CLINICAL AND THERAPY
Psychological and pharmacological medication in psychosis: their meaning in the transference
|Sorrento, May 2003.
In his lectures in the College de France in 1928, Pierre Janet used to describe psychoanalysis as being a kind of psychological medication. At that time, other kinds of "medication" were hypnotism, magnetism and some similar approaches. Psychoanalysis, however, is different in that the therapeutic relationship is based on an understanding of an unconscious dimension of the mind.
This implies of course that whatever the patient may say is important – but even more important is what he or she cannot say, in other words what is unconscious. In appendix C to the paper he published in 1915, Freud tried to give “shape” and bodily existence to the Unconscious as part of the “anatomy” of the personality. He used expressions such as the unconscious “innervation of a word” (1915e: 210). The Unconscious does not have only an abstract existence; it is part of bodily life and the bodily ego. What is fundamental in the body-to-body relationship with the patient is that everything the latter expresses, consciously and unconsciously, is part of his world and is directed towards the analyst in the transference. The concept of transference in neurosis and psychosis is based on the relationship between patient and analyst – this is therefore an intimate experience in which both participants are simultaneously witnesses and actors (physically-existing beings)
in the scenarii that are being played out in the hic et nunc of the analytic field.
I prefer to add to the concept of transference that of “field-work” as a creative space in which analytical life experiences time as a changing rhythm that sometimes – in the case of the psychoses, for example – becomes paralysed and petrified. In the case of psychotic patients as well as in hypochondriasis, the language of the body speaks to the reader, suggesting (sometimes simply with gestures, sounds, noises or smells) what the mind cannot put into words. What is important for me as an analyst is what people cannot say through words, mainly something that is suppressed or projected somewhere – in a part of the body (visceral body), the furniture, a corner of the room, or even out in the wide openness of Nature. In people with a Messianic delusion, the projection is even more ambitious – it goes into the cosmos.
I will try to give an example from my own work with a patient, in which the name of the pharmacological medication, the way in which it was given, its shape and colour and the unconscious relationship with the doctor or analyst as “medicator” all played a very important role. Thus my interest is to discover how pharmacological medication meets up with our psychological medication, and the role they play in the patient’s inner world (as in that of the analyst in the counter-transference).
Usually we analysts look to some other physician to prescribe medication; this is also my case. Though this may be an unavoidable splitting, the analysis of the transference and a good relationship with the pharmacotherapist are necessary.
In mental hospitals a nurse usually distributes the medication to patients in the unit. A continuation of the transference to the distributor of medication is part of the institutional transference in daily life and in pathological states. Is this an extension of the transference and counter-transference concerning the spatial relationship with family members and with the nursing staff in institutionalised patients?
Nowadays, psychotic patients who refuse to take medication per os are injected with slow-absorption drugs that are called a "dépôt" -- the doctor or the institution is felt to be "depositing" inside the patient an imaginary nurse who is going to distribute the medication all through the organism for almost a whole month. Many such patients are not sure whether the inner distributor is friendly or hostile towards them; and besides, the absorption is never perfect – sometimes they feel invaded. Of course, they are prone to have further problems if they drink alcohol or have any other kind of addiction. All these elements are actors or players of a dramatized global unconscious transference between pharmacological, institutional and psychoanalytic inter-relationships. This is a highly complex language which demands careful investigation.
A Clinical Case
I have written previously about this patient in my Mental Space (Resnik, 1995). Charles, a 22-year-old schizophrenic of Spanish descent has been in analysis with me for the past several years. He came to his first appointment with his mother and father and we all sat down in my consultation room. Charles struck me as a slim, handsome young man, tense, silent, indifferent to his surroundings, locked up in his isolation. The mother became the spokesperson for the history of the illness, saying: “Charles has become more and more withdrawn this past year. He interrupted his studies at the Madrid Academy of Fine Art.” The family had moved to Paris, and intended to settle there for some years. Charles’ regression worsened: he had become like a little boy, unable to leave his mother. He used to follow her everywhere – he became her “shadow”, as it were, but at the same time his mother became his living body (and sometimes his living shadow, depending on the circumstances).
Another contact was with his computer (a mechanical object-relationship). We know that nowadays, virtual reality challenges “real” reality, and psychotic patients (as well as “normal” people) often find themselves alienated to some extent. Sometimes Charles became angry with his computer (just as normal people do!), because he wanted the machine to become a kind of magician / or shamanic doctor figure for him. This demand can be dramatized in the transference when the analyst is transformed into a computer or shamanic figure through psychotic projection. The analyst is supposed to have an answer for everything, at least for the questions the patient asks, and also to put himself at the mercy of the patient: in other words, to become his or her computer.
His mother told me that Charles would become violent against the machine, and begin to hit out at it. This is an important theme in which the reality principle is transformed into a delusional / mechanical one. Dr Julio Moreno wrote a very interesting book called Ser Humano (Being Human) (2002), in which he developed his views on the kind of “normal” alienation that occurs in our everyday life and its implications for our human history and system of values. Moreno makes an interesting differentiation between making connections and associations. Chronic psychotic patients may make mechanical links, but they are unable to “feel” and to “think” about them (true associations). For Charles the computer became his mechanical image, a robot that sometimes could make connections but not those that he wanted (and, of course, the computer could not associate, think, feel for him). He felt therefore deluded and sometimes violent, demanding tyrannically what he wanted it to do. This was also his position towards the world in general, as perhaps it is for any psychotic, omnipotent, delusional conception of the world.
As his mother was telling me about his history, Charles’s eyes focussed on one corner of the room in which we were sitting. I had the impression he was transferring something intimate from himself into the corner of the room. At one point, he glanced at me then looked again towards the corner. I had the feeling in my counter-transference that he was telling me something through a personal system of signs, and at the same time he was taking me inside himself and putting me in that corner. I thought that probably he wanted to have a private meeting with me there, in an intimate corner, separate from his family. The patient reacted as though he understood my response to his demand, and wanted perhaps to establish some form of dialogue or to obtain some of my “magic mental medication”.
In such a splitting of the transference between his family and Charles himself, while his parents were telling me all this, Charles was trying to invite me to a particular place, that corner of the room (a corner of his mind projected into physical, concrete reality). In terms of dynamic mental space and the transference, I would say he was transferring something from inside himself to this corner; in other words, Charles did not establish a direct communication with me, but we met, as it were, indirectly, in the corner of the room. The room was not a computer, it was a different kind of container. My consultation room has wooden rafters, which gives a much “warmer” feeling than a mechanical computer (and it is inhabited by real people, not by “virtual” presences….). Charles was discovering the lively side of our meeting space, and he glanced at me again.
Then again he immediately looked towards the same corner. I had the feeling that with his eyes / mouth he had first “orally” incorporated me into his personal space then “deposited” me with his eyes / hands into his chosen corner. (I did not feel that he was spitting me out.)
The omnipotence of schizophrenic patients, as in certain obsessional neurotics with pronounced narcissistic traits, is expressed more in terms of control of the psychoanalytic setting, which they feel they should decide upon. It is because of their own feelings of insecurity that they want to be the stage managers of the analytical situation, the distributors of their own mental medication or system of beliefs (or ideology, which is sometimes delusional, in the case of psychotic patients: a delusion is a system of ideas).
While I was having these sensory infra-verbal impressions, Charles’s mother was still talking about him. The removal to Paris and their new home became the main topic: a new setting for their lives. At one moment, she pointed out that Charles would use the upstairs room (called in France la chambre de bonne or maid’s room). When I first came to Paris, it was quite a privilege to have one: on the top floor of the building, from there one could have a magnificent view over the whole of the city. Before I came to live in Paris, I had always wanted a “chambre de bonne”. Charles’s parents had thought that he could use it as his den or atelier. He was very clever with his hands, a very skilled “do-it-yourself” kind of person (un bon bricoleur); in fact he was quite capable of manufacturing objects and restoring valuable antiques. He was very good at establishing links, making connections, creative connections – but not associations. This gift could be seen as a kind of ability to repair and restore – though it could also be, in Charles's case, a narcissistic way of self-reparation, of self-cure, as is the case with many narcissistic people. Of course, the nature of the connections and the passage towards living mental associations are very important, but for the moment he could manage furniture and concrete objects, not yet with people.
From time to time a "maid's room" implied that I was to be his servant, to be a kind of helpful mother / maid figure – who, all the same, was to remain in his power. While I was writing this paper, I was finishing another article on the tyranny of the internal object (to be published in a book called Le Lien Tyrannique (The Tyrannical Link)).
At the end of this first meeting, in spite of the tyrannical side of the psychotic part, we tried to draw up a preliminary agreement for an analysis. I suggested five sessions per week; the family agreed, but I had the impression that this was perhaps extremely arduous for Charles. He was not always “present” in his body-life, and therefore could not take any decision for himself. His parents became subsidiary egos and the unconscious depositors of his therapeutic wishes. Those wishes appeared later, and they were in conflict with his narcissistic, self-centred position.
Charles came alone to his first session. He was still silent, speechless, and once again I realized that he would speak in many “senses” – for the moment, through his eyes: he looked all around, at everything, using his eyes in a "tactile" way, as Henri Wallon put it in writing about very young infants. It was Charles’s way of feel-ing things through touching and testing objects or people, as autistic children do. This time, he was looking at my books and paintings. I asked him what he was looking for. He replied: “I’m interested in history”. "What history?" I asked. After a short pause, he answered: "In Spain, there was Charles I, then Charles II, Charles III and Charles IV. There was disagreement between them."
I had the impression that time had come to a standstill and had taken on a spatial dimension; he was reciting the historical sequence of the successive Charleses as though they had existed concurrently in his unconscious topography. Spatialization of time is a very useful concept that was developed by Dr E Minkowski (1927: 104). The transformation of the experience of time (le temps vécu) into spatialized thinking is one way of avoiding mental pain and, at certain moments, the unbearable feeling of being alive. What is time in schizophrenia? asks Minkowski. Referring to Bergson, he says that the “fluid mass” or ocean of movement and feelings implies thinking within a mobile experience of time (and therefore thinking about the future). The act of becoming (le devenir) implies a living history, not a computerized one: a virtual life. Being in an enduring experience of time is part of the comprehension of life that Charles can neither attain nor tolerate. Compartmentalization of mental space is a way of paralysing the encounter in space of an agglutinated time. Coagulation of “mental blood”, stopping all “circulation” in the organism, transforms living time and living space into an immovable existence. Charles would like to overcome his mummified state; it is with this metaphysical preoccupation in mind that he said: “A meeting-point for all of these kings may turn into a catastrophic encounter – open war, in fact.” I remarked that none of the kings could live in an entirely independent and alive fashion, since they are all part of the same matter, the same nature, the same nation. Charles answered: “It was only when Charles V of Austria came along that there was reconciliation and the kingdom was united”.
This was Charles's way of telling me that there were four Charleses inside him, each omnipotent and in disagreement with his fellows. This is an excellent description of the spatialization of inner time in schizophrenia. But co-ordination of disagreement and the struggle for power between split-off parts of the ego were very difficult tasks to accomplish. The patient wanted me to be the person who did this, to accomplish Charles V’s reconciliatory task.
Speaking about inner space and time, a contemporary of Bleuler, P. Chaslin, used to describe this as folie discordante. (1912: 772). What I find particularly interesting is the fact that he argues that confusional states should be distinguished from discordance (1915: 442). Herbert Rosenfeld’s paper on confusional states (1950) requires modification in this sense, so as to recognize the differentiation between confusion and discordance. Rosenfeld says that confusional states may also be a positive element and an attempt at recovering unity when, in cases like that of Charles, integration is as yet impossible. An intermediary state of confusion of “borders” is inevitable.
I said to Charles that he had reason to be worried about agreement and dialogue between these different lively parts of himself. I added that his own suggestion was that I as analyst should be someone like Charles V, to help him to bear emotionally and “ideologically” the uniting of his kingdom; I was of course referring to his ego. "I am not Charles V,” I said, “but perhaps the two of us working together may be able to do some uniting".
A silence followed, during which Charles seemed to be thinking (perhaps the ideas floating in the corner of the room had returned to his mental space). He touched his nose and said: "I caught a cold, I have a runny nose." He glanced at a book, then at another: looking at something was his way of making contact with my thoughts transformed into an attractive object - my library. He stared intently at a book called Mental Health, and after a pause said: "It's hard, mental health." All this seemed quite meaningful to me: the therapeutic task was very hard for me, but even more so for him. I commented: "You feel you need to harden yourself sometimes, to put on armour-plating in order to remain solid. If the armour cracks open, the hardness could melt and everything would run out of your nose; then all the solidity would be lost"
In the following session, after a moment or two of silence, Charles turned his head towards the white curtain on the window. I asked him if he could see anything, and he answered: "Yes, the leg of a hen". Using the implements at our disposal, I asked Charles to draw the leg of this hen. In fact what he drew was the leg of a table; I pointed this out to him. His mother had told me that when they moved into their new home in Paris, Charles had found a table in a rubbish dump and had repaired it.
Shortly after this, Charles's eyes moved to the chair standing next to the curtain. He wanted to draw it. He felt quite comfortable with objects such as furniture. He made an excellent and highly detailed sketch of the chair, which in fact is a highly anthropomorphic entity. He made an excellent drawing, except for the fact that it had only one leg: in other words, a partly-mutilated image of his reified being. So, now we had a table-leg without a table and a chair with only one leg. On a theoretical level, we could ask ourselves whether these are part-objects or fragments of objects of a devitalized existence. The nature of the matter (wood) is much warmer and human than the metal of the armour-plating.
Charles studied the chair with considerable interest, and made comments which seemed to me to be full of wisdom: "The chair is very useful for dispersion". I took this to mean that at that particular moment the chair could give refuge to and be a resting-place for his “moving” and “dispersed” feelings of a fragmented existence. Then he looked at the pattern on the chair - hieroglyphics would be an appropriate word to describe it - and seemed fascinated by the language of the chair. The chair was talking to him in a cuneiform way. He was experimenting with hermeneutics, trying to decipher the object, to make it talk to him. "It's probably filigree,” he said. “There's a kind of logic to the writing." In his reified state, Charles had put himself and all his fragments into this unfinished chair, as incomplete as he felt himself to be at that point, with no leg to stand on - floating in mid-air among the clouds. I thought it was quite logical for some of his wandering ideas to settle into his own "house for living in", i.e. his body and his mind. I pointed out to him that in his drawing, the chair did not have its full quota of legs, one of which seemed to be in the previous sketch he had made.
Charles glanced at my lamp and decided to draw it; in fact he drew only part of the lamp. This was his way of becoming more familiar with the furniture-witnesses of our field-work. The objects in the room were becoming actors in the drama as it unfolded, the drama of multiple transference meanings. I felt also that drawing only part of the lamp meant that he could perceive only a small part of reality, or a projection of an incomplete or damaged and mutilated image of his body-mind. Nevertheless, there was a little glimmer of light in his world which could be projected on to real objects. The anatomy of a landscape meets the physiology of the eye with which we look at it; we breathe life into it with our thinking. Man is a maker of fantasies and new “realities”; it is they which enliven reality and make the environment meaningful. Sometimes, in the fragmentation of a psychotic crisis, reality can explode. Charles was showing me both the fragments and his attempts to live together in the same space with those he had projected into my furniture and my space. What he felt to be parts of my personal inner space were making contact with the projected fragments of his body-mind that remained inside his territory after the catastrophe.
After another pause, Charles wanted to do another drawing: a rough sketch of a funfair coconut shy with a middle-aged man taking aim. Beside this is a miserable-looking tree which could almost represent someone raising his hands as though to implore help; there is also the idea of carrying a heavy burden. This was Charles's way of expressing his need for help and his feeling of heaviness, a typical feature of melancholia; such patients carry a heavy weight on their shoulders, an accumulation of things they find unbearable.
Whenever he felt cold or afraid, Charles would try to get close to his younger sister, with whom he had a highly eroticized but living relationship. When he was a little boy, he liked to sleep in her bed; this brings to mind the corner of the room he would stare at – perhaps it meant for Charles something warm and exciting. My hypothesis was that Charles took great pleasure in being drawn to a corner which warmed him up, contained him, breathed life into him - this may be why he would search for his sister's crotch, the angle-corner between her legs. His mother had several times seen him try to approach her and touch her between the thighs. When I mentioned to him that perhaps he was seeking warmth and comfort, he replied, "I find angles very interesting, I'm interested in geometry." I went on, "Yes, but a living geometry," since he had obviously construed my interpretation in terms of Euclidian, plane geometry. Perhaps what his mother had said was experienced by Charles as persecutory pointed corners.
Charles often spoke about lakes and a house which had been destroyed, a house with marshlands all around it. This to me meant a place where it was impossible to find a solid footing; hence his feeling that it was difficult to stand on his own feet and be himself. He was an empty house which had been razed to the ground, about to be engulfed in the shifting sands of the earth-mouth, chaos.
At another moment, Charles drew a car reversing into and colliding with a tree. It was his mother's car he had taken and had had an accident. According to his mother, this corresponded to the time when Charles had begun to withdraw from the outside world, when he had first begun to feel different and fragmented. Getting into the mother's car or into the sister who closely resembled their mother, his little mummy, implies in my view pathological projective identification (Klein, 1955). Mrs Klein, inspired by the French novelist Julian Green’s If I Were You, describes the unfortunate adventures of Fabien Especel who, unhappy and dissatisfied with himself, with his appearance, tried to become – through projective identification – and ideal character. Charles wanted to become a computer, an attractive though incomplete chair, a table-leg, his mother’s lap, and a victorious king. His schizophrenia consists in becoming a character or admired object, while simultaneously losing himself as a person, a real and authentic living creature. One of the main problems in the treatment of psychotic patients is to abandon their magical and powerful projective identification and the status of being a deluded but admired object. To deal with the loss of the capacity to transform reality into an idealized or virtual one is a very painful experience. It means, as Klein says, to deal with “mourning and melancholia”. I call this phenomena “narcissistic depression”, the loss of the idealized but deluded ego ideal and ideal ego. To become oneself implies a painful mourning passage in which the self and its ideal object becomes “deflated”, thereby causing much disappointment. I have tried to develop the concept of “narcissistic depression”, in which the “disillusion of the delusion” has more to do with the ego than with the object, in several of my writings (Resnik, 1986: 54; 1987: 85; 1995: 95; 2001: 226).
To become oneself, to come back from pathological projective identifications implies being out in the world. That means to deal with open spaces and living time. Psychotic patients are fascinated by the outer world, but are frightened at the idea of being outside in a catastrophic way: in bits and pieces, in an exploded fashion. This ontological fear of the open world is manifested in the self by severe agoraphobia and a dramatic inability to deal with open spaces. This is one of the reasons for inhabiting someone else's body, through extremely powerful projective identifications.
In the transference we meet this kind of phenomenon personally (in the counter-transference) when someone "gets stuck into us". Charles gets into me or into parts of my body as he does into the car, into his sister's crotch, into his mother's or his sister's clothes. He remembered how, as a young boy, he liked to dress up in his sister's dancing costume; we could think of this as his need to find a space for himself inside his sister's clothes-being.
During the Easter holiday, Charles went to stay in his country of origin – he was therefore coming out into the open, into vast but living geographical spaces, where time, living time, becomes part of the landscapes. When he returned to France, he became aware of the frontier – he had forgotten his passport. “What’s your name?” he was asked at the border control. He was unable to answer, but remembered that in his bag he had a present that his mother had asked her to buy for him -- it was called “Nobrium”. This was the only “name” he could give – as if his identity became equated with the name “Nobrium”, with its initial syllable “no”. From “brium”, Charles associated (in the following session) to “brio”, which is Spanish for “vigour” and “courage”’, -- without any maternal representations, he had no “courage”, he was dis-couraged and had no identity. In fact, the pharmacological product, Nobrium, meant that his only identity was not (“no”) inside himself but mainly inside his mother at that moment. He himself was either the King of Spain, a real “personality”, but as a person he was still a piece of his mother (or, in a reified manner, of the table or of the chair), as though he were living inside the territory of the maternal transference in the analytical setting. (He was always very depressed during breaks in the analysis.)
He was very upset when he returned from the Spanish frontier to Paris – his father had managed to contact someone at the Embassy and everything was sorted out; he said he phoned me, and that I was not there – I was in fact waiting for him in my consulting room. He went home, saddened by the loss of identity he had suffered at the frontier, drank the entire bottle of Nobrium together with other medication, Coricydin and Haldol, then went to bed. Fortunately, his mother called the paramedics just in time, and he was rushed to a drug rehabilitation facility. I went to see him there, he was still comatose; when he woke up, he said, in a confused way – “I crossed the Red Sea. Are you Moses?” “No, I replied “You are confusing two biblical people – I’m Salomon! But I’m pleased to see you are awake” “Yes, thank God,” he replied. He was trying to think – when I asked him, he said he was thinking about another medication called Surmontil. I said I would try to help him “surmonter” (“overcome”) his present state. Speaking of Moses and the Red Sea implied the presence of a “gap” with respect to reality, where only Moses / Salomon / Charles V could help him cross over.
The following day, I returned to give him a session. He was relieved, and said “I was just coming out of the cave, and I saw Polyphemus. And I saw a woman dying.” I said to Charles that he felt like Ulysses, trying to save his mother from the Nobrium. He was still inside his mother, inside a maternal cave, somewhere between dying and coming back to life. Life became very important to him, like Polyphemus’s shadow. Being alive became a gigantic experience, out of all proportion. It is like being born all over again.
He left the hospital, and was admitted to a psychiatric unity for adolescents. Some uncoordinated administration of two medications, which have to be well-dosed, gave him high blood pressure and paralysed his muscles. He said: “My body is changing. I’m poisoned, I have become a paralysed infernal machine” - or rather, as we saw later, he was imprisoned inside this machine. The medication became infernal for him because it changed him into a machine, as stupid as the one with which he was so angry at the outset of his illness.
The next day he made use of a psychotic solution – he changed into a washing machine. I said he needed to be clean again thanks to a kind of self-analysis / washing – but not in such a mechanical way; perhaps he needed to come back to his sessions and to accept the analyst not as a machine but as a real human being. He did return to my consulting room and said: “Batman saved me – he took me away from the laundry”. I thought of the phonetic relationship between “batman” and “bath-man” – this is what I call a phonetic pre-symbolic equation.
Thereafter I heard nothing from him for several years. Lately he has been phoning me and asking how I am. This happened also with Brenda, a patient I saw in 1958 near Croydon – she asked me how old I was and how I was keeping. I feel moved by these long-term traces of a very intimate transference relationship in which psychoanalytic medication as well as pharmacological ones have to be intentional object relationships that should work together as members of the same therapeutic community. Understanding of the unconscious can only come from an accurate psychoanalytic experience and emotional research – one in which my own emotional instruments are involved.
Psychoanalysis was originally a medical therapeutic cure, at least for Freud. With every patient, but perhaps more particularly with psychotic patients (and certainly with people suffering from hypochondriasis), the meaning in the transference of the dialectic and anti-dialectic relationship between pharmacological medication and the psychoanalytic one covers a very important field of research. This paper is intended to be an introduction to the subject, as was suggested to me for the Sorrento congress.
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