The dead part: An overfulness of emptiness—Some reflections on psychotherapy with young psychotic patients^*

* Translated by Gina Atkinson, M.A.

ABSTRACT

Drawing on his experience of psychotherapy with psychotic children and adolescents, the author puts forward and discusses the idea that a psychically “dead part,” “an overfulness of emptiness,” lies at the core of the psychotic self. Through the presentation of his clinical work with Aldo, a psychotic adolescent, the author shows the deep sensorial, perceptive, presymbolic, and consequently preverbal nature of these originary psychic nuclei, together with the hard work that allows them to emerge during treatment. Moreover, the article focuses on regression-to-dependence phenomena and analysis of the primitive bodily features of countertransferential dynamics in work with these patients, which may be linked to the emergence of the “dead part” in the analytic relationship. The analyst’s psychosomatic experience that characterizes the encounter with these intense anxieties, together with the complex work of figurability that the analyst has to perform, is examined and discussed.

S'appuyant sur sa propre expérience de la psychothérapie d'enfants et d'adolescents psychotiques, l'auteur de cet article propose et discute l'idée que le noyau du self psychotique comporte une « partie psychiquement morte », « un trop-plein de vide ». A travers la présentation de son travail clinique avec Aldo, un adolescent psychotique, l'auteur met en lumière la nature profondément sensorielle, perceptive, pré-symbolique et donc pré-verbale de ces noyaux psychiques originaires, ainsi que le travail ardu consistant à leur permettre d'émerger pendant la cure. De plus, il met l'accent sur les phénomènes de régression à la dépendance et l'analyse des Aspects prinitifs et corporels des dynaniques contre - transferentielles dans le travail avec ces patients, ce qui peut être lié à l'émergence de la « partie morte » dans la relation analytique. Il examine et soumet à la discussion l'expérience psychosomatique qui caracterise la rencoutre analytique avec ces angoisses intenses, de même que le travail complexe de figurabilité que l'analyste doit accomplir.

Gestützt auf die eigene Erfahrung in der Psychotherapie psychotischer Kinder und Jugendlicher erörtert der Autor seine Vorstellung von einem psychisch “toten Teil”, “einer Überfülle an Leere” im Kern des psychotischen Selbst. Der Autor zeigt am Beispiel seiner klinischen Arbeit mit Aldo, einem psychotischen Jugendlichen, die tiefe sensorische, wahrnehmende, präsymbolische und damit präverbale Natur dieser originär psychischen Kerne ebenso wie die harte Arbeit, durch die sie im Verlauf der Behandlung zum Vorschein kommen. Darüber hinaus konzentriert sich der Beitrag auf Phänomene der Regression auf die Abhängigkeit und die Analyse der primitiven körperlichen Merkmale der Gegenübertragungsdynamik in der Arbeit mit diesen Patienten, die möglicherweise mit der Entstehung des “toten Teils” in der analytischen Beziehung im Zusammenhang stehen. Das psychosomatische Erleben des Analytikers, das die Begegnung mit diesen intensiven Ängsten kennzeichnet, wird zusammen mit der komplexen Arbeit der Figurabilität, die der Analytiker zu leisten hat, untersucht und diskutiert.

Attingendo alla sua esperienza di psicoterapia con bambini e adolescenti psicotici, l’Autore avanza e discute l’ipotesi che al cuore del Sé psicotico vi sia una “parte morta” psichicamente, “un troppo pieno di vuoto”. Nel presentare il suo lavoro clinico con Aldo, un adolescente psicotico, egli mostra la natura profondamente sensoriale, percettiva, presimbolica e di conseguenza preverbale che caratterizza questi nuclei originari della mente, evidenziando parimenti il duro lavoro necessario per farli emergere nel corso del trattamento. L’articolo si focalizza inoltre sui fenomeni di regressione alla dipendenza e sull’analisi degli aspetti primitivi e corporei delle dinamiche di controtransfert nel lavoro con questi pazienti – aspetti che possono essere collegati all’emersione della “parte morta” all’interno della relazione analitica. Verranno infine esaminati e discussi sia l’esperienza psicosomatica che tipicamente si presenta nell’analista laddove egli incontra queste intense angosce, sia il complesso lavoro di figurabilità che gli è richiesto di svolgere in questo genere di situazioni cliniche.

El autor, en base a su experiencia en psicoterapia con niños y adolescentes psicóticos, propone y analiza la idea de que en el núcleo del self psicótico se encuentra una “parte muerta” psíquicamente, “un exceso de vacío” psíquico. Mediante la presentación de su trabajo clínico con Aldo, un adolescente psicótico, muestra la naturaleza profundamente sensorial, perceptiva, presimbólica, y, por tanto, preverbal de este núcleo psíquico originario, junto con el arduo trabajo que le permite emerger durante el tratamiento. Asimismo, el artículo se centra en el fenómeno de regresión-a-la-dependencia y en el análisis de los rasgos somáticos de la dinámica contratransferencial en el trabajo con estos pacientes, que pueden vincularse con la emergencia de la “parte muerta” en la relación analítica. Se revisa y analiza la experiencia psicosomática del analista, característica del encuentro con estas angustias intensas, junto con el trabajo complejo de figurabilidad que el analista tiene que llevar a cabo.

Keywords:

• Dead Part
• Psychosis
• Bodily Counter-transference
• emptiness
• Regression to Dependence
• Sensoriality

Notes

* Translated by Gina Atkinson, M.A.

1 Highlighting the traumatic nature of the originary encounter between the psychotic patient and his environment does not mean, of course, failing to acknowledge the existence, in the subject himself, of areas of the personality whose functioning is of a neurotic nature. Indeed, I am personally convinced that “islands” of the ego relatively well-preserved from the invasion of psychosis can be found, of course to a variable degree, in every individual. In this sense, the distinction made by Bion (1957) between the neurotic part and the psychotic part of the personality is of fundamental importance, and integrating this distinction into our way of thinking about psychosis allows us not to interpret all the patient’s material in the same way, and instead to remain sensitive to the oscillations between various levels of complexity and symbolization that can present in the course of treatment, just as in the development of each individual session.

2 According to Roussillon (1999b, 140)—whose work, in my opinion, constitutes one of the most valuable and creative developments of Winnicott’s thinking—psychosis represents “one [of the] means of binding or of psychic ‘solution’ to the treatment of primary trauma.” “I propose,” adds the author, locating “at the centre of the essential subjective experience of psychosis an experience of ‘agonistic terror,’ not worked through, against which the entire psychic apparatus is constructed.” (Translator’s note: This quotation is not included in the published English translation [Roussillon 1999a] of the original French source [Roussillon 1999b]. Therefore, this is the author and translator’s.)

3 Although these authors refer to theoretical models that do not precisely overlap, something that seems to me to bring them together is the idea that the Freudian dualism of word presentation and thing presentation is not sufficient for us to understand the complex modalities with which experience can be inscribed in the primitive areas of the mind. Alongside these representations and affect-presentations (Green), there could be more archaic psychic material, presymbolic, of a sensorial and perceptive nature, which Roussillon (2003) called in one of his papers “the third trace.” It is interesting to note as well that these considerations may have their origins in Freud’s letter #52 to Fliess (dated 6 December 1896), in which Freud speaks of “Wz [Wahrnehmungszeichen (indication of perception)],” defined as “the first registration of the perceptions,” “quite incapable of consciousness and arranged according to associations by simultaneity.” If this third form of psychic inscription is virtually absent in Freudian writing after The Interpretation of Dreams, its importance has gradually re-emerged in the works of those analysts who are most interested in clinical work involving non-neurotic functioning.

4 Some months later, when the analytic relationship was much more solid, Aldo talked at length of his fantasy that his father “always expected too much of me” (a father-analyst who was never satisfied, disappointed!) and of his desire to make him, and to make me—in the transference—proud of him. I think that, in a more general sense, it is often the possibility that the analyst might succeed in identifying, in his countertransference, an exact affect that allows the patient, in après-coup, to feel that particular affect (which earlier he had recognized and/or identified only as incomprehensible sensations) and connect it to relational episodes.

5 The choice of a vis-à-vis setting in my case is based on the idea that the psychosomatic mirroring offered not only by the analyst’s face, but also by his entire body, is essential in allowing these patients who are suffering so much to feel “safe to be” (Little 1985) in the treatment space. As far as the frequency of sessions, the decision was generally limited by issues at least partially external to the analysis. I am, however, convinced of the importance that a more sustained rhythm can assume in the organization of a stable internal object to which one can appeal within the self when the external object is absent or unavailable. Such a process can be achieved, at any rate, at two or three sessions a week as well (it is important to remember that, according to the French model, the standard form of psychoanalytic treatment takes place at a frequency of three sessions per week), although probably in a slower and more difficult way.

6 The therapy was conducted in French. The word knee, genoux, has a sound that recalls—and that made me think of,—je-nous: I-us.

7 The therapy took place at a medical-psychopedagogical centre (CMPP).

8 Although the transferential echoes of the sequence that follows may be evident, it is impossible for me to discuss in the current article the developments to which it gave rise in subsequent sessions.

9 To put it another way, that means that the patient has been able to yield to some form of regression to dependence. Otherwise, the heart of the psychosis remains unapproachable, wrapped (and protected) by a series of extremely rigid and primitive defences (splitting, denial, projection …) that fight against the reactivation of the originary experience of psychic death.

10 I would like to emphasize that, by detaching, I do not mean solely the physical separation from the mother-environment. Many experiences of psychic death, perhaps even the majority of them, are the products of situations of “non-encounter” in which the primary object, though physically present, is psychically absent; thus, it is impossible for the object to guarantee those experiences of holding and containment that underlie the construction of the subjective psychic apparatus.