Hallucinations in the psychotic state: Psychoanalysis and the neurosciences compared

In this contribution, which takes account of important findings in neuroscientific as well as psychoanalytic research, the authors explore the meaning of the deep‐going distortions of psychic functioning occurring in hallucinatory phenomena. Neuroscientific studies have established that hallucinations distort the sense of reality owing to a complex alteration in the balance between top‐down and bottom‐up brain circuits. The present authors postulate that hallucinatory phenomena represent the outcome of a psychotic's distorted use of the mind over an extended period of time. In the hallucinatory state the psychotic part of the personality uses the mind to generate auto‐induced sensations and to achieve a particular sort of regressive pleasure. In these cases, therefore, the mind is not used as an organ of knowledge or as an instrument for fostering relationships with others. The hallucinating psychotic decathects psychic (relational) reality and withdraws into a personal, bodily, and sensory space of his own. The opposing realities are not only external and internal but also psychic and sensory. Visual hallucinations could thus be said to originate from seeing with the ‘eyes’ of the mind, and auditory hallucinations from hearing with the mind's ‘ears’. In these conditions, mental functioning is restricted, cutting out the more mature functions, which are thus no longer able to assign real meaning to the surrounding world and to the subject's psychic experience. The findings of the neurosciences facilitate understanding of how, in the psychotic hallucinatory process, the mind can modify the working of a somatic organ such as the brain.     

The non-mirroring mother and the missing paternal dimension in a case of narcissistic disturbance

SUMMARY

Heinz Kohut (1971, 1972, 1977), has developed an innovative framework for understanding the dynamics and genesis of disturbances in the sense of self — broadly speaking, the area of narcissistic disturbance. He has emphasized the failure of the primary objects (in his terms ‘selfobjects’) to be available as responsive mirroring figures who can also be idealized. The role of oedipal conflict is specifically de-emphasized. In this paper a patient is described for whom the factors noted by Kohut were relevant, but as well as these, issues related to a failure to negotiate the oedipal position and a denial of the primal scene were also crucial. These phenomena are not described in Kohut's writings. For this patient, the exclusion or foreclosure of the ‘paternal dimension’ (Chiland 1982) left her with a fundamental defect in psychic structure with profound ramifications. In addition various features of the transference pointed to a failure of early communication via projective identification and maternal containment, of the kind described by Bion (1962). This process is compared with that subsumed by Kohut's concept of mirroring.     

Fear and Shame in an Israeli Psychoanalyst and His Patient: Lessons Learned in Times of War

Living in the midst of a war presents unique challenges to ongoing psychotherapeutic treatment. This paper focuses on the ever-present threat of fracture to the analytic frame and the limited ability of the therapist to create a safe, insulated environment— a reliable container—in which to work, while coping with a violent external reality. Using an intrapsychic lens, as well as an interpersonal one, the dynamics of both the analyst's and the patient's fear and shame are brought into focus. This delicate balance is illustrated through two cases: one occurring during the First Gulf War (1991) and the second taking place during the Second Lebanon War (2006). In both cases, fear and shame cause a stalemate in the psychotherapeutic process. The analyst recalls his active duty as a soldier during the Yom Kippur War (1973). These memories and their attendant acknowledgement of fear and shame by the analyst, as well as his analysand's “supervisory” comments, gradually dissolve the knot and repair the rupture in the analytic process. The ability to fully experience fear, shame, and helplessness is at the core of psychic health, a health once destroyed by dissociation and denial of these feelings. This ability to experience fear and shame is the psyche's antidote to mental breakdown. Following discussion of the two case studies, this paper seeks to illustrate how the very structure of a society, in this case Israel, can codify societal defense mechanisms against emotions like fear and shame, exacerbating the very problems it seeks to assuage.     

Adorno,Hegel, and Dialectic

This article explores critical theory's relations to German idealism by clarifying how Adorno's thought relates to Hegel's. Adorno's apparently mixed responses to Hegel centre on the dialectic and actually form a coherent whole. In his Logic, Hegel outlines the dialectical process by which categories – fundamental forms of thought and reality – necessarily follow one another in three stages: abstraction, dialectic proper, and the speculative (famously simplified as ‘thesis, antithesis, synthesis’). Adorno's allegiance to Hegel's dialectic emerges when he traces the dialectical process whereby enlightenment reverts to myth and human domination over nature reverts into our domination by nature. However, Adorno criticizes Hegel's dialectic as the ultimate form of ‘identity thinking’, subsuming unique, material objects under universal concepts by using dialectical reason to expand those concepts to cover objects utterly. These two responses cohere because Adorno shares Hegel's view that dialectical contradictions require reconciliation, but differs from Hegel on the nature of reconciliation. For Hegel, reconciliation unites differences into a whole; for Adorno, reconciled differences co-exist as differences. Finally, against Habermas who holds that Adorno cannot consistently criticize the enlightenment practice of critique, I show that Adorno can do so consistently because of how he reshapes Hegelian dialectic.     

False Memories,Negative Affects,and Psychic Reality: The Role of Extra‐Clinical Data in Psychoanalysis1

Psychoanalysis as a treatment originated in the idea that neurosis is related to the ways in which individual psychic reality departs from actuality. Psychic reality includes memories, beliefs and their associated affects and fantasies connected with an individual's experience of the inner and outer world. The psychoanalytic determination of what meaningful memories or beliefs are inaccurate, distorted or false ordinarily relies upon principles of intra‐clinical validation. By itself, however, intra‐clinical validation is subject to limitations and pitfalls that conviction alone about what is actual cannot circumvent. Despite this fact, there are remarkably few analytic case reports demonstrating false or signifi cantly distorted memories through the use of data obtained from outside the consulting room. This paucity of reports may be related, at least in part, to the belief that the use of extra‐clinical data is essentially unanalytic or supports resistance. Based on the views that (a) psychic reality cannot be regarded as exclusively subjective or objective but is inherently both; and that (b) a goal of analysis is to achieve a different, acceptable and more accurate view of reality, the authors report a clinical case involving a confi rmably false pivotal memory and its associated negative affects. They discuss theoretical and technical considerations in utilizing extra‐clinical data during the treatment process.     

Fire at the theatre: (Un)reality of/in the transference and interpretation1

Only in Bion's extended idea of ‘waking dream thought’ is the oneiric paradigm of the cure (already an obvious Freudian principle) completely applicable. The author's basic hypothesis is that, by adopting this paradigm thoroughly, one can combine the radical antirealism which is expressed in the postulate by which all the patient's communications are transference‐connected (here meaning ‘false connection’‐i.e. as projection/displacement of elements of the patient's inner psychic world) with the ‘reality’ of the transference, that is to say with the conviction that the facts of the analysis are co‐determined by the patient‐analyst dyad and actually rooted in how they interact. The Freudian metaphor of the fi re at the theatre is reintroduced here to suggest the crisis of the therapist's internal setting and capacity for reverie, which occurs when the irreducible ambiguity of the transference is resolved defensively, either in the patient's external reality or in his unconscious fantasy constellation. The author gives three clinical examples. The fi rst shows some of the not necessarily negative effects of this temporary crisis. The other two vignettes show a way of listening to the traumatic events of the patient's life from a perspective (that of the ‘analytic fi eld’) which is thought to be potentially the most transformative and vital to the analytical relationship.     

MOURNING IN THE PSYCHOANALYTIC SITUATION AND IN SHAKESPEARE'S THE TEMPEST

Recognizing that mourning builds psychic structure, the author highlights the ubiquitous and essential nature of mourning in the psychoanalytic situation. Reality testing is intimately connected to mourning and is the warp on which psychic structure is woven in the analytic situation. Reality testing necessarily involves opportunities for mourning and thus will be present in every analytic hour. The confrontation with reality is the basis for all processes of mourning, or for creating defenses against this painful experience. The author views mourning as fundamentally a transformational process, and Shakespeare's The Tempest is used to illustrate this aspect of mourning.     

Outside‐In: Jung's myth of interiority ambiguated. Or ‐ Knowing me,Knowing Jung – ahah!

Given his lifelong battle against one‐sidedness Jung's persistent prioritising of the ‘inner life’ over the ‘outer’ can seem problematic. The question is raised as to whether an approach that seems to verge uncomfortably close to solipsism can sometimes render Jung blind to the intuition that psychic life is constituted by an on‐going interplay between inner and outer, self and other (an intuition that he himself sometimes articulated so brilliantly). The ‘ambiguation’ of Jung's work offers an opportunity to confront this problem by utilising a critical dynamic that is consistent with Jung's psychological insights.     

Working with chronic and relentless self‐hatred,self‐harm,and existential shame: a clinical study and reflections (Paper 2 of 2)

This second of two papers focuses on the shame which emerged in the first 14 years of analysis of a woman who was bulimic, self‐harmed, and repeatedly described herself as ‘feeling like a piece of shit’. To explore this intense and pervasive shame I draw on Jung's and Laplanche's emphasis on experiences of unresolvable, non‐pathological ‘foreignness’ or ‘otherness’ at the heart of the psyche. Images, metaphors, elements of clinical experience, and working hypotheses from a number of analytic traditions are used to flesh out this exploration. These include Kilborne's use of Pirandello's image of shame as like a ‘hole in the paper sky’ which, I suggest, points to a crack in subjectivity, and reveals our belief in the efficacy of the self to be illusory. Hultberg's observations on shame as having an existential mode (function) are also explored, as is the nature of analytic truth. Using these ideas I describe my patient's process of finding some small but freeing space in relation to her shame and self‐hatred. Through enduring and learning from her shame in analysis she realized that it was part of a desperate unconscious attempt to draw close to her troubled father and so to ‘love him better’.     

Mourning the dead,mourning the disappeared: The enigma of the absent–presence

Freud's interest in the impact of death on the living goes back further than Mourning and Melancholia (1917e, [1915]). In Totem and Taboo (1912–13) Freud noted the ambivalence of the emotions we experience in relation to the dead. In this paper, I focus on Mourning and Melancholia as a landmark in the understanding of both the normal and psychopathological aspects of mourning and depressive processes in human beings. Mourning and Melancholia bridges Freud's first and second topographic theories of the psychic apparatus and constitutes for many authors the foundation of his theory of internal object relations. With this psychoanalytic understanding of mourning as a framework, I discuss ‘special mourning processes,’ such as the those confronted by psychoanalysts in Argentina when treating the relatives of thousands of people who were ‘disappeared’ by the military dictatorship in the 1970s; they are ‘special’ in the sense that the external reality [which] constitutes the starting point of the psychic mourning process, as described by Freud, is absent. I argue that the ‘absent–presence’ of the body as an enigmatic message initiates a special mourning process that bears certain characteristics of, and is isomorphic to, Laplanche's seduction theory.     

Fonagy and Freud. Psychological versus psychic reality

Peter Fonagy and Mary Target present their Playing with reality theory as a developmental theory centred on the concept of psychic reality. This paper compares Fonagy and Target's use of the concept of psychic reality with Freud's original concept. It is argued that the concept of psychic reality has been redefined from delineating a psychic reality stemming from the unconscious to denoting a kind of conscious or preconscious psychological reality characterized by an experience of equality between the internal and the external worlds. The theoretical discussion is illustrated by being applied to eating disorder pathology, which by Fonagy and colleagues is described as associated with thought processes characterized by psychic reality.     

Transcending the caesura: Reverie,dreaming and counter‐dreaming

The author reflects about our capacity to get in touch with primitive, irrepresentable, seemingly unreachable parts of the Self and with the unrepressed unconscious. It is suggested that when the patient's dreaming comes to a halt, or encounters a caesura, the analyst dreams that which the patient cannot. Getting in touch with such primitive mental states and with the origin of the Self is aspired to, not so much for discovering historical truth or recovering unconscious content, as for generating motion between different parts of the psyche. The movement itself is what expands the mind and facilitates psychic growth. Bion's brave and daring notion of ‘caesura’, suggesting a link between mature emotions and thinking and intra‐uterine life, serves as a model for bridging seemingly unbridgeable states of mind. Bion inspires us to ‘dream’ creatively, to let our minds roam freely, stressing the analyst's speculative imagination and intuition often bordering on hallucination. However, being on the seam between conscious and unconscious, dreaming subverts the psychic equilibrium and poses a threat of catastrophe as a result of the confusion it affords between the psychotic and the non‐psychotic parts of the personality. Hence there is a tendency to try and evade it through a more saturated mode of thinking, often relying on external reality. The analyst's dreaming and intuition, perhaps a remnant of intra‐uterine life, is elaborated as means of penetrating and transcending the caesura, thus facilitating patient and analyst to bear unbearable states of mind and the painful awareness of the unknowability of the emotional experience. This is illustrated clinically.     

Exposed: phallic protections,shame and damaged parental objects 1

Using ideas derived from Dana Birksted-Breen (‘Phallus, penis and mental space’, International Journal of Psycho-Analysis, 77: 649–57, 1996), this article explores the clinical experience with ‘Tommy’, a young boy who suffered multiple traumas and neglect. Birksted-Breen describes a phallic state of mind, which, amongst other things, serves to repudiate the potential for a creative link between internal parental objects and a capacity for thinking. In order to survive psychically, Tommy frequently turned to a phallic state of mind. The deficits in his internal and external objects meant that helpful parental qualities, linked with the development of psychic bisexuality, were not available for introjection and identification. The paper suggests a link between Tommy's employment of phallic (and at times perverse) ways of thinking, related to his intrusive attempts to expose and humiliate his psychotherapist, and to an experience of shame associated with inadequate internal objects. The serious compromise to the development of a creative psychic bisexuality in the patient is reflected in the countertransference strain on the psychotherapist's own internal couple.     

The analyst's narrative function: Inventing a possibility

This article describes a psychic function common to analysts that was gradually revealed through clinical work with children. It is a psychic quality derived from function α, which involves analysts’ capacity for reverie – their narrative function. The author presents two clinical situations where this function developed in the analytic field in relation to patients’ difficulty in symbolizing. In the first case there was an early traumatic experience unavailable for representation. The analyst lent the patient her ability to represent and produced a narrative that made it possible to create a world of phantasies and transform nightmares into ‘dreamable’ dreams. In other words, she removed the quality of unbearable, irrepresentable reality that characterized those raw experiences encrypted in the psyche. In the second case the analyst's narrative function sought to connect with the isolation, the shell that housed a child suffering from an autistic disorder whose ability to represent had not been established. The analyst provided meaning for the patient's repetitive, stereotyped play, thus weaving the child's subjectivity and gradually introducing a notion of alterity. The author seeks to show how this function, in the thematic construction of the session, facilitated both the working‐through of a traumatic situation (with the ability to share representations) and the constitution of the psychic fabric.     

Homage to Dora: Commentary on Paper by Melanie Suchet

This discussion of Suchet's paper further explores Butler's double disavowal of love and loss as it relates to racialized bonds. It also examines Yoshino's concept about the cost of “covering” difference and supports the need to uncover white privilege and lack while being mindful of holding the tension of sameness and difference between the psychic and the social. Surrender is considered within a frame of multiplicity and of Buddhist thought, and the author associates to the sensory realm of childhood through her own early attachment. Finally, the author wonders about the nature and complexity of racialized shame and its delicate place in clinical work.     

Law and psychology in conflict

It is argued that a link prevails between the phenomenology of externality present in classical liberal theory and the state of mind known as schizophrenia. To escape the social reality of possessive individualism, especially the conception of consequences, ends, habits, routine, the schizophrenic individual ‘withdraws’ or regresses into a psychic universe that contains a dimension unrelated to the consciousness and values of externality: the pursuit of wealth and things, the calculated regard of the other as an instrument for enriching the self. The schizophrenic is incapable of adapting his ‘ego’ to the necessities of the social environment; he cannot defend himself in ‘conventional’ or ‘normal’ ways from the demands of living in a social milieu where the expectations and judgments of others impose intolerable pressures on consciousness. Instead the individual undergoing the painful process of withdrawal constructs a set of psychic defenses that from the standpoint of the external world appear to be ‘strange’, ‘odd’, ‘bizarre’, or ‘demented’. The ‘mode of Being’ of the schizophrenic has nothing in common with the life‐style of the acquisitive, status‐conscious society. Some consideration is given to the political implications and meaning of the schizophrenic's withdrawal.     

Frühe Störungen aus der Sicht zunehmender Mentalisierung

The term “mentalization” describes the capacity to judge other humans in terms of their mental activities such as wishes, hopes, beliefs and intentions, as well as the ability to think about one’s own thinking. Mentalization and reflective function are equivalent to each other. They play an important role in selforganization, impulse control, and affect regulation. Mentalization develops during approximately the first five years of life on the basis of attachment in Bowlby’s sense. Around the 9th month of life the child begins to understand her mother as an intentional agent. Mirroring by the mother, in a way of reproducing the child’s state of mind but in a slightly different “marked” manner, enables the child to establish a second “objectified” representation of her condition besides her primary unreflected one. Consequences of lacking, unmarked, or distorted mirroring for later narcissistic or borderline personality are discussed. The child begins now thinking, i.e. playing with representations, but the state of brain development allows to conceive of only one reality. Internal world and external reality appear undistinguishably identical. This is called the “equivalence mode” of psychic functioning. As-if-games open, in a further developmental step, the possibility of including a second reality, namely a pretended one. This is called the “pretend mode” of psychic functioning. At age four to five the child has reached the capacity to take multiple realities into consideration, to take the perspective of an other and to decentrate. She now has a “theory of mind”. Patients with early disturbances have reached this stage only partially. They may also regress to one of the earlier modes of psychic functioning as a consequence of stress or trauma. The knowledge of these early mechanisms helps to identify and understand them when they appear in our clinical practice.     

Human time and dreaming

One characteristic of massive trauma is a persistent feeling that time is frozen, i.e., an experience impossible to integrate into a psychic reality. In this paper, the author sets out to explore the dimension of time in the psychoanalytical situation in an effort to shed light on this question. The infant acquires an immediate sense of time through the rhythm of frustration and satisfaction, and out of these encounters, a fundamental dialogue evolves. This primary dialogue is internalised and is regarded as an indispensable structure for psychic life. The child's existence is impregnated by unconscious desires or beliefs of the adult world—enigmatic messages that will constitute an unconscious source of the child's own psychic reality. Timeless desires and enigmatic messages urge on a dreaming in attempts to carry over the psychical sense of time and the implacable time of existence. When we infuse a time dimension through our dreaming and our narratives, we give shape to our timeless wishes. The psychoanalytic situation arouses the primary dialogue and an elementary experience of time. Traumatic experiences are tantamount to the absence of the primary object and thereby the death of time. Dreaming becomes an endeavour to create a psychic space, the aim of which is to restore the primary dialogue. If circumstances obliterate all hope of re-establishing the bond to the primary object, the sense of time is destroyed as well. The author concludes that the experience of time and elaboration of traumatic experiences are closely connected.     

A psychoanalytical phenomenology of perversion1

After stating that the current tasks of psychoanalytic research should fundamentally include the exploration of the analyst's mental processes in sessions with the patient, the author describes the analytical relation as one having an intersubjective nature. Seen from the outside, the analytical relation evidences two poles: a symmetric structural pole where both analyst and patient share a single world and a single approach to reality, and a functional asymmetric pole that defines the assignment of the respective roles. In the analysis of a perverse patient, the symmetry‐asymmetry polarities acquire some very particular characteristics. Seen from the perspective of the analyst's subjectivity, perversion appears in the analyst's mind as a surreptitious and unexpected transgression of the basic agreement that facilitates and structures intersubjective encounters. It may go as far as altering the Aristotelian rules of logic. When coming into contact with the psychic reality of a perverse patient, what happens in the analyst's mind is that a world takes shape. This world is misleadingly coloured by an erotisation that sooner or later will acquire some characteristics of violence. The perverse nucleus, as a false reality, remains dangling in mid‐air as an experience that is inaccessible to the analyst's empathy. The only way the analyst can reach it is from the ‘periphery’ of the patient's psychic reality, by trying in an indirect way to lead him back to his intersubjective roots. At this point, the author's intention is to explain this intersubjective phenomenon in terms of metapsychological and empirical research‐based theories. Finally, some ideas on the psychogenesis of perversion are set forth.