Introduction to object relations group psychotherapy.

The author shows how object relations group therapy focuses on primitive defense mechanisms that shape the group-entity image or "basic assumptions group." Such primitive defense mechanisms as splitting, projective identification, omnipotent denial, projection, and introjection are the mental resources to protect the endangered self and the threatened objects from the fantasized imminent destruction. Object relations group psychotherapy addresses those defenses and the underlying psychotic anxieties, offering members opportunities to search for other ways to respond to their primitive fears. The author introduces two extensive clinical vignettes to illustrate how object relations group methods are different from other group-centered psychoanalytic techniques. He concludes by commenting on future theoretical refinements and on the problems in the professional practice of this modality.     

The Patient-Staff Community Meeting: A Tea Party with the Mad Hatter

The author shows how object relations group therapy focuses on primitive defense mechanisms that shape the group-entity image or “basic assumptions group.” Such primitive defense mechanisms as splitting, projective identification, omnipotent denial, projection, and introjection are the mental resources to protect the endangered self and the threatened objects from the fantasized imminent destruction. Object relations group psychotherapy addresses those defenses and the underlying psychotic anxieties, offering members opportunities to search for other ways to respond to their primitive fears. The author introduces two extensive clinical vignettes to illustrate how object relations group methods are different from other group-centered psychoanalytic techniques. He concludes by commenting on future theoretical refinements and on the problems in the professional practice of this modality.     

Mourning and psychosis: a psychoanalytic perspective

The author attempts to develop some of the basic models and concepts relating to mourning processes in psychotic patients on the assumption that situations of loss and mourning are key moments for psychoanalysis, psychotherapy, and therapeutic approaches in general. Secondly, he reminds us that 'mourning processes in psychotics' are not always 'psychotic mourning processes', that is to say, that they do not necessarily occur within, or give rise to, a psychotic clinical picture. These ideas are illustrated by a number of sessions and vignettes concerning two psychotic patients in psychotherapeutic and psychoanalytic treatment. In theoretical terms, it seems vitally important in this context to combine a relationship-based approach within a framework of special psychoanalytic psychopathology with an updated view of processes of mourning and affective loss. A fundamental requirement at clinical level is to determine the role to be played by psychoanalytically based treatments in combined, integrated or global therapies when working with psychotic patients. For this purpose, the paper ends by outlining a set of principles and objectives for such treatments.     

ENCOUNTERS WITH PSYCHOSIS

This essay offers a personal account of one physician's attempt to engage with psychotic patients in an inner‐city hospital. It considers some of the obstacles to psychoanalytic work with psychotic patients, including anxiety in the psychotherapist, anxiety in the patient, institutional resistances, and paradigmatic errors. A discussion of paradigmatic errors in Western mental health care is expanded upon. Rorty's ( 1979 ) critique of objectivity and Kuhn's ( 1962 ) work on scientific paradigm shifts are discussed in an attempt to demonstrate how we might better understand psychosis as an illness and connect with patients across the entire diagnostic spectrum.     

Freud and Klein in The Lion King

This paper is presented as a potential teaching resource for those starting out in their psychoanalytic understanding, whether aiming at clinical work or the academic study of psychoanalytic ideas. Some central ideas from Freud and Klein are illustrated and illuminated in an accessible way using the Disney film The Lion King. Key elements from the film are used to bring to life concepts such as infantile omnipotence, manic defences, Oedipal conflict, persecutory guilt, destructive envy, the superego, reparation and mourning. The story of Simba is taken as demonstrating universal struggles to overcome Oedipal rivalry and destructive envy in order to reach maturity.     

'Poor girl': a case of active psychosis

The paper provides a structural account of a clinical case of psychosis based on a two-year analysis conducted from a Lacanian perspective. It illustrates the Lacanian theoretical and clinical approach to psychosis through discussing the different phases of the analytic work with the particular analysand from her gradual stabilization to her breakdown and hospitalization. Following through the development of the analysis in a chronological order enables a presentation of the different modalities of psychotic transference at different points in the work as well as a discussion of the mechanisms responsible for stabilization and, conversely, psychotic breakdown. The paper discusses the use of language in psychosis as well as the strategies of binding jouissance that the analysand developed as a means of preventing psychotic crises and maintaining a functional relation to the world. Finally,issues are raised about the aim and direction of psychoanalytic treatment of psychosis.     

The explosion of the present and the encapsulation of time: Transference phenomena in the analysis of a psychotic patient

The paper deals with some basic problems concerning the experience of time and space in the psychoanalytic treatment of psychotic patients. Whereas borderline patients tend to distort the experience of time and space under emotional pressure, the concepts of time and space seem to dissolve in acute psychotic states of mind. Sometimes this manifests itself in an explosion of the present, where the past is ubiquitous and the future is perceived as the end of all times. The case of a 48 year‐old patient with the external diagnosis of ‘paranoid–hallucinatory schizophrenia’ is presented to illustrate that the main task is to recreate a structure to contain the experience of space and time. Such a development may occur if primitive psychotic anxieties can be taken up and metabolized. A near‐psychotic decompensation before the first break and the development of a transference psychosis in the second year of the analysis are depicted in detail. Subsequently some developments became visible which helped the patient to better tolerate catastrophic fears of loss. This included the formation of a structure which the patient called ‘hibernation’ enabling her to psychically survive without falling apart. By retreating into her ‘time capsule’ she managed to overcome breaks and to delay her fears of fragmentation until they could be taken up and worked through in the transference. The creation of a structure like the patient's ‘time capsule’ is considered to be an attempt to construct the experience of time and space. It prevented a collapse of her internal space thereby enabling further steps towards thinking and symbolization. In conclusion, some theoretical and clinical aspects are discussed including the role of the countertransference.     

Mental models and language registers in the psychoanalysis of psychosis: An overview of a thirteen‐year analysis2

The author suggests that the use of mental models and language registers may help an analysis to proceed, especially in psychosis, when the patient has not yet developed a mental space that will allow him/her the functions of knowledge and containment of emotions. Models, according to Bion, are a primitive approach to abstraction and a manifestation of the analyst's reverie that enables him/her to transform sense data into alpha‐elements. Ferrari, in a further development of Bion's theories, hypothesises a relationship between the transference and the internal level of body‐mind communication, and proposes the use of language registers to sustain the psychoanalytic process. The author presents several clinical examples from a thirteen‐year, four‐session‐a‐week analysis of a psychotic analysand who was initially confused, paranoid and altogether unable to bring self‐reflective thought to bear on her overwhelming emotions and had, by the end of the analysis, completely recovered from her psychotic symptoms. The clinical material shows how the technical tools of mental models and language registers helped in the construction of a mental space and spatio‐temporal parameters, permitting the patient to tolerate overwhelming concrete emotions and finally to recognise and work through the emotions of an intense transference.     

Thoughts about the development of a potential space in the psychotherapeutic treatment of infantile psychosis

This paper describes the usefulness for the child psychotherapist of some Winnicottian concepts in psychoanalytic treatment of very young psychotic children. Particular attention is given to the concept of ‘potential space’ as Winnicott has formulated it in his writings. Three clinical cases are presented, one of these includes a complete mother-child session in order to show how the therapist can work to create a space where psychic events can become possible.     

Sullivan und die intersubjektive Sichtweise

The author sees H.S. Sullivan??s (1892?C1949) interpersonal theory as the best theoretical framework for the contemporary intersubjective perspective in psychoanalysis and presents it in its pluridimensional articulation. After having extended Freud??s therapeutic approach to psychotic patients, Sullivan developed both a developmental psychology and a psychoanalytic and psychotherapeutic technique based on the ??interpersonal field?? as the basic unit of study. To the pluridimensional character of his theory also belongs its application to the cultural and social aspects of our personal identity. Because the contemporary psychoanalytic authors who shaped the intersubjective perspective limited themselves to the clinical dimension, Sullivan??s interpersonal theory can still provide the theoretical framework which any psychoanalytic perspective needs.     

A Mixed Bag: The Realities of Psychoanalytic Practice

For a variety of reasons, psychoanalytic training is done in somewhat of a vacuum. It teaches a theory and a way of practicing that does not always translate well to day-to-day private practice work. The clinical realities of psychoanalytic practice prove the psychoanalytic method to be one that provides help to a wider audience than classical psychoanalytic training programs might suggest. The psychoanalytic approach offers the analyst many special opportunities to work with and help a wide variety of patients. Analysts who accept both the limitations as well as the wide application and broad benefits of the psychoanalytic approach may have a more fulfilling experience than their training experiences might foster. At the same time, the analyst's level of therapeutic skill, the patient's diagnosis, and many multiple external factors create different limitations in the practice and outcome of psychoanalytic work. Extensive case material is used to show the broad range of patients who are helped by the psychoanalytic method. The clinical material also shows the less than perfect, but often good enough outcomes of these difficult cases with often severely disturbed patients.     

More than enough guilt to go around: oedipal guilt, survival guilt, separation guilt

The concepts of oedipal guilt, survivor guilt, and separation guilt are examined using clinical material from a child case to demonstrate the intermingling of these constructs. A brief review of their evolution in the psychoanalytic literature reveals a frequent conflation of the terms guilt and fear, the former at times standing in for both meanings. The fear/guilt distinction and the subsequent differentiation of guilt into oedipal, survivor, and separation guilt have implications for how analysts understand and interpret particular kinds of clinical material. Two sets of adult clinical data are next presented: the first illustrates a shift from interpreting a patient's fear of retribution for forbidden desires to interpreting guilt over pursuing those desires. The second vignette illustrates a common dynamic in which a patient's fear/anxiety regarding the ability to lead an independent life defends against deeper feelings of guilt over this same desire. This latter dynamic can play an important role in negative therapeutic reactions and interminable analyses. Developmental research suggests that toward the end of the first year of life, infants' capacity to attribute independent mental states and intentionality to self and others allows for the rudimentary experience of guilt.     

Three Phases of Treatment with Borderline and Psychotic Patients

Three distinct, yet overlapping, phases of treatment emerge when working with some borderline and psychotic patients. This are patients who test the ordinary limits of psychoanalysis, but can profit from its deep exploration. The first phase is colored by acting out, interpersonally and intrapsychically. An analytic envelope of containment is necessary to sustain the treatment. Interpretive holding and containing help the patient find a psychic receptacle capable of detoxifying violent projections. Many of these patients terminate prematurely. The second phase is centered around the patient's defensive use of the death instinct to extinguish or destroy certain parts of their mental functioning. This difficult standoff between parts of the patient's mind becomes replicated in the transference. The third phase reveals the more fundamental problem of paranoid～schizoid anxieties of loss and primitive experiences of guilt. These include fears of persecution and annihilation. Some patients abort treatment in the first or second phase and never work through the phantasies and feelings of loss. Nevertheless, much intrapsychic and interpersonal progress is possible. Given the instability and chaotic nature of these patient's object relations, the analyst must be cautiously optimistic in their work and realize the potential to help the patient even when presented with less than optimal working conditions.     

A group-centered object relations approach to group psychotherapy with severely disturbed patients

This paper discusses how the application of object relations theory to clinical intervention has extended the application of psychoanalytic group psychotherapy to more severely disturbed patients. The author suggests how to structure the group based on individual and group needs. Clinical issues are presented, including the group as a container, communication peculiarities, and psychotic response to separation, sexuality, and interpretation.     

The symbolic and concrete: Psychotic adolescents in psychoanalytic psychotherapy

Unique disturbances in symbolisation are characteristic of the pathology of schizophrenia. Drawing on the case vignette of a psychotic adolescent, the author discusses theoretical problems in the symbolisation process in general and then in psychosis, in particular the relation between 'concretism' as a thought disorder and other psychotic defences. The ability to symbolise on the one hand and to maintain sufficiently stable ego boundaries on the other hand are examined in their relation. The author's clinical experience supports her hypothesis that there is a close relationship between the impairment of the symbolisation process in the adolescent or adult psychotic patient and his/her inability to engage in symbolic play as a child. Special attention is paid to the role of early trauma and consequent pathology of object relations for disturbances of symbolic play in childhood. Regression to concrete thinking is understood as the chance of the psychotic patient to give some meaning to reality in an unreal, delusional world and as his/her last chance to communicate at all. Conclusions are drawn for psychoanalytic techniques in the treatment of patients who are deeply regressed in this respect. Special attention is given to the particular circumstances and challenges of adolescence and to providing psychoanalytic psychotherapy to adolescent psychotic patients.     

THE MEANING OF DREAMS IN THE PSYCHOTIC STATE: THEORETICAL CONSIDERATIONS AND CLINICAL APPLICATIONS

The authors consider that the Freudian theory of dreams is not directly applicable to psychotic and borderline patients with their constantly varying states of mental integration. Because these patients' dreams lack associations, the usual psychoanalytic approach cannot be used to ascertain their meaning. After reviewing the literature on the specific quality of dreams in the psychotic state, the authors point out that such dreams have nothing to do with the metaphorical language of the dream work but instead express the concreteness of the hallucinatory construction. For this reason, a dream's meaning may fail to be understood by the patient even if it seems clear to an observer. Yet the analyst's reception of a 'psychotic dream' is a unique and essential source of valuable information on the manner of construction of the delusional system, allowing analytic work on the psychotic nucleus. In the authors'view, such dreams may help the analyst and the patient— while still lucid—to acquire insight, thus affording a stable foundation for emergence from psychosis. The paper includes some case histories, in one of which a psychotic female patient is enabled by work on dreams to reconstruct a psychotic episode and thereby to ward off an imminent fresh lapse into psychosis.     

The work of the psychoanalyst in the field of psychosis1

Psychosis questions the foundations of psychoanalytic theory and challenges our ultimate convictions about psychic functioning. Using her clinical practice, the author explores the foundations of representation and underscores the central position of sensoriality in constituting a representation. Psychoanalytical work with a psychotic subject requires a certain sharing of the psychotic experience which puts the analyst in touch with raw material grasped as a fragment of sensoriality that must consequently be shaped and figured so that the subject's representational activity can resume. The author thus uses the Freudian notion of figuration to specify this ‘raw material’ and its sensory texture. She then refers to Aulagnier's pictograms as a way of thinking about sensoriality under the sign of displeasure and pain rather than pleasure. In the light of this theoretical development, the author re‐examines the opening excerpts from her clinical cases to come up with a practice of interpretation as figuration that allows jointly for the shaping of the raw material and the identifying import of this shaping.     

Psychoanalytic thinking in primary care: The Tavistock Psychotherapy Consultation model

This paper describes the conceptual underpinnings, structure and operations of a novel service, the City and Hackney Primary Care Psychotherapy Consultation Service – a service set up partly with the aim of addressing the needs of patients who present with ‘medically unexplained symptoms’. As part of the Tavistock and Portman NHS Trust, this service moves its clinical base, staff members and daily work, as well as the foundations of psychoanalytic thinking that define the Trust's work, into the heart of a community, and provides psychoanalytically informed clinical practice and consultation to patients and general practitioners in the City and Hackney, one of London's (and the UK's) most deprived and ethnically diverse boroughs. The authors describe the psychoanalytical underpinnings of the model, the design and structure of the service, patient demographics and preliminary outcome data, as well as an example of consultation work with general practitioners. The authors propose that psychoanalytic applications have a place in primary care and that psychoanalytic thinking can help general practitioners and patients alike, even when the clinical interventions offered are not solely based on psychoanalytic technique or therapeutic approaches. The paper concludes with thoughts about the model, its origins and its future.     

Mutilation of self and object: the destructive world of the paranoid-schizoid patient and the struggle for containment and integration

Using case material, I have described the three overlapping phases of treatment that occur with some borderline, narcissistic, or psychotic patients. These patients are dealing with paranoid-schizoid experiences of the self and the object. In this part-self, part-object world, many shifting, opposing, and contrary states of feeling and thought occur. Acting out is the first phase of analytic treatment. This is an externalization of persecutory anxiety, primitive guilt, and phantasies of annihilation. Projective identification, splitting, and denial are common and tend to make for difficult transference and countertransference problems. During the middle phase of treatment, pathological superego states and manifestations of death instinct color the analysis. The death instinct reacts defensively to the sadistic superego. Technically, the destructive internal conflicts created by these two elements must be clarified and interpreted in the transference. Flexible analytic management and containment are crucial supplements to ongoing interpretation. If these chaotic patients are able to stay in treatment for a period time, the acting out and the superego/death instinct phase gradually give way to phantasies of loss. This is still a paranoid-schinoid perspective of loss, making it persecutory experience. Although depressive anxieties do enter the picture, these still involve pathological anddestructive states of guilt and all-or-nothing threats of abandonment and attack. A case was presented in which the patient managed to continue into the third stage of analytic treatment, long enough to benefit frominternal, structure change. In this final stage, the patient "O" was able to acknowledge, work through, and integrate her prior feelings and phantasies of loss, persecution, and abandonment anxiety into more manageable and reality-based depressive functioning.     

What happens before and after acute enactments? An exercise in clinical validation and the broadening of hypotheses

This paper seeks to validate clinical facts and theoretical hypotheses that have been discussed before and that address configurations involving chronic and acute enactments. Its validation process compares clinical material from psychoanalytic work in different psychoanalytic cultures - work from South America-Uruguay (Yardino), Europe-Spain (Sapisochin), South Africa (Ivey), Europe-UK (Bateman). It documents clinical facts described in four articles and confirms that during chronic enactments the analytic dyad gets caught up in a dual relationship that veils and congeals the triangular situation because acknowledging it would be traumatic. The lack of triangular space impedes the formation of symbols as well as dreaming and creates non-dreams-for-two. During chronic enactments analysts use their implicit alpha-function to assemble traumatic areas. These areas emerge as a mix of discharges and non-dreams that are dreamed through acute enactments. Acute enactments occur when chronic enactments dissolve and patients experience an abrupt contact with reality. The attenuated trauma is then dreamed alive. The linking of new symbols develops a network of symbolic thought and creates dreams-for-two and broadens the patient's mental universe. The validation process has deepened our vision concerning clinical facts, especially in relation to: (1) the wavering between acute and chronic enactments, (2) analysts' inhibitions and feelings of guilt, and (3) the influence of analysts' personalities on the configurations they describe. These theoretical hypotheses have been confirmed and broadened not only in relation to the vicissitudes of dream work in traumatic areas, but also in relation to defenses such as thin or thick skin, and in relation to listening in countertransferential detours.