A Psychoanalytic Approach to Treating Psychosis: Genesis, Psychopathology and Case Study

169 Pages·2020·1.934 MB·English

by  Franco de Masi

A Psychoanalytic Approach to
Treating Psychosis
A Psychoanalytic Approach to Treating Psychosis shows how, by understanding
the antecedents and dynamics of psychosis, a psychoanalytic approach can offer
a long-term alternative to the only psychotropic therapy and an explanation of the
infantile origin of the illness.
This ground-breaking examination begins by clearly explaining complex terms
and theories from the most significant thinkers in psychoanalysis. Split into three
parts, it then explores the problems faced when following one specific technique
for understanding the psychotic process. Practical as well as theoretical, Part 2
illustrates how to prepare an appropriate setting for the patient, including the
importance of listening and the analyst’s approach, as well as highlighting key
features of the condition, such as delusions, hallucinations, infantile withdrawal
and psychotic dreams. Acknowledging that psychosis is a psychic transformation
which the mind works as a sensorial organ, the author asserts that the seeds are
sown in childhood through emotional trauma, leading to withdrawal into a fantasy
world.
Brimming with real-life vignettes throughout, Part 3 is dedicated to a unique
and lengthy case study to illustrate the challenges of working with such patients.
It also looks positively towards future research on psychosis informed by insights
from neuroscience.
Innovative and accessible, this book will be essential reading for anyone
working in psychosis, including psychoanalysts, psychiatrists, psychologists and
physicians.
Franco de Masi is a former president of the Centro Milanese di Psicoanalisi and
Secretary of the Training Institute of Milan. He has published papers in
international psychoanalytical journals and books translated into English,
French, German, Spanish and Polish.

A Psychoanalytic Approach to
Treating Psychosis
Genesis, Psychopathology and Case Study
Franco de Masi
First published 2020
by Routledge
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© 2020 Franco de Masi
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British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
Names: de Masi, Franco, author.
Title: A psychoanalytic approach to treating psychosis : genesis,
psychopathology and case study / Franco de Masi.
Description: 1 Edition. | New York : Routledge, 2020. | Includes
bibliographical references and index.
Identifiers: LCCN 2019046799 | ISBN 9780367430429 (hardback) |
ISBN 9780367416416 (paperback) | ISBN 9781003000884 (ebook)
Subjects: LCSH: Psychoanalysis. | Psychoses.
Classification: LCC BF173 .D394 2020 | DDC 150.19/5—dc23
LC record available at https://lccn.loc.gov/2019046799
ISBN: 978-0-367-43042-9 (hbk)
ISBN: 978-0-367-41641-6 (pbk)
ISBN: 978-1-003-00088-4 (ebk)
Typeset in Times New Roman
by Apex CoVantage, LLC
Contents
Foreword vii
HOWARD B. LEVINE
Introduction 1
PART 1 7
1 Psychosis: The problem of a specific technique 9
2 Non systematic models 15
3 Kleinian contributions 30
PART 2 47
4 The setting and transference in psychosis 49
5 The psychic withdrawal and the psychotic part of the personality 54
6 Dreams and delusions in psychosis 62
7 Hallucinations 81
8 Trauma and the Super-ego in psychosis 90
PART 3 97
9 A psychoanalytic therapy 99
vi Contents
10 Clinical considerations 130
11 Future perspectives 138
References 144
Index 149
Foreword
How do we understand psychosis?
The enigma unveiled?
Howard B. Levine, MD
Broadly speaking, there are two fundamentally different theoretical discourses
in psychoanalysis regarding psychosis, each of which has its roots in the writ-
ings of Freud. In the one, psychosis is a malignant variation of early psychic
development and the forces that produce neurosis, but its metapsychological for-
mulation remains continuous with neurosis and with early, normative primitive
mechanisms and mind states that have not been sufficiently transformed and are
believed to have failed to develop.
In the second discourse, one that is persuasively advanced by Franco de Masi
in this book and in his other writings, psychosis is of a different order than
neurosis, structurally and metapsychologically. It is a particular form of seduc-
tive psychic retreat, an altered mind state and alternative (false) reality that
often begins very early in life, has the power to seduce, colonise and conquer
the more reality adapted functions of the mind and reflects ‘a mysterious world
that no discipline has so far been able to explain convincingly’ (de Masi 2009,
p. xxiii).
Support for the first position may be found in Freud’s (1911) understanding
of Schreber’s psychosis as a particularly severe variation of Oedipal conflicts;
in Freud’s (1924b) assertion of ‘the unity and intimate connection of all the
disorders that present themselves as neurotic and psychotic’ (p. 204); and in
his description of dreams as ‘a psychosis . . . [that] can be undone and give
place to normal functioning’ (Freud 1940, p. 172). (Note the implied link here
between psychosis and the primary process of neurotic dream work, a link
that readers of this book will realise is far from substantiated in the clinical
setting.)
Similar to this line of thinking in Freud, Klein considered psychosis as analo-
gous to and continuous with normative infantile mental states, the former being
an exacerbation of the latter. As de Masi carefully explains (Chapter 3), Klein
believed that ‘the disposition to psychosis depended on primitive impulses and
anxieties that were normally transformed in the course of infantile development’
(de Masi 2009, p. 3). The determinative factors for Klein, and for a number of her
viii Foreword
followers such as Segal, Rosenfeld, Meltzer and to some extent Bion, involved
the vicissitudes of the death instinct and the presence of pathological envy and
destructive phantasies towards the primary object (mother figure).
In contrast, Freud (1894) had earlier argued that psychosis (paranoia) was a
defensive flight from an unacceptable, unbearable reality,1 that the primary prob-
lem in psychosis was a withdrawal of cathexes from representations of reality and
that psychotic symptoms – delusions, paranoia, hallucinations – were miscarried
attempts at restitution and reconnection with that reality (Freud 1911). It was not
until later that Freud (1915, 1924a) began to more systematically consider that
the response in psychosis of withdrawal of cathexes from representations of real-
ity might involve a mechanism (Verwerfung: foreclosure, or Verleugnung: disa-
vowal) that was different from that of the ‘ordinary’ repression (Verdrangung)
found in neurosis or might produce or reflect a very different metapsychological
situation.2
Bion (e.g. 1970) offers a potential insight into this second metapsychological
view of psychosis when he notes that intolerance of pain can drive a patient ‘to
destroy the thought function and therefore to deprive himself of the only means
whereby he could confront or modify the situation of frustration’ (de Masi 2009,
p. 19). Winnicott (1971) describes a more passively endured but similarly destruc-
tive process in terms of de-cathexis. (Think, too, of Robertson’s (1970) descrip-
tions of children who begin to fall into a miasmic decline following too long a
separation from their maternal objects.)
Bion (1970) also followed this later trend in Freud, when he noted that while
neurotic patients banish painful realities to the repressed unconscious where
the ideational perception of those realities remain more or less intact, ‘psychot-
ics destroyed the instrument [i.e. the psychic thought function, and the capac-
ity for perception] that would have enabled the unconscious to understand the
psychic experience’ (de Masi 2009, p. 19) that was the source of their agony.
Whether or when this disabling of vital psychic functions has motivational
intention (unconscious but intentional attacks on linking) or is passively (trau-
matically) undergone is a moot point. Either condition may obtain, and speak-
ing metapsychologically, the consequences are similar (see Bergstein 2015 for
further discussion).
Based on extensive clinical experience treating psychotic patients, an expe-
rience that is richly illustrated in this text, it is de Masi’s contention – and a
very important contribution that should be paid careful attention to by analysts
and analytic therapists at all levels of experience – that psychotic disorders
take root in the seductive, dissociated world that is begun to be built up and
resorted to in childhood to replace a potentially traumatic and/or disruptive
actual reality. These movements begin long before overt, psychiatric clinical
manifestations of psychosis appear. What is crucial is that ‘There is no thought
in the withdrawal, only dissociated sensory content that wipes out psychic real-
ity’ (Chapter 5).
The origins of and stimulus for this withdrawal may include the infant’s reac-
tion to primary objects that are unable to accommodate the infant’s or child’s
Foreword ix
emotional communications or who invade the infant’s or child’s mind with dis-
turbing emotional projections. Thus, while not yet qualified as a ‘defence’ in the
neurotic sense of the term, the withdrawal may serve as a protection against aver-
sive contact with primary objects and the relational world.
The price for withdrawing, however, is considerable: ‘Constantly creating an
imaginary sensorial reality saps energy from emotional and affective develop-
ment, hamstringing experience the individual needs for growth, and compromis-
ing . . . the development of personal identity’ (Chapter 5). What is sacrificed is the
psychic and emotional truth that Bion described as being as essential for psychic
development as alimentation is for physical growth and somatic well-being.
Interestingly, de Masi has found that:
When emotional input is lacking on the part of the caregiver, the child uses his
own body for the purposes of arousal; sensation, devoid of a relational qual-
ity that develops only within good affective caretaking, deviates. To combat
a sense of disintegration, the deprived child clings to a series of sensations (a
light, a voice, a smell etc.) that can serve to hold together the scattered parts
of the personality, or he uses the body in masturbatory terms.
(Chapter 5)
Other authors, such as Aulagnier (2001), Fain (2019), Tustin (1986) and Miller
(2014) have described a similar turn from the object relational world to auto-
sensorial self-stimulation as a ‘survival’ mechanism and developmental derail-
ment in infants and young children who find themselves helplessly ensnared in
situations of overwhelming deprivation or impingement. The turn away from the
relational world of objects and external reality to sensorial self-stimulation has
been implicated in the aetiology of various conditions that lie at the limits of ana-
lyzability, such as perversions, addictions, impulse disorders, somatic discharge
or the creation of autistic nuclei and defences.
De Masi concludes that it is not so much destructiveness that spurs the child
who is destined to become psychotic, but a particular seductive pleasure and/
or need to escape from frustration and pain that drives him to leave the rela-
tional world in favour of building ‘another world’ that he himself creates and can
omnipotently govern. The latter, to which the patient may repeatedly retreat in the
face of subsequent frustration, helplessness and deprivation, is then perceived as
superior to psychic reality precisely because of the sensations it can generate as
the patient alters his sense organs and destroys the psychic organs of knowledge.
This is a malignant process through which the psyche loses its capacity to func-
tion as an organ of thought and instead becomes an organ whose primary purpose
seems to be that of generating sensations. Eventually, this initially euphoric world
turns persecutory and malignant.3
Prior to doing so, however, this dissociated world can be resorted to by the
child as a defence against a real world made uninhabitable by prolonged maternal
depression, lack of parental emotional involvement, intrusive impingement or
other sources of early or severe agonies and frustrations that drive the organism