Notes on Psychotic Processes From an Object Relations Perspective

Thinking about psychosis in the contexts of supervision, psychotherapy and in discussion with colleagues, the potential perplexity arising might be alleviated (if only for the work of psychotherapy) by repeatedly reflecting on the theoretical ideas of previous and perhaps familiar thinkers in the area of psychoanalytical thought. Following are some of these thoughts that have proven useful.

Margaret Mahler stated that the more intrusive the love object’s emotional attitude in the outside world has been, the greater the extent to which the object remains or becomes an unassimilated foreign body – a ‘bad’ introject in the intrapsychic emotional economy. In the effort to eject this ‘bad introject, derivatives of the aggressive drive come into play; and there seems to develop an increased proclivity to identify the self-representation with the ‘bad introject’ or at least to confuse the two (In:’ The psychological birth of the human infant’, 1975).

Winnicott in his paper ‘ Mind and its relation to the Psyche-Soma’ (1949), held the view that psychosis can be seen as an environmental deficiency disease. It is particularly the failure of the mother and in the case of psychosis, the erratic behaviour of the mother that produces overactivity of the mental functioning, where an opposition between the mind and the psyche-soma can develop. In an abnormal environmental state, the thinking of the individual begins to take over and organize the caring for the psyche-soma, whereas in health it is the function of the environment to fulfil this function.

‘In health, the mind does not usurp the environment’s function, but makes possible an understanding and eventually a making use of its relative failure.’(In D.W. Winnicott, Collected Papers, 1985:246).

In illness mental functioning becomes a thing in itself, practically replacing the good mother and making her unnecessary. Clinically this can go along with dependence on the actual mother and a false growth based on compliance. The psyche of the individual gets ‘seduced’ into the mind, away from the intimate relationship, which the psyche originally had with the soma. The result is a mind-psyche, which is pathological when there cannot be a direct partnership between the mind-psyche and the body of the individual. The mind-psyche is localized by the individual and is placed either inside the head or outside it in some special relationship to the head. Thinking might be characterized by ‘cataloguing’. Breakdown inevitably threatens or occurs as what the individual all the time needs is to find someone else who will make real this ‘good-enough environment’ concept, in order to return to the dependent psyche-soma which forms the only place to live from and from where a sense of continuity without excessive impingements from the care environment can occur. In such a case ’without mind’ becomes a desired state. In the psychotherapeutic encounter, regression has to be allowed for.

Bion’s notion of No-K relates to being ‘without mind’ in Winnicott’s terms. He used K as an indicator of ‘a capacity to know’ which is at the core of mental life and when No-K occurs, there might be a psychotic condition without the capacity to think. His term the ‘bizarre object’ introduces the psychotic mentality, however, as part of a configuration that contains the ‘psychotic’ and the ‘non-psychotic’ personality. In this context the psychotic personality is not a psychiatric diagnosis but designates a way of functioning that co-exists with other ways of functioning and according to the dominance of one way of functioning over another; certain behaviour will become observable and thus determine a diagnosis of psychosis or neurosis in the clinical sense.

The psychotic personality refers then to a mental state rather than a psychiatric diagnosis. One of the outstanding features of the psychotic personality is the intolerance of frustration, which together with a predominance of destructive impulses, manifests as violent hatred of internal and external reality. Because of the intensity of destructive impulses, love is transformed into sadism and the conflict between life and death instincts is not resolved.

The term bizarre object created by Bion describes the kind of object by which the psychotic patient feels surrounded. Through pathological splitting and projective identification, there is an attempt to get rid of the object and also deliberately of all ego functions connected with the reality principle, especially of those elements that have a linking function. In the patient’s belief, the particles of ego function that are fragmented and violently evacuated penetrate and occupy the real objects and engulf them. In turn, the engulfed object attacks the projected part of the personality and strips it of vitality. This results in a bizarre object composed of a part of the personality and parts of the object, in a relation of container-contained that strip both of vitality and meaning.

In terms of the development of thought, the bizarre object is formed by beta elements, residues of the ego, superego and external objects (Grinberg, L.; Sor, D.; Tabak de Banchedi, E. New Introduction to the work of Bion, 1993).

The schizophrenic, for example, due to an almost incomplete incapacity to tolerate reality, replaces perception with an extreme form of projective identification, characterized by fragmentation of the perceptual functions (still to some extent experienced as self) into the object, which is a bizarre object perceived as having a life of its own (in Ogden, 1983).

Beta elements are unmetabolized elements that become transformed into Alpha elements through modification by another: the scream of the infant to be understood and put into thoughts by a mother in order for the infant to feel known. In the dialectic of the therapeutic relationship, it implies the ‘setting before the mind’s eye something to be contemplated’ (Margareth Waddell: Verbal Communication, Scientific Meeting, Psychoanalytic Study Group, Johannesburg, 2003).

In a presentation to The Johannesburg Psychoanalytic Study Group Fakry Davids (2002) stressed that there are impulses attached to the bizarre object i.e. in the psychic economy there might be some kind of perverse longing for the bizarre object with the result that it cannot be given up that easily and has to be understood and modified by both patient and analyst. The role of projective identification for understanding and modification is of paramount importance.

Several authors see the self – and object undifferentiation as part of the psychotic process when primitive self- and object representations invested with badness are split off and perpetually projected onto or into the external world which is then perceived as a ‘dangerous world of persecuting objects’ (Kernberg, Rosenfeld, Klein, in Buckley, P.; ‘Essential Papers on Object relations’, 1986).

As a consequence, the cathexis (transfer of libido) to the outside world and objects are withdrawn and the hypercathexis of the self results in the establishment or re-establishment of a primary narcissistic state which Freud described as ‘primary narcissism’ and what Klein described as ‘infantile omnipotence’.

In my opinion the withdrawal also implies a surge of the Freudian ‘death instinct’ which cathects objects and the self with wishes for extinction and a return to primary- fusion or narcissism, however, with strong aggressive qualities that may be projected.

Fairbairn (In Buckley, 1986) in writing on schizoid processes suggested the internal withdrawal of libido in varying degrees e.g. it may be withdrawn from the conscious into the unconscious. When the libido deserts the conscious part of the ego it ‘might relapse into the primal id’ with manifestations of ‘primary process ’ and its characteristics.

Rapaport (1953) described the primary process as genetically the more primitive, and it operates with unneutralized drive energies and strives toward immediate discharge of energy accumulations by a direct route and through mechanisms such as displacement and condensations observable in dream material and hallucinations. In contrast, in the secondary process energies are relatively neutralized and relatively bound in motives of a highly socialized nature; ego activities oriented toward objective reality.

It is in the counter-transference in particular that the effects of excessive projective identification are felt and remain taxing for the psychotherapist and potentially the therapeutic alliance.

MORE POSTS

References to Pathological Organisations as described in 'Melanie Klein Today'