encounter with one of his school masters. At a more neurotic level this patient
was full of homosexual anxieties regarding his male therapist.
Only a partial understanding of the index offence was achieved, namely
identification with the falcon, and he being identified with the sheep in terms of the
homosexual encounter. As a matter of interest no reference was made by the patient
to his family during the course of the therapy. One of the things that might strike one
when discussing the casemany years after the therapy took place is how obvious the
identifications with the falcon are. This was not so at the time, which I think reflects
the degree of impact that psychotic processes have on one’s own capacity to think,
whether as a therapist or supervisor, when working with this group of patients.
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An important aspect of technique in paranoid states of mind is the challenge
of how to talk to the patient. Powerful projection into the therapist takes place so
the therapist cannot make direct interpretation or even directly address the patient
because the patient experiences this as being attacked by their own projections.
This patient found a creative solution to this problem by bringing the painting, a
third object that both therapist and patient could look at, and communication
could then take place via this third object. This aspect of technique is reflected in
a less concrete way in John Steiner’s paper on therapist-centred and patient-
centred interpretations (Steiner, 1993).
Case 4
The final case is also someone who presents with a rigid coherent belief system.
She was referred by a plastic surgeon because she had a rigid belief that she was
ugly and wanted cosmetic surgery. She was in fact an attractive, successful young
woman but she held the belief about her ugliness with delusional intensity and on
presentation hid herself under a curtain of long hair so her face was hardly visible;
she was also becoming more and more socially withdrawn. A formal diagnosis of
Body Dysmorphic Disorder (BDD) was made and her problems regarded as a
neurotic disorder. However, these difficulties were progressively taking over her
life and it became apparent that she was in a mono-symptomatic delusional state,
a common diagnosis in the past but now out of fashion. The patient ostensibly
only attended in order to persuade the therapist and psychiatrist to prevail over
the surgeon so that she could have surgery. She believed that she was right and
everybody else was not. In this type of case there are clear battle lines: the patient
is convinced they are right, the therapist thinks they are delusional. So there is no
overt therapeutic alliance at the beginning of treatment.
The mental geography in such cases is clear. All their psychopathology is
projected onto the surface of the body, their appearance. There is a clear split
between the psychotic part of the mind, which totally dominated her thinking, and
the non-psychotic part of hermind,which in a therapeutic set-up is located and held
in the therapist. The early phase of therapy in this case, as in many others, consists
of a relentless attack on the therapist’s sanity and objectivity, with attempts by the
psychotic part of the patient’s mind to triumph. In effect this is an externalization
of the inner battle between the psychotic and the non-psychotic parts of the mind.
The problem in such cases is that the psychotic part of the mind is larger and more
powerful than the sane part of the mind. Reinforcements are needed. The therapist
functions as an aspect of that reinforcement, representing the sane auxiliary ego.
In very severe cases of this sort additional reinforcements are often recruited
such as behavioural/cognitive interventions. These can be helpful and valued by
the patient, but in my experience are not sufficient in themselves because focus on
symptom removal is insufficient. They do not address the troubled internal world
of the patient with its unconscious determinants, including the vast area of
emotional deprivation and developmental psychopathology. These patients and the
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psychotic part of their minds want a manic solution to their problems, an
‘exorcism’, preferably surgical. This has a seductive appeal and holds out the
magical solution of a transformation without psychic pain, a form of manic repair.
This type of case is I think also a metaphor for a type of thinking prevalent in
society, and in the NHS in particular, which results in the marginalization of the
psychoanalytic approach. Converting depression to common misery (Freud,
1895) is not a very appealing strap line!
Wearing down the psychotic part of this patient’s mind was slow, difficult
work and invariably in this type of case the process of shifting the psychic world
back from the surface and her appearance to the inside, re-establishing the
internal world in her mind, resulted in psychic pain and depression. It was only
then that the true reparatory work could be undertaken and she could continue her
voyage to ultimate improvement.
What holds such a patient in treatment? It is the small aspect of the patient’s
mind that knows that they need help to remedy their inner problems, in
conjunction with the therapist focusing on engagement with the inner world of
the patient and using psychoanalytic understanding to speak to that sane part of
the patient. The therapist’s ability to stay in a human relationship with the patient
and navigate this difficult and uncertain terrain is the basis from which a
therapeutic relationship and alliance can slowly be built. For that to occur,
confidence, tenacity and belief in the analytic undertaking, as well as realistic
hope, need to be held by the therapist. This building of alliance also needs
pragmatism and humility so that we can learn from the patient by being
introduced to their personal world.
A rigid clinical approach, psychoanalytic or not, which is ritualistic in form
impedes the work; equally too much pragmatism and flexibility also impedes the
work because there isn’t a sufficiently firm container. A difficult balance has to be
struck which enables there to be a consistent and firm holding of one’s own
psychoanalytic frame of mind. This is no easy task, and as I have written above I
think it needs the support of both supervision and clinical workshops like the
psychosis workshop to support such an undertaking.
I hope that this paper has given a flavour of the challenges of this type of work
and issues of technique that need to be considered. I hope it will act as a stimulus,
so that the work that Richard was so talented at is taken up by younger
generations of psychiatrists, psychotherapists and psychoanalysts.
References
Beard, R.M. (1969). An outline of Piaget’s developmental psychology. London: Routledge.Bion, W.R. (1955). The development of schizophrenic thought. International Journal of
Psycho-Analysis, 37, p. 266–275. Reprinted in Second thoughts (1967).Bion, W.R. (1957). Differentiation of the psychotic from the non-psychotic personality.
In Second thoughts (pp. 43–64). New York: Jason Aronson (1967).Bion, W.R. (1962). A theory of thinking. International Journal of Psycho-Analysis, 43,
p. 306–310. Reprinted in Second thoughts (1967).
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Freud, S. (1895). Studies on hysteria. In SE, 2, p. 305. London: Hogarth.Lucas, R. (2009). The psychotic wavelength. London: Routledge.Rey, H. (1994). Universals of psychoanalysis in the treatment of psychotic and borderline
states, p. 7. London: Free Association Books.Rosenfeld, H. (1987). Impasse and interpretation. London: Tavistock Publications.Steiner, J. (1993). Problems of psychoanalytic technique. In Psychic Retreats (pp. 131–147).
London: Routledge.
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