The psychotic personality: A psychoanalytic theory and its application in clinical practice

This paper presents and discusses aspects of Bion's theory of the psychotic personality. In particular, it focuses on the psychotic personality's attacks on the dependent and needy self. The paper considers how Bion's theory can be applied to understanding the schizophrenic patient. Examples are given to show its importance not only in analytic practice, but also within general psychiatry.     

The trauma of attempted suicide

Suicide is a traumatic event, one which may acutely recreate a previously-experienced traumatic situation. The person's capacity to think after a failed suicide attempt is affected by the use of defence mechanisms against persecutory anxieties and depressive pain, and there is a wish to turn a blind eye to the seriousness of the suicidal act. This includes the damaging effects on the person's relationships with others, and damage to his own psychic integrity.

The need to turn a blind eye to the consequences of a failed suicide attempt may also be mirrored by the therapist who assesses and treats the patient in the early hours after such an event. Suicide is associated not only with the pain of despair but also with a ruthless abandonment of life. It is a complex and difficult task for a therapist in the immediate aftermath of a suicide attempt to be able to keep in mind a concept of suicide that includes both the patient's role as the perpetrator of great violence against himself, in which death is the intended outcome of his actions, and at the same time recognise the patient's identification with an abandoned and cruelly treated object.

In this paper, we describe some of the psychodynamic factors that affect and influence the assessment and treatment of patients in the immediate period following a failed suicide attempt. We emphasise the importance of supervision in helping prevent destructive acting-out by the therapist when treating disturbed patients under such painful circumstances.     

The value of grandparents

This paper is a slightly revised version of a paper presented on 26 October 1989 as one of the Tavistock Open Lectures. The role of grandparents is discussed and the value of a supportive presence, both externally and internally, is emphasised, especially at birth and at times of mental illness. This concept is extended to the maternal or ‘grand’-maternal role adopted by agencies attempting to improve the quality of mental care, and its value is also visible in the transference in psychotherapeutic work.     

Knowledge,learning, and freedom from thought

This paper discusses the acquisition of knowledge by one generation from another, and the problems inherent in the process. The difficulties are seen as falling into three areas: (i) the difficulty of understanding the knowledge itself; (ii) the difficulty that a fact or a theory becomes an internal object subject to all the vicissitudes of object relations; and (iii) the difficulty of finding a training method that will enable the learner to assimilate knowledge and use it judiciously rather than to swallow it in an uncomprehending way. Examples are drawn from the history of ideas in general, and from the author's experience of therapeutic communities, particularly the Cassel Hospital. The danger of allowing a body of knowledge to become, in its passage from one person to another, a mere set of never-to-be-questioned beliefs is illustrated. The common frailties of both trainers and trainees are discussed and methods suggested for understanding and overcoming them.     

Different origins and meanings of acute acting-out in an inpatient psychotherapeutic setting

In this paper I describe four different sources of acute acting-out behaviour as may be observed in long-term hospitalised patients suffering from severe personality disorders. I hope to demonstrate that acute psychological distress does not happen in a vacuum, but that specific intrapsychic and interpersonal dynamics within the hospital setting are at the root of what appears overtly as nonspecific emotional and behavioural disturbance. I argue that the hospital team's correct insight into the factors underlying acute acting-out is crucial to the implementation of therapeutic interventions aimed to decrease the patient's disturbed state of mind.     

Working with incest survivors

The purpose of this paper is to convey more widely the existence of this kind of specialist group in the NHS. We also wish to show some of the advantages and disadvantages in setting up such a group to other professionals who may be considering the possibility of starting an incest-survivors group. The paper describes the group which ran at the Psychiatric Day Hospital at the Whittington Hospital for forty weeks: how we adopted the group structure; some of the problems we faced; and some of the emotional issues generated in therapists and patients. Conclusions are drawn about the usefulness of such a group.     

Psychoanalysis and the political process

The Political Process is Society's mechanism for debating value systems. The term can also be used to describe a debate in a variety of other settings — subsystems of Society — about value systems. This paper is about the contributions that psychoanalysis, both as a theory and in its various applications, can make to the understanding of the process of debate and its setting. It is also about the implications for our conduct that arise from this understanding.     

When it is not the patient who pays

This paper looks at the question of third-party payments in psychotherapy and psychoanalysis. This is of particular relevance in Holland, where the Dutch government makes substantial payments for psychoanalytic treatment via a state insurance system. The literature concerning third-party payments is reviewed. Freud himself was inconsistent about this matter and cannot therefore be relied on to give a clear guideline. The majority of writers are heavily in favour of ‘personal sacrifice’ and show a strong bias, especially against insurance payments for fees. These arguments are examined in detail and the two main conclusions are explored, namely that (1) certain unconscious conflicts cannot be mobilised where there is external financing, and (2) that the absence of personal sacrifice engenders too much wish-fulfilment. Both these arguments are rejected as being biased and are found not to stand up to detailed scrutiny.

The effects that different types of payment have on the development of the therapeutic situation, and the different types of transference and countertransference problems that each engenders, are explored. There is some speculation as to the reason for the persistence of this view if it is so patently false. Finally there is some consideration of the positive effects third-party payments can have on psychoanalytic practice.     

Manic-depressive psychosis: Psychopathology and individual psychotherapy within a psychodynamic milieu

Manic-depressive patients are not usually regarded by psychiatrists as suitable subjects for psychotherapy, and there are many reasons for this view. Psychological support tends to take the form of helping the patient adjust to his disability, to become more aware of the life situations which may disturb him, of warning symptoms, of the need for appropriate medication, and perhaps to explore the most significant life conflicts. Psychoanalytic psychotherapy aimed at conflict resolution and personality development is widely regarded as impracticable, or ineffectual at best, or, at worst, as a potentially dangerous intervention. Considering the fact that the risk of suicide in the depressive phases may be so great, the problems of containing the disinhibited manic episode so serious, and the social consequences of such episodes so disastrous, it is not surprising that pharmacological control of pathological symptoms is so often regarded as the only therapeutic aim.

This paper is based on an account of a single patient suffering from a severe manic-depressive disorder with schizoid features, and a family history of manic-depressive illness, who was treated with individual intensive psychoanalytic psychotherapy in a context of a psychodynamic psychiatric ward, with encouraging results. Some implications of this experience will be discussed.