Therapeutic Strategy and Interpretative Tactics in Psychosis

Therapeutic Strategy and Interpretative Tactics in Psychosis

Alan Gibout

(EPF Conference Helsinki 2004: The Unconscious

Is there a transference in psychosis? This has been a controversial question throughout the history of psychoanalysis. For Freud the discovery of the transference related mainly to the ‘psychoneuroses’ and presupposed a capacity for the displacement of affects and representations derived from differentiated father and mother imagos on to people in the patient’s current life. Freud contrasted the transference neuroses with the group of narcissistic neuroses, characterized both by the difficulty or impossibility of an object-related transference and by withdrawal of libido on to the ego. At first he saw the narcissistic neuroses as equivalent to the psychoses in general and not as restricted to melancholia, as was to be his view in 1924 when he wrote the following in ‘Neurosis and Psychosis’: “Transference neuroses correspond to a conflict between the ego and the id; narcissistic neuroses, to a conflict between the ego and the super-ego; and psychoses, to one between the ego and the external world” (p. 152). He notes that, in psychosis, the external world begins to function like the unconscious and in accordance with its essential mechanism – namely, the primary process.


The theory of psychosis

This implies a continuum extending from the capacity to organize an object cathexis in neurosis to the loss of this capacity in psychosis – and the latter, for Freud, automatically entailed a loss of the capacity to organize a transference. In seeking a mechanism specific to psychosis, Freud, as we know, came to contrast repression in neurosis with the psychotic disavowal of reality. In terms of this intention to distinguish neurosis from psychosis, the loss of reality in psychosis necessarily entails a total disavowal of reality. This tends to bear out the idea that the transference cannot be utilized in the treatment of psychotic patients, even if the formation of delusions is seen as an “attempt at healing” and at reconnection with the world of objects. From this point of view, the state of withdrawal exhibited both by psychotic children and by schizophrenics corresponds to a regression to an objectless autoerotism, which in Freud’s opinion underlies the absence of transference in psychotics and makes it impossible to use the classical psychoanalytic method with them.

At the end of his career, however, Freud (1940 [1938]) qualified this view and declared that the disavowal in psychosis was never total: the hypothesis of a “splitting of the ego” presupposed the juxtaposition of two psychic currents, one of which accepted the mother’s castration while the other disavowed and repudiated it (Verleugnung and Verwerfung respectively). Yet the hypothesis of a “rift in the ego” which, according to Freud, corresponded to the splitting of the ego, could be understood either from a topographical standpoint, involving an unbridgeable hiatus between neurosis and psychosis, or in economic terms, in which lines of communication between narcissistic withdrawal and object cathexis might be conceivable. Rather than as an insuperable deficiency, the splitting of the ego can be seen as an economic extension of a mechanism of defence and organization of the primary ego. In this approach, distinguishing between nosographic entities is less relevant than the possibility of showing in what ways differences in the psychic economy can give rise to structural differences. Likewise, disavowal can then be regarded as a specific form of repression in which not only representations and affects but also a mode of functioning of the ego are repressed.

In classical repression as observed in neurotic organizations, representations and affects can always be linked together. In psychotic and perverse organizations, where narcissistic cathexes predominate, the economy is modified and there is a failure of anticathexis. The ego, having lost its synthesizing function, is no longer capable of making associative links between the two opposing positions, and finds itself compelled to resort to disavowal and splitting – to the juxtaposition of two opposing and parallel positions – in order to emerge from confusion with the object and thereby to contain the annihilation anxiety that swamps it.

Both psychosis and neurosis always involve a non-recognition of reality correlated with involvement of the drives. The only entity through which the topographical distinction can genuinely be understood is time. Neurosis becomes established in a historical time, which permits of the process of retroactive attribution of meaning (Nachträglichkeit) that underlies the distinction made by Freud, after Breuer, between perception and memory: in memory, perception actually appears in place of the memory trace (as in the model of the mystic writing-pad (Freud, 1925a)); the two cannot exist at the same time, and simultaneity is never absolute.

Psychosis too involves a historical time, but one which lacks the possibility of Nachträglichkeit, and which constitutes a temporal vacuum: the splitting of the ego corresponds to an abolition of time, in which the substitution takes place at the same time as the process of disavowal. The model of psychosis described by Freud involves the erection of defences against psychic death in which the issue is less that of living in time than of surviving in the immediate present.

All these observations concerning assessment of the economic importance of cathexes for repression constitute the foundation of psychoanalytic research on the treatment of psychotic patients. Without discussing the various conceptions of the transference in psychosis, we can say that the status of the object and the role of projection in a given psychotic state always entail a specific approach to psychotic transferences. As suggested by Evelyne Kestemberg (1981), in psychosis it is probably more appropriate to think in terms of a transference cathexis of undifferentiated imagos than of a transference proper, which presupposes imago differentiation.

Again, depending on the configuration of the transference and of the analytic work in psychotic states, two contrasting solutions – cold, or non-delusional, psychosis on the one hand and delusional psychosis on the other – are possible. According to the use of the object, two different economies may lead to different psychotic solutions. The first involves the suppression of affects and the splitting-off of the body, coupled with the exclusion of all symbolization; this is the situation in the non-delusional psychoses, whose paradigm is probably anorexia nervosa, which has features in common with autistic withdrawal.

As pointed out by E. Kestemberg (1975), the object is as it were present in outline only, and the formation of a fetishistic relationship with the object might appear as a possible solution to the disavowal of the body and of the object, often giving rise to an “airtight” and immovable splitting of the ego. The actual death of some anorexic patients demonstrates the economic power of these primitive mechanisms. Transsexualism, from this point of view, may also be seen as a non-delusional psychotic solution of this kind.

The psychic economy of other psychotic organizations, on the other hand, tends to preserve these affects at psychic level in a symbolic efflorescence, which, while seeking to eliminate separation and distance, nevertheless points to a representation-based solution. This is the situation in the delusional psychoses, which demonstrate the existence of a capacity for healing through the creation of a neo-reality.


Psychosis and variations in technique

The above points concerning assessment of the economic importance of narcissistic and object cathexes underlie the variations in technique observed in the treatment of psychotic patients. Since the psychotic ego is incapable of a neurotic type of object transference owing to deep-rooted difficulties of introjection and identification, technical modifications prove necessary. The first of these concerns the analytic setting, as the patient’s inability to displace differentiated imagos on to the analyst calls for departures from the standard couch-based technique, such as face-to-face psychotherapy, individual analytic psychodrama, or the involvement of a psychiatrist and/or a psychiatric institution as a third party. Visual and motor support not only encourages a process of symbolization but also provides a material third element, interposed to limit the danger of non-differentiation and intrusion.

Technical modifications are also required in the approach to interpretation, which should be directed not so much to unconscious fantasy contents as to the forms of mental functioning. The need is as it were to establish and maintain a continuity of the ego, protected from internal or external objects. This economic viewpoint consequently sometimes necessitates a provisional acceptance of the relationship with an idealized object, as often observed in the treatment of psychotic patients, without immediately interpreting the vicissitudes of the negative transference as such.

Analytic work with psychotic patients shows that they are incapable of playing with language and representations. Freud (1917) had already pointed out that dreams involved a topographical regression, of which psychotic patients were incapable because preconscious word cathexes were cut off from unconscious thing cathexes owing to the crushing of the psychic topography. This incapacity for topographical regression is synonymous, too, with an incapacity for formal regression – i.e. for transformation of thoughts into images. Only the progressive integration of topographical and formal regression, and of the conflicts and resolutions arrived at to cope with the consequent anxiety, will permit of temporal regression in its threefold object-related, libidinal and narcissistic aspects – that is, as Freud (1916-1917) put it, a return to the first objects cathected and the first libidinal organizations, extending back to primary narcissism as a yearning for absolute satisfaction (pp. 339-357).

The essential aim of any technical approach to working with psychotic patients is to encourage the freedom to play in regression, in the analytic sense, without the consequence of psychic disorganization. Hence the analyst’s work, by virtue of both the setting offered and his interpretative technique, will be directed towards the creation of a space for play that will enable the patient to take an interest in his own productions and to cease to experience them as sensations and representations stemming from a persecutory external world. The analyst’s task will be to put thoughts and psychic working hypotheses to the patient, in a form that the patient can grasp and use in his own way.

Negation as defined by Freud (1925b) – as a mechanism allowing the partial lifting of repression – will then enable the patient to identify with the analyst’s interpretative function and ensure that interpretation does not take place in a state of coincidence and confusion between the act of interpreting and the content of the interpretation (J.-L. Donnet, 1983). The aim of the various hypotheses that will then be, not forced on, but suggested to, the patient is to restore to psychic reality its character of ambivalence, doubt and uncertainty, in contrast to the psychotic defences, which seek to deny the conflict of ambivalence and to place the subject in the world of the predictable and of absolute certainty.

To this end, the particular form of psychotherapy represented by individual psychodrama introduces a variation of setting and technique based on play. The paradox of analytic psychodrama is that it systematically prescribes, in the form of play, something that is otherwise regarded as an obstacle to the development of the analytic process – in particular, the lateralization of the transference and motor or verbal action. The fact that this action can take place in a context of play prevents it from becoming a resistance of the kind characteristic of these defences, in the form of acting out; so that, instead, it becomes a preferential means of working through for patients unable to tolerate a transference relationship organized around a single analyst. While both the mainspring of the process in psychodrama – namely, the transference – and its aim are those of classical psychoanalytic treatment, it is the setting that differs.

Analytic psychodrama, in accordance with the theories of Serge Lebovici and René Diatkine developed in the 1950s, of Evelyne and Jean Kestemberg, and more recently of Jean Gillibert and Philippe Jeammet, provides the economic and topographical conditions whereby interpretations can be heard without being experienced as intrusive, and can thus be introjected. This kind of psychodrama centres on a single patient and involves a group of therapists comprising the leader, who is responsible for interpreting, and not less than four co-therapists – two of each sex – as potential actors. Each weekly session lasts about half an hour.

The specific setting of individual analytic psychodrama is intended for adult or child patients who in general present major phenomena of either pronounced excitation or inhibition, which are often characteristic of psychotic functioning or a phase of large-scale reorganization, such as immediate pre-adolescence or adolescence itself. The difference between the leader and the other members of the team breaks up any massive transference cathexis and thereby reduces the economic weight of the excitation where present: in favourable cases, alternate play and non-play interpretation will result in a concentration of the displaced and ambivalent impulse on to the person of the leader, when it can be dealt with in the same way as in analytic treatment with a single analyst.

The aim of the interpretative tactics is in fact less that of systematic analysis of the transference than of encouraging a process of representation corresponding to the establishment of formal and topographical regression. Considered in these terms, the fragmentation of the transference cathexis over the entire group of psychodramatists is directed towards the organization of the analytic process; it is only at a second stage, by virtue of the temporal regression, that it might become possible to interpret the transference on to the leader.


Mr A: from self-begetting to the primal scene

These interpretative tactics can be illustrated by the case of Mr A, a psychotic patient in individual psychoanalytic psychodrama (A. Gibeault 2002, 2004) At the first interview, Mr A told the therapist: ‘I bought a pistol. I then spent two days going round and round the Seine looking for somewhere to kill myself…. Well, in the end, I don’t know why, I chose the bridges… the idea was to shoot myself and then fall into the water…I don’t know what stopped me … maybe …it was because, with a pistol, you have to press the trigger very hard, and, well, a few moments elapse between putting…, aiming at myself and pressing the trigger. I found the delay too long, and when I couldn’t bring myself to do it, I went along to the psychiatric emergency unit at St Anne’s Hospital.”

This suicide attempt resulted in Mr A’s spending several months in the ASM 13 (Paris 13 Mental Health Association) Polyclinic and having a consultation at the E. & J. Kestemberg Centre with Jean Gillibert, its former head. This introduction left no room for any kind of “play” (in the sense either of playing or of leeway), combining as it did the image of immediate action with that of the suspension of time – the “few moments that elapsed” – which halted the fatal action.

The analyst’s approach to this lethal problem situation was to suggest play in the form of psychodrama, to encourage the creation of a psychic space and of temporality with a view to overcoming the patient’s recourse to omnipotent disavowal and splitting of the ego. After all, Mr A’s psychotic functioning had already been responsible for the failure of a two-year couch-based psychoanalysis and of a further two years of face-to-face psychotherapy, the latter having been suddenly interrupted by the suicide attempt. The analytic work had not enabled the patient to bind his violence and destructiveness, which had been his only possible means of escape from the annihilating threat of non-differentiation from the object – a process described by A. Green (1980) as a casting out of the object. The only remaining option for emerging from this confusion was then to destroy the object or the subject himself.

Mr A’s psychodrama treatment, under the direction of Jean Gillibert for the first two years and then of myself for the last eight years, was intended to allow him to contemplate solutions other than destruction. At the time of his consultation, he was in a state of great distress. Having been made redundant two years earlier, he said that he was no longer able to work or even to seek a job; he had “stayed in bed, playing dead”, until he finally resolved upon suicide as the way out.

He was tormented by a humiliating and shameful paternal history, his paternal grandfather and father having collaborated with the Germans during the Second World War; tormented also by the tales of war and destruction that had been his staple reading matter since childhood, he felt assailed by images of mutilated bodies, associated both with his fragmentation anxieties and with their mastery as, in his imagination, he constantly rehearsed the themes that obsessed him. In accordance with his father’s wishes, he had spent five years in the army at the end of his adolescence. During this period he had felt “confined to barracks” – his way of describing the anxiety-inducing experience of being unable to get out once he had gone inside. This corresponded to the terrifying experience of incorporation by the object, a psychotic parallel to the vision portrayed in Buñuel’s famous film The Exterminating Angel, in which guests at a dinner party are suddenly locked inside a house and lack the strength to leave.

The only way to avoid being thus locked in by the object was to take flight from it into decathexis – “letting myself fall”, as Mr A was to say in recalling an event that had taken place when he was two years old: “My father was walking along the left bank of the River Marne, far away. My mother was with me on the right bank. I moved forward into the water. As I was very small, I must have lost my footing very quickly, or perhaps I stepped into a hole, but I have a precise memory of actually feeling myself … falling. It lasted a long time. I didn’t feel any anxiety; in fact, it was almost pleasurable.”

He had stepped out of time, enjoying the fascination of an endless fall in which the primal scene was disavowed in favour of an experience of eternity and immortality, perhaps corresponding to a fantasy of death and rebirth, of which the subject was the sole master. The fantasy was therefore one of self-begetting, involving a recourse to omnipotence as the only way of avoiding incestuous confusion with the mother in the absence of a father who was, as he said, “far away”. As it happens, Mr A’s parents had divorced when he was thirteen and the mother had then invited her son to share her bed!

I should now like to present a sequence that occurred after about eight years of psychodrama, which enabled Mr A and me to glimpse the possibility of his emerging from the psychotic solution in which he had no doubt felt locked up for so long. Mr A was now 54 years old, but looked fifteen years younger, having retained a juvenile, almost adolescent, appearance. He was dressed relatively smartly as befitted an adult, in contrast to the state in which he had presented himself at the beginning of the psychodrama treatment, when he had worn a shapeless tracksuit and his dishevelled, “pudding-basin” haircut, as he called it, had made him look lost. In line with his formless outward appearance, he had been so passive in the scenes that one was put in mind of a being with no outline and nothing inside. However, this masochistic submission to the object was merely the other side of the coin of a terrifying fantasy life that was seemingly expressed without affect: for instance, he had jokingly suggested acting a scene in which his two younger sisters (one of them a year and the other two years his junior) were cut into pieces and buried in the family garden.

This patient’s passive bodily presence with its lack of outline bore witness to his surrender to the object, to his abandonment of his body to his mother and her pleasure. Considered in these terms, the psychodrama scene perhaps offered him an opportunity to free himself from this enslavement and threat of non-differentiation by an alternative path to that of destructive violence. Passivity being intolerable owing to this incorporation anxiety, the technique of psychodrama held out the possibility of activity through play, the themes and roles being prepared by the patient. In this way, he was able to regain possession of a bodily image that had until then been characterized by lacunae, fault lines and fragmentation owing to the deficiencies of primary maternal cathexis.

Mr A was a patient who had found it impossible to work or even to seek a job, and this had led to his suicide attempt. Psychodrama had enabled him to resume his work as a computer engineer, as well as to take up painting again; indeed, one day he even brought us some of his pictures, which were in the abstract style of Poliakoff. Yet he always wondered why he needed to work and earn money. Furthermore, he would spend all the money he earned on a girlfriend whom he felt to be a vampire. He also had great difficulty in getting paid. For him, working and being paid meant earning his living “like everybody else”.

In a scene staging his curiosity about his parents’ sexual intercourse, he had expressed a disavowal of the primal scene. He had of course found it intolerable for his parents to be together, and his exclusion from the primal scene was suggested by the two psychodramatists through the wish not to be disturbed by their children while alone together. Mr A then felt called upon to express a desire to see, and said: “I’m looking right through them; it’s like a white hole.” This white hole could be seen as the representation of a negative hallucination that disavowed the primal scene at the very moment when Mr A was directly confronted with it.

In his associations after the playing of this scene, he had remembered that, as an adolescent, he had thought that his parents had never had a sex life and that children were born by spontaneous generation. The work on this scene afforded an opportunity to interpret the unconscious fantasy underlying his lack of pragmatism and his difficulty in earning money: “Earning a living like everybody else was tantamount to accepting the idea of having been born of a mother and father like everybody else, which had for a long time been intolerable and unacceptable to him.” This psychodrama representation of the disavowal of the primal scene had enabled us to surpass the psychotic mechanisms of disavowal and splitting of the ego, as a result of which he was able to introject the relevant interpretation without experiencing it as a violent intrusion into his psychic world.

It is interesting to note, too, that for Mr A the primal scene had come to be represented by way of the theme of concentration camps. He had one day mentioned that his parents often quarrelled violently about the extermination of the Jews in the camps: his father had refused to accept the reality of the Nazi extermination of the Jews in Europe, whereas his mother had taken the opposite view. Confronted with such a violent and destructive primal scene, Mr A had had no option other than to transform the black hole into a white one and to banish all traces of terror and violence; however, this had been at the cost of the “rift in the ego” that was Freud’s image for describing the splitting of the ego in psychosis.

In this transition from the fantasy of self-begetting to the working through of the primal scene, Mr A discovered himself to be the subject of his drives rather than the object of persecution by others. In the ensuing sessions, he came to wonder whether his hatred had not ultimately distorted his view of his parents; conscious now of the importance of temporality, he realized that whatever he experienced in the present, in particular in his relationships with women, stemmed “from everything he had created in his head when he was small”. He also became aware of the difference between thinking and doing and, having had so many violent fantasies, he was surprised to hear himself say: “I haven’t bumped off anyone so far.” It was also noteworthy that in the sessions with the most violent subject-matter, he preferred to take the part of an observer and leave it to a psychodramatist to express the most primitive fantasies – such as cutting his sisters into little pieces and leaving them at the left-luggage office of the “Gare de Lyon” railway station in Paris, which, under the pressure of the primary process, then became the “gare des lions” [Lion Station].

Just when Mr A was emerging from psychotic confusion and becoming human again, he fell physically ill. We shall never know whether what he called a severe cold for which he spent some time in hospital was or was not meningitis; the same situation is sometimes observed in invulnerable autistic children who contract one physical illness after another when they emerge from psychotic encapsulation. Now physically ill for the first time, Mr A was reluctant to contemplate the idea of a terminal illness; although he thought of death: “I would rather,” he said, “not think I might be afraid of it.” Becoming human and entering the realm of time did indeed involve the capacity to accept birth and death.

As Mr A was one day to say: “Time has to be remade a little bit every day.” While this admittedly suggested the risk of being locked into the juxtaposition of instants, it was also indicative of a desire to give himself a place in duration and permanence. This presupposed a capacity for temporary suspension of the vicissitudes of life and death, albeit without disavowing them, in a pleasure in play, which was equally a pleasure in thinking and fantasying.

How did the transference manifest itself? Remarkably, just as Mr A was beginning to exhibit the capacity to overcome his conflict of ambivalence with regard to the parental imagos, he had his first transference dream after eight years of psychodrama; in it, he brought me a huge bunch of fragrant, coloured flowers, behind which I disappeared.

This highly condensed dream revealed a capacity to stage a reversed Oedipus complex, in which the patient projected the female position on to his analyst, while at the same time portraying his own anxiety at the devouring “vagina-woman-flower”. The subject of flowers representing the female sex had come up in earlier scenes, in which it had been possible to think about his fear of touching the flower-woman and being sucked in by her, as well as the need to keep these flowers at a distance and just to smell their perfume. In the transference dream, the fragrant flowers were at the same time flowers that could be touched, albeit not without danger.


The memory of the helpless child

In this process of working through, it might be wondered why Mr A had never been able to express directly the helplessness of the child he had been. Having regained his capacity for formal and topographical regression, Mr A continued until recently with the work of remembering and reconstruction entailed by temporal regression. In the penultimate session before the summer holiday break, he suggested to the psychodrama team the idea of tackling, and thereby retrieving, the memory of a child abandoned to incomprehensible affects and sensations in the presence of his parents; this afforded a glimpse of the possibility of his acquiring the capacity to be alone in the presence of others (Winnicott, 1958).

I reminded him of the dates of our summer holidays. Mr A said he had nothing to say. However, he had been to his firm’s conciliation board to demand the money his boss owed him, but she had not been there. Furthermore, the chairman of the board had forgotten the file: “He’s a CGT man [the CGT is a left-wing trade union in France], so he came empty-handed and I have no money.”

He spoke about Marie (his current girlfriend, with whom, for the first time, he had a stable relationship): having worked for a month, she was about to take a week’s holiday in Sardinia; previously she had been on RMI [the French State guaranteed minimum income]. He would not be going with her because he had no money. He remained silent, and I asked him what scene we were to play. Nothing occurred to him. In the end, however, he said he wanted to play a scene with his girlfriend Marie. He chose the part of the observer, casting Mr M in the role of himself and Mrs I in that of Marie.

Marie said: “I’m going away, you have no money and no work.” He answered that he was in a void and imagined that some other man – a rich man – might look after Marie. I had Dr B, one of the male therapists, act the part of a friend who suggested that Mr A should stay with him while Marie was away and lend him his tubes of paint. Mr A replied: “Basically we’re unattached; I’m afraid of swallowing her up in my void.” The idea came up that everyone was abandoning him, including the psychodrama group.

At this point I brought the scene to a halt so as to consider with him why he associated separation with the void. He replied: “Either you’re stuck fast to someone or there is the void.” I answered that this was how he had seen his relations with other women for a long time, but that it seemed to me that he had built up a different kind of relationship with Marie. Could separation only carry the void in its wake, considering that, for the last few weeks, he had realized that we had shared many important things together, which could remain inside him if we were separated? He commented doubtfully that he felt that nothing had been happening in the psychodrama for a month – in fact, since he had no longer been earning money. He wondered why he associated separation with the void and whether he had not been abandoned in the past. When I asked him about these abandonments, he said: “They were when I was four.” To my enquiry about what had occurred at that age, he replied: “I don’t remember what happened when I was four, but before that, when I was in my pushchair, I remember the silence – my parents were there but not saying anything; they were quarrelling and I could not understand anything – it was just soundless words.” He explained to us that the quarrel was about the rent being demanded by the landlord, which his father had not paid, and commented: “It’s a bit like me today.”

When I suggested that he play this scene, he chose the role of himself, casting Mrs E as his mother, Dr B as his father and Mr M as the landlord. The mother was silent, with the child facing her, while the landlord argued with the father about the unpaid rent. The mother quietly asked them to be silent. Mr A joined in the conversation, telling us: “I don’t understand anything of what’s going on.” All the same, he commented on the scene by describing a father who was struck dumb and unresponsive to the landlord. Remarking that he was facing the wrong way for a child in a pushchair, he turned his back on his mother, who exclaimed: “But now my child understands; I wasn’t talking to him because I thought he wouldn’t understand!”

He now presented the image of himself as a child in the dark: a door opened, he saw the white light and did not know what was happening. This image took us back to the white hole of the primal scene, to how he was dazzled by the maternal object, “the blinding breast”. The mother, now addressing the father, told him: “It’s us on the other side of the door.” “They are quarrelling,” Mr A said to us. Accusingly, the mother told the father: “You see, when we were quarrelling, our son thought you were cutting me to pieces.”

I then asked two female colleagues to play the parts of a mother and daughter in a tender relationship with each other. The child, realizing that she was face to face with her mother, turned her back on her: “No, no, you’re behind me; I can feel you behind me.” The mother responded gently: “You’re my baby, you’re very beautiful.” Referring to his own parents, Mr A continued: “They ought to have taken an example from it.”

I reflected with him on the meaning of this scene and he once again made a link between abandonment and the void. I pointed out that it was paradoxical to have a feeling of abandonment and separation in the presence of one’s parents: we ourselves were in fact now facing a separation which, he might think, would not feel like a void if he kept the words we had shared inside him, for they were not soundless words.

It was the impossibility of integrating all these sensations that had caused Mr A to construct links with other people solely in the form of excessive absence or excessive presence. This had been demonstrated by the child in his pushchair who was unable to understand “soundless words”. This was Mr A’s odd term for “wordless sounds” – an incomprehensible noise equivalent to “soundless words”, to a destructive silence by the parental couple, resulting, by virtue of their quarrels, in a decathexis of and a disregard for their child’s emotional life.

As a manifestation of this transference, Mr A, without giving any notice, failed to turn up for the first session after the summer holidays. Although he said he had got his dates mixed up, it emerged clearly that his absence was due to the wish to be the master of the separation himself rather than letting it be determined by the leader and the psychodrama group, by reversing the roles and being the abandoner rather than the abandoned one. I interpreted this to him, and the continuation of our work revealed the importance of working through the father transference on to the leader. Mr A then for the first time expressed admiration for his father: he had been not only a bastard who had collaborated with the Nazis and aroused his hatred, but also the respectable, well-liked mayor of a municipality in France whom he loved. This father transference later helped him to cope better with his genital and pregenital anxieties about the mother imago and to allow himself a stable, long-term love relationship with a woman.

Thinking recently about the benefit he had derived from our analytic work, he commented: “Ten years ago I was unemployed and wanted to commit suicide; today I am temporarily out of work, but have no desire to kill myself!” Mr A had actually lost his job because his firm had gone bankrupt, but, in contrast to his despair of ten years earlier, the transference on to the psychodrama leader and group now enabled him to find within himself the wish and resources to seek another job and to find satisfaction in it. This suggests that the psychodrama had enabled Mr A to accept the vicissitudes of birth and death, of the primal scene and of human sexuality. Emergence from psychosis was in fact tantamount to the possibility of accepting the limits of being human, and, subject to this condition, of living his life instead of dreaming it.



The aim of the therapeutic strategy and interpretative tactics with psychotic patients is to encourage the functions of symbolization in subjects who have often lost the capacity to distinguish between a symbol and the symbolized object, between present and past, and between father and mother imagos. Because psychotic anxiety is bound up with the unrepresentable conflict of being at one and the same time the devouring subject and the devoured object, the patient needs to be offered an external and internal setting that allows interpretations to be introjected. That is why the option of initially concentrating on the modes of psychic functioning rather than unconscious fantasies and the transference relationship may facilitate the creation of a psychic space in which subject and object can meet in mutual enrichment without confusion between each other. Interpretation of the transference, both positive and negative, can be embarked upon only at a second stage. This was what Winnicott had in mind in pointing out that the most important thing for the analyst was his capacity to play with images, representations and words, with a view to enabling patients – in particular, those exhibiting psychotic functioning – to acquire the capacity to play, whether in individual treatment or in psychodrama.

The principal aim of analytic work with psychotic patients will be to develop this capacity for play. This is illustrated with particular clarity by the case of Mr A, who, after several years of psychodrama, began every session by asking himself a question about his psychic functioning – for example: “I wondered if there might have been a problem about my birth”; or: “Might my hate have prevented me from doing well at school?”; or, again: “Could my hate be stopping me from painting?” Analytic psychodrama had allowed Mr A to achieve the self-reflective capacity indicative of the establishment of a genuine analytic process.

The fact that a psychotic patient can ask himself such questions in this way means that he has acquired a capacity to play with his representations, to fantasize and to think, rather than discharging an excitation in the quest for immediate satisfaction. That is the object of all analytic work, regardless of the patient’s psychic organization, based as it is on the activity of negation as described by Freud (1925b) as the psychic mechanism underlying the processes of thought. At the end of each psychodrama scene, the leader often asks the patient: “What did you think of what was played today?” The patient is thereby given an opportunity of accepting some of the representations offered and of rejecting others, so that he or she can exist as a fully-fledged subject vis-à-vis other people.



(Translated from the French by Philip Slotkin MA Cantab. MITI)



Alain Gibeault
Paris Psychoanalytical Society (SPP)


DONNET, J. L. (1983). L’enjeu de l’interprétation. In Le divan bien tempéré. Paris, P.U.F., 1995, pp. 175-188

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—–    (1924). Névrose et psychose. In Névrose, psychose et perversion. Paris, P.U.F. 1973, pp. 283-286

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—–    (1925b). La négation. In Résultats, idées, problèmes (II: 1921-1938). Paris, P.U.F., 1985, pp.135-139

—–    (1938). Le clivage du moi dans le processus de défense. In Résultats, idées, problèmes, (II : 1921-1938), Paris, P.U.F., 1985, pp. 283-286

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—–    (2004). Omnipotence et finitude: le sexuel et la création chez Monsieur A. In Psychanalyse et psychose (Figures de la sexualité). Centre de Psychanalyse et de Psychothérapie Evelyne et Jean Kestemberg (Association de Santé Mentale de Paris 13ème), pp. 135-150

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KESTEMBERG, E. (1975). La relation fétichique à l’objet. In La psychose froide. Paris, P.U.F., 2001, pp. 77-101

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KESTEMBERG, E. et JEAMMET, P. (1987). Le psychodrame psychanalytique. Paris, PUF

LEBOVICI, S., DIATKINE, R. & KESTEMBERG, E. (1969-1970). Bilan de dix ans de pratique psychodramatique chez l’enfant et l’adolescent. Bulletin de Psychologie, 285, XXXIII, 13-16, pp. 839-888

WINNICOTT, D.W. (1958). La capacité d’être seul. In De la pédiatrie à la psychanalyse. Paris, Payot, pp. 205-213. The capacity to be alone. In Through Paediatrics to Psycho-analysis. London, Hogarth Press, 1977


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