The Psychotic: Aspects of the Personality

338 Pages·1992·39.34 MB·English

by  David Rosenfeld

D A V I D R O S E N F E

THE PSYCHOTIC

Aspects of the Personality
KARNAC BOOKS
THE PSYCHOTIC

Aspects of the Personality
David Rosenfeld
THE PSYCHOTIC

Aspects of the Personality

David Rosenfeld
Foreword by
Otto Kernberg
Karnac Books
London 1992 New York
Chapter two reprinted with amendments from the International Journal of
Psycho-Analysis, 67 (1986), 53-64.
Chapter seven adapted from the International Journal of Psycho-Analysis, 61
(1980), 71-83.
Chapter eight reprinted with amendments from the International Journal of
Psycho-Analysis, 65 (1984), 377-387,
Chapter ten reprinted with amendments from the Analytic Psychotherapy, 9
(1982-83), 435-^46.
First published in 1992 by
H. Karnac (Books) Ltd,
118 Finchley Road,
London NW3 5HT
Distributed in the United States of America by
Brunner/Mazel, Inc.
19 Union Square West
New York, NY 10003
Copyright © 1992
by David Rosenfeld
All rights reserved. No part of this book may be reproduced,
in any form, by any process or technique,
without the prior written permission of the publisher.
British Library Cataloguing in Publication Data.
A catalogue record for this book is available from the British Library.
ISBN 978 0 946439 96 6
Printed and bound in Great Britain by
print in black, Midsomer Norton, Bath
CONTENTS

FOREWORD Oto F. Kernberg vi

PREFACE XV

PART ONE

Psychosis and psychotic part

1. Psychosis and psychotic part:

a clinical aproach 3

2. Identification and its vicissitudes

in relation to the Nazi phenomenon 41

3. Psychosis
and cardiac transplant

with Natalio Cvik 63

4. Countertransference and the psychotic part

of the personality 79

5. Child analysis:
technique and psychotic aspects of the personality

with Alicia D. de Lisondo 101

v
v i C O N T E N T S
P A R T T W O
Psychosis, technique, and body image
6. Technique, acting out, and psychosomatics 141

7. The handling of resistances in adult patients 157

8. Hypochondria, somatic delusion, and body image 179

PART THREE
Drug addiction, impulsions, and linguistics
9. Drug abuse and inanimate objects 201

10. Psychoanalysis of the impulsive character:

a linguistic-communicative study 259

1. Linguistics and psychosis 27

REFERENCES A N D BIBLIOGRAPHY 295

INDEX 308
FOREWORD
Otto F. Kernberg
he recently renewed interest in the psychoanalytic inves­
tigation of psychosis stems from several sources:
T First, the assumption that the psychopharmacological
treatment of schizophrenia would render psychotherapeutic
approaches to this illness obsolete has proved illusory. We have
learned that psychosocial interventions in schizophrenia are
crucial to consolidating the achievements brought about with
medication and in preventing relapse, and that indeed a toxic
psychosocial environment may precipitate a relapse. The
importance of psychoanalytic psychotherapy for psychosis
becomes evident when we consider the effectiveness of ordinary
Dr Otto Kernberg is Associate Chairman and Medical Director at
the New York Hospital-Cornell Medical Center, Westchester Division;
Professor of Psychiatry at Cornell University Medical College; and
Training and Supervising Analyst at the Columbia University Center
for Psychoanalytic Training and Research.
vii
V i i i FOREWORD
psychosocial interventions in the aftercare of chronic schizo­
phrenic patients and further consider that these interventions
are a far cry from what skilled psychoanalytic treatment might
do in selected cases. In addition, we are accumulating clinical
evidence to show that certain schizophrenic patients who do not
respond to psychopharmacological treatment may be receptive
to a psychotherapeutic approach, if they present at least a cer­
tain degree of integration of their personality, a capacity for dif­
ferentiated object relations within the psychotic regression, at
least normal intelligence, and an absence of antisocial features.
A second reason for the renewed interest in psychoanalytic
psychotherapy of psychosis is our deeper understanding
provided by the pioneering work of E d i t h Jacobson, Herbert
Rosenfeld, Harold Searles, Wilfred Bion, and Piera Aulagnier.
We can now be more effective in dealing with psychotic regres­
sion and psychotic transferences, as a result of our ability to
analyse the psychological structures of psychosis.
The third reason is perhaps clinically the most important: we
have found that psychotic transferences and mechanisms also
make their appearance in patients with borderline personality
organization, narcissistic pathology, the perversions, addictions,
as well as patients with impulse disorders and antisocial tenden­
cies.
Lastly , the psychoanalytic investigation of psychosis dramati­
cally provides us with insights into the functioning of the early
and the primitive mind, which is a source of direct investigation
of the dynamic unconscious that enriches psychoanalytic under­
standing i n theory and practice.
The Psychotic: Aspects of the Personality, building on the
work of the pioneers mentioned, expands the psychoanalytic
understanding of psychosis both clinically and theoretically.
David Rosenfeld's sophisticated approach is based on British
object relations theory. He stresses—correctly, it seems to
me—that the evaluation of the functions of psychotic symptoms
in the transference is more important than the investigation of
their psychogenetic origins. He underlines the importance of
analysing the role that primitive defenses, particularly patho­
logical types of projective identification, splitting, and denial,
play i n reducing the patient's very capacity for thinking and for
FOREWORD i x
coming to grips with his intrapsychic reality. Rosenfeld's focus
on the central significance of the analyst's functions of con­
taining, diagnosing, and interpretively utilizing his counter­
transference is illustrated in his moving and convincing clinical
data. Overall, the interplay of case material and theoretical for­
mulations makes his book eminently readable and stimulating.
The vicissitudes of the intrapsychic organization of inter­
nalized object relations emerge as the basic frame that differen­
tiates various types of defensive organization and clinical
developments in the treatment of psychotic patients. At one
extreme we find a dismantling of internalized object relations
under conditions of primitive terror—and, I would add, a prim­
ary disorganization of either the basic affective structures or the
capability for sensorial integration i n the form of 'pictograms'
(Piera Aulagnier's term). Only slightly less severe is the autistic
encapsulation of early object relations under conditions of
extreme trauma. Towards the middle of the spectrum of severity
of psychosis we find the dominance of symbiotic, fused, or
undifferentiated relations between self and object, with the
patient unable to distinguish his own psychic operations from
those of the therapist. Here, i n order to avoid pervasive con­
fusional states, the patient may set up secondary defenses in the
form of violent acting out. At the less pathological pole of psy­
chosis, we find that differentiation proceeds, and more sophisti­
cated splits between idealized and persecutory relationships are
played out in the context of improved reality testing. D r Rosen­
feld covers the entire spectrum of psychotic conditions, describ­
ing transference and countertransference developments and the
technical management of each.
Of particular interest is his original description of the 'primi­
tive psychotic body image' characteristic of psychotic patients
wherein the development of a ' s k i n ' surrounding the body image
and a related concept of a differentiated self fails (usually i n
response to inordinately traumatic early interactions with the
primary caretaker). He describes the fantasy of a liquid body
content contained within the equivalent of a 'sack' constituted
by blood vessels, clinically expressed in the patient's fears of
emptying the content of the body or wishes for filling up the
content of the body as a prerequisite for remaining alive. T h i s