Three contributions on psychosis: A brief introduction

The psychoanalytic investigation of psychosis dates back to the very origins of psychoanalysis itself. Freud discusses the process of psychotic symptom-formation on several occasions in his letters to Fließ (for instance in Draft H. on paranoia from January 1895; Freud 1950, 206–212), in his “Project of a Scientific Psychology” (Freud 1950 [1895], 283–397), as well as in his papers on the “Neuro-Psychoses of Defence” (Freud 1894, 1896), where he differentiates paranoia from obsessional neurosis through the prevailing mechanism of projection. He touched on the theme of hallucination and perceptual identity in his “Interpretation of Dreams” (Freud 1900, 535, 565–569) and in his pivotal paper on the “Two Principles of Psychic Functioning” (Freud 1911a).

In the same year, Freud published his study on the paranoid psychosis of Daniel P. Schreber, based on the former court president’s autobiographical accounts. Analysing the nature of Schreber’s psychotic breakdown and his resulting complex delusional system, Freud came to the conclusion that the “delusional formation which we take to be the pathological product, is in reality an attempt at recovery, a process of reconstruction.” (Freud 1911b, 71) It was following his Schreber paper that Freud wrote “On Narcissism” (1914, 84–86) where he formulated the idea that under certain psychic conditions there is a withdrawal of the libido from the objects to the ego.

The theme of psychosis is present in Freud’s metapsychological papers from 1915 and is again a topic of several papers between 1915 and 1923 (Freud 1915, 1922). It is also extensively dealt with in the XXVI and XXVII chapter of his Introductory Lectures (Freud 1916–1917a), but it gained new weight after the revision of his drive theory (Freud 1920) and the introduction of his structural model in The Ego and the Id (Freud 1923). Now the relationship between ego and reality became a focus of attention. In his paper “The Loss of Reality in Neurosis and Psychosis” (1924e), Freud differentiates psychosis from neurosis by sugesting that “the imaginary world of a psychosis attempts to put itself in the place of external reality” (367), whilst the imaginary world remains as phantasy in neurosis. With regard to the radical rupture that takes place in the psychotic process, Freud concludes that neurosis originates from a conflict between the Ego and the Id, whereas psychosis is the result of a similar conflict “between the ego and the external world” (Freud 1924, “Neurosis and Psychosis”, 152).

One year later, in his brief contribution on “Negation”, Freud examined disturbances in the judgmental function of the ego. With reference to the negativism that is prominent in some psychotics, he regards “expulsion” and “negation” “as a sign of a defusion of instincts that has taken place through a withdrawal of the libidinal components” (Freud 1925, 239).

Splitting phenomena was already recognised in Freud’s exploration of Schreber’s delusional system. Concerning symptom formation in paranoia, Freud supposed that there must be a special “mechanism by which repression is brought about” (65). A mechanism, which he characterised in his “Metapsychological Supplement to the Theory of Dreams” (Freud 1916–17b), as a “breach between the ego and one of its organs” (233). Splitting processes were examined later on in more detail in his paper on “Fetishism” (Freud 1927), as well as in his late contribution on the “Splitting of the Ego in the Process of Defence” (Freud 1940b). Freud returns to the theme in “Outline of Psychoanalysis” (Freud 1940a), where he states that the detachment of the ego from reality is never complete:

Even in a state so far removed from the reality of the external world as one of hallucinatory confusion, one learns from patients after their recovery that at the time in some corner of their mind (as they put it) there was a normal person hidden, who, like a detached spectator, watched the hubbub of illness go past him (201–202).

However, despite his great interest in psychotic mechanisms, Freud always held doubts about the accessibility of psychotic patients to psychoanalytic treatment: “at least not for the method as it has been practised up to the present”. But he did not regard it as “impossible that by suitable changes in the method we may succeed in overcoming this contra indication – and so be able to initiate a psychotherapy of the psychoses” (Freud 1905, 264). The two main obstacles mentioned by Freud were the psychotic patient’s difficulty in building a working alliance with the analyst (Freud 1940a, 173) and their presumed inability to establish a transference relationship due to their “narcissistic” defenses (Freud 1916–17a, 422–424, 438–439). At least the latter of these two assumptions was refuted and adjusted by later analysts who found that psychotic patients quite often developed intense and complex transferences, which were sometimes obscured by counter-transference reactions on the part of the analyst.

It is almost impossible to summarise the richness and ramifications of the psychoanalytic investigation of psychosis. Freud’s pioneering work encouraged important contributions during his own lifetime, like for instance Karl Abraham (1907, 1908, 1924), whose insights partly anticipated and interrelated with Freud’s findings, Sandor Ferenczi’s (1913) reflections on the development of the sense of reality, or Victor Tausk’s (1919) paper on the origin of the schizophrenic “influencing machine”. Karl Landauer (1914, 1926), Hermann Nunberg (1920, 1921), René Laforgue (1926, 1929), and Maurits Katan (1939, 1950, 1954), were other important contributors in this field. In their book Psychoanalytic Treatment of Schizophrenic and Characterological Disorders (1967), Bryce Boyer and Peter Giovacchini give an excellent overview of these early developments and the evolving, sometimes diverging therapeutic strategies. Perhaps one can say that all these approaches did not differ so much in their theoretical understanding of the various psychotic mechanisms as in their attitude towards technique.

In Ego Psychology, Paul Federn’s early contributions (Federn 1933) and his book Ego Psychology and the Psychosis (Federn 1952) became standard references. He recommended, like other authors after him, that the negative and psychotic transference should not be analysed before the Ego is sufficiently strengthened.

In contrast, Melanie Klein’s work with very disturbed children (Klein 1932) and, in particular, her paper “Notes on some Schizoid Mechanisms” (1946), became the starting point for the pioneering work of Herbert Rosenfeld (1947, 1950, 1952, 1965), Hanna Segal (1950, 1956, 1957, 1972), Wilfred Bion (1954, 1956, 1957, 1959, 1962) and others who analysed borderline and psychotic patients within the classical analytic setting. Their examinations of the psychotic transference (and counter-transference) led to a new understanding of the mental processes underlying psychotic transformations like excessive projective identification, minute splitting, distortions in the process of symbol-formation, the role of a destructive super-ego and pathological reparative attempts. Heinz Weiss and Esther Horn (2007) give a survey of the developments within the Kleinian tradition including some more recent contributions like Henri Rey’s (1994) reflections on schizoid phenomena in the borderline and John Steiner’s (1993) theory of psychic retreats (see also Steiner 1991, 2001, 2004) and distortions of the experience of time and space (Rey 1979; Weiss 2013).

Of great importance were, on the other hand, the pioneering work of Frieda Fromm-Reichmann (1939, 1955), the interpersonal approach of Harry Stack Sullivan (1962), Harold Searles’ (1965) expeditions into the world of his schizophrenic patients, and many other contributions in the United States. John Kafka (2019) gives a lucid survey of the innovative, sometimes experimental therapeutic methods that were deployed at Chestnut Lodge Sanatorium, Rockville, Maryland, over a period of more than five decades.

In Europe, Marguerite Séchehaye (1947), Gisela Pankow (1956, 1968, 1977) and Gaetano Benedetti (1980; 1983), have developed their own original concepts and approaches. In Latin America Ángel Garma (1931, 1945), Enrique Pichon-Rivière (1946, 1952), and others were influenced by Kleinian ideas and worked with psychotic patients from early on. In Jacques Lacan’s (1955–56) structuralist approach to psychoanalysis, psychosis is seen as resulting from a rejection of the “symbolic order”, i.e. a refutation of the triangular oedipal situation, for which he used Freud’s term “Verwerfung” (in Lacan’s terminology “foreclosure of the name of the father”). His ideas were extended and further developed by Hermann Lang (2011) in Germany.

Some of the more recent developments are outlined and compiled in a book Psychoanalysis of the Psychoses, edited by Riccardo Lombardi, Rinaldi and Thanopoulos (2019). Two chapters in this volume refer to the integration between psychoanalysis and psychopharmacological treatment.

It was from the 1960s and 1970s onwards that the introduction of new, potent antipsychotic drugs seemed to push long-term psychoanalytic treatment into the background. However, with the insight that neuroleptics are effective in reducing acute psychotic symptoms, but may have long-term adverse side effects and cannot resolve the patients’ problems, over the last two decades there has been renewed interest in psychotherapeutic approaches, including psychoanalysis, facilitated by adequate psychosocial and psychiatric management (see Evans 2008, 2018; Lucas 2009).

The three papers in this Education section examine the psychoanalytic understanding of psychosis from a developmental, historical and therapeutic point of view.

Franco de Masi has extensive experience in working with psychotic patients and he has written abundantly about the subject. Some of his papers that have been published in this journal are embedded into his book Vulnerability to Psychosis (see De Masi 2006), which also provides a very instructive survey of the different psychoanalytic models of psychosis. His contribution examines the complex relationship between psychosis and analytic therapy. He focusses on the fundamental difference between psychotic and non-psychotic functioning and differentiates between intuitive non-systematic and theoretic-systematic psychoanalytic models; amongst the former, he sees the work of Frieda Fromm-Reichmann, Marguérite Séchehaye, Gaetano Benedetti and others, and the latter are represented by Melanie Klein and her school. In his view, the psychotic disorder originates in a dissociated world in early childhood, due to traumatic experiences and the lack of parental containment. It creates a dissociated, seductive world of (hallucinatory) perception-identity, grandiosity and pleasure, which later on turns into a prison and destroys the psychic organs of knowledge. It is from this point that the analyst must start his work and help the patient to tolerate frustrations and grapple with the painful task of acknowledging psychic reality. De Masi discusses in detail the structure and function of hallucinations and delusions in order to maintain the “alternative” concrete reality where thinking and symbol-formation do not seem necessary. He also discusses current neurobiological findings, Bion’s (1962) concepts of the alpha function and a contact-barrier, and he concludes that the very nature of the psychotic process consists in transforming thoughts into sensory perceptions. Therapeutically, he emphasises that the aim is to gradually develop the psychotic patient’s personality, which has been frozen and entrapped in psychotic constructions over long periods of time.

Following the developmental path sketched by De Masi, Catalina Bronstein examines the role of adolescence as a critical phase where psychotic symptoms often become manifest. Referring to authors from the Kleinian, Freudian and Independent traditions, she focusses on the challenges that this period brings about: the loss of childhood, the bodily changes, the emergence of adult sexual desires, and consequently a re-configuration of sexual and subjective identity. It is a time when early integration processes re-surface and the outcome, as the author puts it, depends on the way in which infantile development has taken place. The changes of this period may evoke powerful anxieties, early oedipal and super-ego conflicts, the disillusionment of omnipotent phantasies, and consequently intense feelings of shame and guilt. Early traumatic experiences and identifications can now acquire a new significance and challenge the individual’s capacity for integration – a constellation, which may provide the ground for different forms of crisis (obsessive-compulsive symptoms, eating disorders, drug abuse, self-harm, suicidal ruminations). Concerning adolescent psychosis, Bronstein prefers to speak of “adolescent breakdown” or “psychotic functioning” rather than “psychosis” proper, since the outcome is often unpredictable. Referring to the work of Laufer and Laufer (1989), she assumes that the adolescent’s break with reality often takes place in relationship with the body and she discusses strategies to establish a secure environment and to develop a therapeutic space.

The body-image is also a central theme in Gisela Pankow’s pioneering work, which is hardly known amongst English speaking analysts. Gisela Pankow was brought-up in Germany and suffered the totalitarianism of the Nazi regime. She started a first analysis in 1944, went to Paris in 1951, became a member of the French Psychoanalytic Society (1953–1959) and the German Psychoanalytic Association (DPV), but distanced herself from the Lacanian group. Thus, she found herself in an in-between situation when she started her work with psychotic patients. She published in German and French, but settled in France. As a former supervisee, Philippe Valon gives a lucid account of her life and work, her background in psychoanalysis and medicine, in German philosophy and phenomenology, and the development of her concepts. In the mid-1950s she developed the technique of “dynamic structuring of the body image” as a way to hear the patient’s speech as an expression of their fragmented experience of the body and to establish a minimal contact via listening, drawing/sculpturing, and playing, similar to child analysis. Referring to detailed sequences from Pankow’s clinical work, Valon illustrates how by doing so the analyst may help the patient to structure phantasy through linking the dispersed fragments, to offer herself as a transference object, and to open a path to the imaginary and symbolic registers. Thus, it is the “lived body”, which contains the dimensions of space and meaning. In a final paragraph, Valon shows how Pankow linked this understanding of the body with the deficiencies she observed in the family structure of her psychotic patients.

Of course, three papers and a brief introduction cannot account for the variety and richness of the psychoanalytic approaches to psychosis. However, they may at least portray some facets, which are relevant from the past to present and may stimulate further interest.