Clinical considerations

Francesco’s clinical story enables us to understand how the psychotic process develops progressively and unpredictably. Once one pathological construction was demolished, another immediately appeared, all the work done up to that point being to no avail: the new psychotic break would cancel out any insight gained as well as the patient's opportunity to learn from experience.

The fact that Francesco slowly became aware of his overpowering tendency to replace the world of reality with that of the imagination was positive; he therefore understood that he needed another mind to help him circumscribe the pathological process and develop his healthy part, which was not particularly distinct from his ill part. As I had said to him once, his mind was like a sieve, allowing thoughts of every kind to pass through it indiscriminately.

In my description of this case, I have underlined above all how Francesco deceived himself by creating an alternative reality. It is clear from my way of working that only on rare occasions did I formulate symbolic or transference interpretations as they would not have been understood and would have added to the patient’s state of confusion; I worked instead to describe and analyse his psychotic mental functioning, giving a description of his mental functioning each time his ‘little worm’ would get the better of him. As can be inferred from my account, I worked mainly on the delusion formation.

It was clear in my mind that, in Francesco’s delusions, not only had the distinction between internal and external reality been obliterated, but psychic reality had been replaced with sensory reality: he could hear and see from his mind. His delusion was characterised by confusion between external and internal and by a concrete fact quality, his psyche being unable to free itself of it, let alone transform it, given its sensoiy nature. Had Francesco been able to confine himself to dreaming, he would have understood that the dream represented an unconscious conflict (for example, with Anna's relatives) and could therefore have contained his fear in a processable symbolic narration. Instead, his delusion was a sensory construction (he heard and saw his persecutors), unlike the representation of the dream entirely, which can be transformed and understood.

The delusion is purely sensoiy and therefore has no access to representation and symbolisation; it is made up of symbolic equations (Segal 1957), and it is in this sense that Bion’s inversion of the alpha function should, I believe, be understood: in the delusion, the imagination, which in normal conditions conveys an ideative or representative content, is transformed outside awareness into beta elements: that is, into pure sensorial elements. (‘I can see through the mind’s eyes’.)

The delusion uses the psychotic mind’s capacity to make imaginative thought sensory: the delusion cannot enter dream work to produce transformative psychic experiences such as fantasy or thought because it corresponds to a non-thought, to Bion’s -K (1992). How the mind constructs the delusion must be explained repeatedly to the patient so that he becomes aware of this process.

The specific difficulty in this particular therapy was the fact that the delusion remained silent - always ready, however, to virulently reactivate; despite free intervals, the pathogenic potential of the delusion remained intact, prepared at any moment to re-explode. It was important that Francesco and I, in spite of the presence of the delusion themes, were able to reconstruct his childhood experience and see that the psychotic process had been formed in a grandiose infantile withdrawal. Francesco had grown up in a well-to-do, middle-class cultivated family, without any evident traumas. Despite this, he was not a ‘normal’ little boy; there were episodes in his childhood that had worried his teachers and his parents, such as when he ran away from school (sometimes with an adventure companion) to do great daring deeds or defy adults; once he had hidden for such a long time that his parents, naturally worried, called the police.

The first time we met, Francesco told me that he had wonderful parents who had never scolded or punished him. Afterwards, I understood what this meant: his parents had not been able to provide the necessary frustrations or structure his personality. Francesco had lived in a grandiose infantile withdrawal that his parents knew nothing of; on several occasions, however, they had been concerned, as they had taken him to a psychologist to whom the child said that he scolded and tried to beat his parents. The psychologist did not consider this a problem and, instead, advised Francesco’s mother to see a therapist.

I was convinced that Francesco, who for a long time had lived in a fantasy world, could not bear the frustrations and hurdles of real life; while growing up, conflicts proved to be harder than his constant state of exaltation could tolerate, and, at a certain point, hatred towards frustrating objects stained his world with sombre colours.

Being outstanding and unbeatable had been his childhood and teenage leitmotiv. He had to beat every record: he would organise tournaments with his younger cousins, who obviously lost, or he would ask his father to explain mathematics to him to astound his teachers and classmates. Naturally, he could not tolerate being scolded by adults, and when this happened, he would react with fierce anger. We might say that he had already structured a maniacal false Self that needed to be sustained in every way possible; after university, the collapse of this defensive structure contributed to the psychotic explosion.

Fundamental in this long and complex therapy was that neither Francesco nor I lost faith in the analytic work, even when the umpteenth crisis would wipe out all our prior work. When each relapse occurred, I tried to understand what had happened, what had brought on the episode and how his mind worked. Francesco really was a good patient, attached to his analysis and collaborating always, thus making it possible to discuss and rebuild what had happened.

I believe that the reappearance of delusion themes is a very frequent occurrence in psychotic conditions. I once carried out the supervision of a chronic female patient in the care of a group of psychiatrists in a psychiatric ward; she had been in the care of three psychiatrists from the group for fifteen years, one after the other, and it had been observed that the delusion repeated itself with the same pattern despite the characters and contexts changing.

Francesco’s delusional structure, too, presented itself each time with the same nucleus, which never changed in spite of the new characters who would come onto the scene and the increased strength the delusion would gain. My initial hope was that once the structure had been clarified, the delusion could be deconstructed and treated like a dream, which, once understood, can be forgotten. Unfortunately, as I am not tired of repeating, I was not dealing with a dream but sensory delusional reality, and I continued to ask myself how it could be transformed, given that it had a concrete and not a symbolic nature.

I noted that the psychotic episodes often appeared when there were signs of improvement. Francesco clearly felt driven towards having new experiences, but he was not quite ready to really live them. For example, when he tried to have a girlfriend, he was unable to understand the other’s character and personality; he just went about things blindly, and when faced with the complexity of emotions, he would be in a state of chaos that then led him into the delusion. He did not understand emotions, nor did he place himself in others’ shoes to understand their character, wishes or thoughts; for example, if he found himself facing someone who was stern and lacking empathy, he immediately felt that this person was an enemy. More often than not, he was unable to understand people who were different from him, and when he was unable to get to know someone, he would consider them bad; from here derived his suspicion, followed by the persecutory delusional construction. My job was to describe those psychic processes that he was unable to grasp the meaning of and which led to his constructing delusional realities.

The delusion did not suddenly present itself as a well-organised structure but proceeded slowly, as can be seen with respect to Anna’s relatives: it stemmed from small cues that were limited to the behaviour of a few of the relatives, from some random utterance or a smile or absent greeting. Francesco felt left out by this girl, who maintained close ties with her family members; anger followed, as did their transformation into evil villains. All the little delusional interpretations stayed in his mind, no critical awareness whatsoever imparted to them, and they would then suddenly merge into one coherent whole, like tesserae in a mosaic.

From a certain point of view, it had been easier for me to work on Francesco’s last delusional pattern as it regarded the world of his family affects. Here, it had been simpler to talk about the double truth of his delusional experience, given that the projection was not onto alleged distant, anonymous enemies, but his partner that he himself appreciated being close to; the delusional territory was circumscribed, which enabled a better comparison with his emotional reality. In the first part of the analysis, his delusions had a universal dimension: his enemies moved

Clinical considerations 133 around from one country to another, from one city to the next, and on one occasion the CIA and KGB had been brought into it.

As mentioned earlier, Francesco’s inability to tolerate frustration created a strong push towards the delusion: a triumphant entrance was expected into the girl’s family, which did not happen. If anything, great enthusiasm was lacking, and there was perhaps even a little indifference. He then realised, however, that he had become angry because of his disappointment and had projected his worst aggressive instincts onto these people.

We understood together that frustration was unbearable, above all when he found himself in a mental state of grandeur. In the case of his partner’s family, the tepid welcoming had hugely disappointed his expectations, which disintegrated like a sandcastle, leaving him disoriented and gripped by violent narcissistic resentment. Those responsible for his frustration - in this case, the girl's relatives - then became his enemies.

On this subject, I would like to recall what Freud (1915b) stated with regard to the primitive Ego:

The ego hates, abhors and pursues with intent to destroy all objects which are a source of unpleasurable feeling for it, without taking into account whether they mean a frustration of sexual satisfaction or of the satisfaction of selfpreservative needs. Indeed, it may be asserted that the true prototypes of the relation of hate are derived not from sexual life, but from the ego’s struggle to preserve and maintain itself.

(Freud 1915a, p. 138)

These considerations perfectly suit Francesco’s grandiose mental state and describe exactly what happened in his exalted mind when he experienced frustration.

The delusion is in itself a traumatic event: like trauma, it gets dissociated and remains an unprocessed fact that cannot be forgotten. The following is a short fragment to illustrate how the delusion remains encysted in the mind and then suddenly re-emerges, out of apparently random associative links.

After meeting Anna, Francesco decided to buy a single bed to put next to his in order to sleep with her in his studio flat. When the shop assistant suggested a particular bed and mattress that, in his opinion, were good and reasonably priced, Francesco suddenly became distressed about this offer, was suspicious of the shop assistant and thought that he was part of a conspiracy to kill him.

What had happened? What link had made the delusion re-emerge and transform the shop assistant’s friendly sales proposal into a death threat?

To an outside observer, the connection between a sales proposal for a mattress and a persecutory threat would be difficult to understand, and perhaps, even the patient himself might have had some difficulty explaining it. Having remembered the work done on his previous delusional experiences, the connection between the mattress, the shop assistant and the persecution was immediately clear: I imagined Francesco awake at night, gripped by fear, staring at the shimmering lightcoming from the mattress, his clear proof that radioactive material had been put there by his enemies. When the shop assistant said the mattress was selling at a good price, Francesco immediately thought that he was an agent, working for his enemies, who wanted to kill him with a tailor-made mattress. In this case, my associations connected to the development of Francesco’s previous delusional episodes were helpful to contain a new take of the delusion.

The delusional experience was recreated from associative links: the word became a concrete fact that would unleash the delusion. Freud (1915a) wrote that, in psychosis, words enter the primary process: Tn schizophrenia words are subjected to the same process as that which makes the dream-images out of latent dream-thoughts - to what we have called the primary psychical process' (p. 198). And he added:

These endeavours are directed towards regaining the lost object, and it may well be that to achieve this purpose they set off on a path that leads to the object via the verbal part of it, but then find themselves obliged to be content with words instead of things.

(p. 203)

The sensory and fantasy world of the delusion, as stated earlier, presented itself in Francesco’s case as another reality that never encountered psychic reality or the relational experience.

The two visions - that of the sensory withdrawal and that of psychic reality -although existing side by side, could not integrate to produce insight. In Francesco’s words, his vision was divided in two; it was bi-ocular: with one eye he could live inside the world of the withdrawal, and with the other he could go back to seeing reality. Since the two visions did not come together, Francesco could not experience binocular vision, which would have promoted his understanding that the delusion had a falsified nature. It was as if the mind created the delusion availing itself of the same sensory channels and structures that build the perception of true and shared reality. The delusion and psychic reality, constructed within the same circuits, alternately occupied the place of the other without ever being contradictory.

In the delusion, in fact, the principle of non-contradiction fails, and therefore if a statement is true and its negative is true, too, then any statement is tme; this result is defined by logicians as the principle of explosion. This is why the difference between true, real, improbable, probable, possible and impossible is lost in the delusional system, and an unstoppable omnipotent mechanism that knows no boundaries is implanted; the absurd, with all loss of the notion of time, place, separateness and identity, are thus possible and potentially progress endlessly.

An example that is particularly reminiscent of the dual reality in the psychotic process is reported by Mark Solms, who cites the case of a patient who suffered a stroke, causing paralysis to her left arm.1 Solms repeatedly tried to make her understand that her left arm was paralysed, but she would firmly deny it. Even when it seemed that she had accepted reality, immediately afterwards she would go back to denying the paralysis. When Solms showed her once more the difference in mobility between her right and left arm, the patient said that she did not want to be thought of as ill and that ‘with her “mind’s eye” she sees her arm moving, while with her “physical eyes” she sees that her arm is not lifting as it should’ (Oppenheim 2013, p. 5). It is clear in this case that the internal image of the arm moving is just as real as the image perceived by the eyes and that both can coexist without being contradictory.

Facilitating the creation of Francesco’s persecutory world was his fascination with evil. A great deal of his time in childhood and adolescence had been spent reading comics and stories about villains who would get fired up in their cynical exploits; thus, his delusional persecutory world became populated by these same figures, the comic characters he had read about in his youth, who were fascinated by absolute evil. When people he met seemed indifferent to him, it meant they were bad; it was clear that Francesco had preserved a childish way of seeing the world.

In addition, he was influenced by reports he heard, by films and TV news; he seemed to know about the world not through direct experience but via the filter of his imagination; his future projects therefore could not but be unrealistic, based on alleged abilities only and an unrealistic lack of difficulty. His thought functioned by categories: good-bad, sensitive-insensitive, success-failure, without considering the complexities of the real world.

Important working through done in the last period regarded the ‘reparative’ aspect of the omnipotent persecutory delusion. At its base was the megalomaniac idea to reform the world and free it of all its injustice. Francesco wanted to be the new Gandhi. What he was endeavouring to do, though, was not raise humanity from inevitable, objective injustice that leads to suffering but fight against enemies who bring about evil. It was thus an individual, maniacal and omnipotent attempt at reparation, a struggle against the powerfill that, should they have obtained knowledge of it, would have unleashed the persecution.

In the last period of analysis, Francesco showed growing emotional maturity: he had acquired a greater ability to understand others and had a more realistic idea of his parents; not only did he love them and feel grateful to them, but he had also begun to weigh himself up against them. Keeping his distance from his father's idealised and grandiose parts was important for Francesco’s mental growth, and his maturation went hand in hand with his inner transformation.

In several dreams from his final period of analysis, it was clear that Francesco was making an effort to work out the falsified parts of his personality; as you may remember, his grandiosity was accompanied by the construction of a megalomaniac false Self (he was a great artist, psychologist, computer scientist, economist and so forth), which exposed him to disappointments and failures. His grand mythomaniacal part made me think that had Francesco had a sturdier personality structure, he could have become an imposter.

One fact that really struck me in analysis during this last period was that, when examining the first years of his life more closely, Francesco realised that he remembered nothing of his childhood. He had no memory of his childhood before the age of seven or eight: no recollections of his nursery school, his first years at school or his playmates, for instance. Comparing himself to his own son, whom he had continued to take care of over these past few years, this difference seemed even more profound to him. He remembered that on one occasion when he was little, he had hurt his arm and gone into hospital: he claimed that he stayed alone without his parents for a week, not even complaining about missing them. This points to a very marked detachment from emotions and a strong tendency towards passivity, as if Francesco had already built a withdrawal from the emotional world during those early years. Comparing himself to his son, his own childhood life seemed listless, almost non-existent; Francesco spent a good part of his free time with his child, who was lively and interacted with him, indirectly contributing to his emotional recovery.

The revival and development of the emotional field during the last period of analysis seemed capable also of enlightening the past. Recollecting his school days, secondary school in particular, Francesco was amazed at being able to see his classmates with depth never experienced before. Back in his school days, his classmates had seemed distant, homogeneous, undifferentiated.

I should like to make just a brief comment on the transference. During the first part of Francesco’s therapy, transference was of a psychotic nature: Francesco projected distrust and persecutoriness onto me, to the extent that he considered me a potential ally of his enemies. The psychotic transference, which on one occasion visibly manifested, could have distanced him from the analysis, but the danger was averted. Only later, when basic trust had been established between us, and Francesco’s psychotic part was less dominant, did the transference take on a neurotic-type quality, with an evident oedipal hue that repeated the childhood relationship with his parents, his father in particular. He even began to experience with me a relationship of admiration, mixed with competition and imitation.

This experience with Francesco made me understand that analytic therapy for a psychotic patient should not be limited to treating the symptoms only - that is, hallucinations and delusions, extremely destabilising as they may be - but it should favour the patient’s affective development and his acquisition of tools in order to deal with life and develop a true personality. It is clear that Francesco had, for various reasons, preserved a very infantile and naive character: having lived for a long time in a fantasy world, it seemed he had been unable to develop strength of character via continuous experience in relation with significant others.

Much work was also done on Francesco’s inability to understand reality, above all emotional experiences, in themselves rather complex and which he seemed to have no experience of. It was as if he had been used to observing the world from a certain distance without any real participation, cataloguing it using simple attributions that more often than not were moral: good-bad, empathic-nonempathic, familiar-strange etc. Luckily, though, Francesco was intelligent and versatile; he was well educated and had been selected to do highly professional work.

The following theme was central to my analytic work. I tried to create triangulation based on dialogue between two non-psychotic minds: that is, the non-psychotic parts of the patient’s mind and the analyst's mind, which collaborated in order to analyse the third vertex of the triangle - the patient’s psychotic part (Williams 2014). In Francesco’s case, the difficulty lay in having to treat a continuous psychotic process that transformed perceptions, thereby pushing the healthy part into madness; it was a much more complex task than when dealing with a relatively stable pathological construction, which can be contrasted with the healthy part of the personality.

Lastly, we come to dreams. At the start, Francesco’s dreams were of a psychotic nature. They did not convey a comprehensible narration and were fragmented and concrete; that is, they were in line with his condition of suffering and his psychic fragmentation. Later on, however, they displayed narrative continuity, and some dreams could describe to the patient his psychotic functioning: for example, the dream in which Mirò’s flight of steps appears describes to the patient his very own construction of the delusion.

This kind of dream is quite typical during the therapy of psychosis and also in other psychotic patients who undergo analytic treatment, often appearing when there is improvement; it means that the mind is beginning to be aware of the mechanism of the delusion transformation, and it can therefore begin to describe it. In these dreams, the mad part is represented by a figure who transforms reality, such as the artist Joan Miró, which is the way Francesco described his fascination for the delusion and the possibility of changing reality through fantasy.

As I have already mentioned and underlined, this type of dream is important because through it the delusional experience can be shown to involve the patient's psychic participation and to be a construction of his own mind, despite his experiencing it as a sudden and concrete event coming from the outside. The nature of the delusion can thus be better analysed and, with the patient’s help, its uncontain-able and unstoppable nature modified. As can be seen from the clinical material of this case, dreams progressively changed until they became similar to neurotic dreams, with symbolic language that enabled suitable interpretations to be made to unveil implicit emotional meaning. This means that Francesco had begun to make his unconscious operate to represent, albeit it in a disguised fashion, psychic reality and emotional states; then transference dreams were brought, which could not have appeared earlier, not only because Francesco was unable to experience me, the analyst, as a person who was emotionally tied to him, but also because the transference is formed via symbolic operations, which he had been unable to carry out prior to then.


1 The transcript of the video of this interview with Mark Sohns can be found in Imagination from Fantasy to Delusion by Lois Oppenheim (Routledge 2013).

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