small study in psychosis

A psychotic patient began treatment with erotomania. There was a man in her building who was her "husband". She initially talked about her comfort with him and that they liked the arrangement of living in separate apartments and having some space between them, but that they would one day live together. After a month or so someone appeared, "the enemy," who was trying to interfere with the relationship and bring up a man that she had been intimate with. Soon the husband dropped out of her sessions but the enemy grew in power. My patient said she used to be able to lose weight just by picturing herself as thin and the enemy wasn't letting her and was putting bad thoughts in her head about her ugliness and obesity. In her 'private language' the enemy was trying to "put a statement on her" and she feared to talk about many things because it would attract the enemy. 

Alot of the therapy involved 'holding statements' that tried to capture her ontological position and expressing frustration on her behalf. 'What made the enemy chose you?' 'You can't escape the enemy, you can't even talk about them, and so you're stuck with this curse you did nothing to deserve and just have to wait in your house alone and don't get to have a life'.  

Soon she was able to get angry at the enemy for choosing her and interfering with her life. This opened two avenues. The first was father-substitutes from the past. Doctors and police officers who mistreated her came up in the sessions. She couldn't talk about what happened for long before experiencing thought-blocks and we would sometimes sit in silence for minutes. Additionally, a volar triangulation appeared. Her neighbor's apartment was sometimes growing and encroaching into her apartment. Her neighbor, a woman, was "a whore" in my patient's delusuions and sometimes her pimp would be by and my patient didn't like it. The enemy still appeared during this time and her anger at him or her continued and the angrier she got the less the enemy appeared in the sessions. 

The next and last development (before I moved and had to end treatment) was that her neighbor, the woman, sat beside her and she was fearful that others would think she was a lesbian. At this time the husband (erotomania) was no longer part of her delusions and she was also expressing worries that she would always be alone. She also no longer mentioned her magical abilities to wish herself thin and was talking about practical things she was doing to lose weight. Her neighbor's apartment was no longer encroaching on hers and her concern was whether she should stay at home in her apartment or whether she should go out more. 

She was still in fear of someone putting a statement on her and still paranoid about others in general but in a few months there was a palpable change in the content of her delusions and her desire for engagement with the social body. Also very important was a change in her facial and ocular armoring. Many psychotic people have mask-like faces and far-away eyes. Her eyes opened significantly more and became much more bright and haunting. Also, in her moments of silence, expressions of pain and sadness began to show up in her face. 

I also have to say that I experienced some of the worst projective identification with her that I've ever experienced. I was fine with my patient before and my patient after, and I also had a colleague who was able to vouch for my feeling with this patient. She was able to suck all of the energy from you. My eyes would grow very heavy during the session and I wanted to escape into sleep.

She wasn't the first patient I've had this feeling with but was the one I felt it most strongly with. I did ask her at some point if I should be feeling tired and sleepy during one point. She smiled and said no, and I couldn't tell if her smile was meaningful or not. The strength of my objective counter-transference changed soon after but I don't know what this came from.  

I wasn't sure how to conceptualize this sleepiness. Was she putting her bad conscience into me and I wanted to process it by escaping consciousness and going to sleep? It was clear that with her "whore" and lesbian neighbor that she was avoiding bad conscience. Additionally, in out last couple sessions she began to give me advice for my life and she had a low ego ideal/deutero fixations that seem to be a necessary part of projective identification defenses. 

     

melancholia, depression, and the volar home

I came across this and thought that in its utter simplicity there was a base connection between home as father-substitute and melancholia.

In my experience with melancholia I've seen patients who self-revile about being incompetent and unable to work well (phallic), who are more generally hated by others and should be scorned (anal), and then are abase themselves for being wretched and wrong without reference to the social body or social activities.

I've also toyed with the idea that this is a subject altruist defense and that there is melancholia in body dysmorphic disorder and other instances of the object egoist hating her body or appearance.

Besides these melancholic reactions I think that there is just depression as emptiness, coldness, and loss of the sense of beauty in participating in, being an insider in, the group. It goes along with the sense of having sinned or done something wrong that one is being punished for. This might attach to actual wrongs or bad things one has done but I've also had the experience of having a couple patients confess a sin that they had been obsessing about and there was no change in the next few weeks of their depression. To my mind it's still valuable that they opened up in this way but I had the sense that the feeling of having done something wrong came first and the sins were brought about secondarily to rationalize the pre-existing feeling. But, this was just a feeling.

I think that the song is bad. In fact, I've never been much of a fan of Tom Waits. I don't Wanna Grow Up and Downtown Train and a few of his "hit songs" were pleasing to me but never quite enough to make me rifle through his albums searching for more.

Anyway, the song works with cliche as far as the altruistic aspect goes, but what I thought was more revealing was the house being old, "cracked and peeled" and generally expressing the author's feelings of object egoistic melancholia.

In previous posts I've shown that the house was a volar deutero castration complex. The phallic mother is the central figure and her possession of the beautiful home is her possession of the father. The ugly home in this song is the loss of the beautiful home. However, the father imago can't be totally denigrated without foreclosure or psychotic consequences. It must be defended against in paranoia or melancholia or something that keeps it there to protect against the return to the mother.

So, I think that ugly and run down home that is contrasted with a "palace" is a comment on how the author of the song feels about himself.

"House Where Nobody Lives"

There's a house on my block
That's abandoned and cold
Folks moved out of it a
Long time ago
And they took all their things
And they never came back
Looks like it's haunted
With the windows all cracked
And everyone call it
The house, the house where
Nobody lives

Once it held laughter
Once it held dreams
Did they throw it away
Did they know what it means
Did someone's heart break
Or did someone do somebody wrong?

Well the paint was all cracked
It was peeled off of the wood
Papers were stacked on the porch
Where I stood
And the weeds had grown up
Just as high as the door
There were birds in the chimney
And an old chest of drawers
Looks like no one will ever
Come back to the
House were nobody lives

Once it held laughter
Once it held dreams
Did they throw it away
Did they know what it means
Did someone's heart break
Or did someone do someone wrong?
So if you find someone
Someone to have, someone to hold
Don't trade it for silver
Don't trade it for gold
I have all of life's treasures
And they are fine and they are good
They remind me that houses
Are just made of wood
What makes a house grand
Ain't the roof or the doors
If there's love in a house
It's a palace for sure
Without love...
It ain't nothin but a house
A house where nobody lives
Without love it ain't nothin
But a house, a house where
Nobody lives.

A few first principles for analytic technique

This is my first stab at analytic technique for patients who are pre-genital but aren't so regressed that they can't handle some activity from the analyst.

As with many of my posts I'll probably end up recycling it and give more examples of the processes involved and break up the stages into sub-sections.

I'm not sure how valuable it could be to anyone at this point but here it is.


ego- superego- id

1. ego- see whether the patient is leading the initial talk about their life in regards to their ego (social) drives or object (sexual relationship) drives.

-don't interpret and challenge but ask client questions about others and their reactions to them to get the patient to tell the fullest story, or, if the patient is too regressed then you'll have to approach from a modern analytic or Kleinian technique

-you are looking for recent social humiliations or disappointments in love with parental-substitutes

-you are also looking for life-long patterns or repetitions

-you are waiting for a transference to form and you are storing information that later techniques may refer back to.

-you are looking for chronic inhibitions of aggression/self-assertion and affection/empathy

2. superego- at some point you will begin to see what ontological relation the patient is in regards to the ego or object drives. For example, is he concerned about his image or success, or is he concerned with being a member of society or not, is he concerned with having a perfect life or not. In the object drives, the patient might have no place in her life for a man, might have a current relationship in which she is identified with the parental imago and treating her partner like she used to be treated, etc. The ego defences will be worked through at the same time as the patient's relation to the father-substitutes is being spelled out.

In the ego drives one can offer 'holding statements' about how the patient functions in relation to the social body. For example, you have a common patient who is living below their potential. He is in a mediocre job and there is criticism of his boss, the idea that he doesn't want to "pretend to be busy" and isn't getting enough direction from his boss, and observations about what the company might do that he doesn't share or shares half-heartedly. This situation naturally brings to mind the opposite picture in which there is an ideal in which the patient's time is used efficiently and he is led by a boss who is perfect to realize the fullest potential of his job. The patient on their own will begin to compare their current employer to other employers and the picture will emerge of the ideal father-substitute that is needed and you have to get the patient to begin to express him in his imagination.

The perfect use of time (volar trito) is in confluence with the anal father-substitute who represents the superlative father who the patient needs to join "society" and work-life.

In the object drives the reference to the social body is less explicit. However, there is often reference to how much time and control the sexual object wants. Many narcissistic patients will have a partner who wants to be the only person in their lives and doesn't want them to have any friends or leave the house. This can be represented mythically. The jealous controlling boyfriend seems like some dragon or ogre who lives outside of society and keeps the patient as his treasure. This representation obviously gives the sexual object a lot of power and this is what the patient has to express in the fantasy. Whether she is making a narcissistic object choice, secretly feeling more powerful than him by taking care of him, feels inadequate to live life on her own, striving to restore him to his former glory or potency, etc. his place of power in relation to the social body should be spelled out and then ego defences on both the egoistic and altruistic poles can be analyzed.

3 id- you don't have to just analyze the transference, but can also study extra-transference relations because you are searching for aggression and affection in recent narcissistic injuries and disappointments in love. By following slips, dreams, and asking for associations for idiosyncratic word choices you either find phantasies that can be used in transference interpretations, you can find self-states that allow the patient to more fully elaborate her defusions and defences, and you he or she can express the ego drives functioning in relationships that aren't conscious.

These techniques take you back to both the superego (2) and ego (1) stages of work. However, the distinctively important id work has to do with the specific forms of aggression and affection that need to be expressed.

When a slip leads the patient to tell a story from her past that is triangulated you should always perk up and wait for the id impulse of aggression and affection to become noticeable. When the patient, for example, gets angry as she is telling the story you can acknowledge this anger in her and ask her to note where it is in her body. Ask her where she feels power and where she can attack someone and damage or hurt them. Often they will reference the body part. Power, for example, will be felt in the hands and impulses to strangle might be felt. After she stays with these body feelings you can instruct her to imagine attacking someone (or, if you're a somatic psychologist you can actually have her strangle a sheet or pillow). It is always important, however, to elicit the words and what she would like to say to the object of the aggression.



 

narcissistic object choice.

I haven't known what to do with Freud's idea of narcissistic object choice.

I've used it broadly to refer to the object egoist wanting a subject egoist who was successful and showed her worth.

I've had one straight and some gay patients who were very clearly looking for a romantic partner who was exactly the same as them.

However, I have also had a patient who was with a sociopath. She told him she wanted him to leave and he stole some of her things and he threatened to put her naked pictures online and she called the police on him to no avail.

she described him as a sociopath, that he doesn't care about others, that he's threatened the police and is lawless or above the law, that prison is like a vacation for him, that he'd break any restraining order... he also cheated on her many times and was attractive to women and viewed as strong.

It took me a while to place it but my patient had often referred to her wild days in the past and how she didn't care for others either. She broke homes, took what she wanted, and was quite lawless herself. 

At some point she became anxiety ridden, isolated in her home, and while small chances for her to move on came up that she didn't take I knew she needed him in some way. I analyzed it based upon her echoism and fear of starting her own life, I analyzed it based upon her narcissism and preferring to imagine having the perfect life rather than attempting to actually attempt to have a real life, and though these were part of the situation I think that the narcissistic object choice in which her boyfriend represented the wild, sexually desirable, selfish, and uncaring part of herself seemed to have the most weight for her. If memory serves me correctly her response was "that is gross" and that it felt right and was 'disgusting' to think about and a surprise.

No longer having this part of her personality operating means that the function is different than the second examples of people who want to have romantic partners who are just like them because their drives are still functioning. My patient ejected a part of herself and wasn't functioning in many active ways.

Additionally, her staying in the house also seemed very significant to me because of what I've come to understand about the volar father-substitute. I wish I would have asked her to talk about the house itself.

I'm loathe to call this projective identification because as I've understood Klein to use it, it seems to be about taking the place of the parental imago and putting one's anxiety or ego ideal tensions into the other person. 

So, maybe narcissistic object choice is the way to go here...  

Death in Altruism

Now that I'm more attuned to altruism and the deep object of death several instances of it appear very much on the surface of my patients.

In comparison, striving for perfection or feeling oneself to be perfect (high self-regard/low ego ideal) is also very much on the surface with egoists.

With altruists there is often death apparent in the absence of others or them "not being there" even when physically present. For example, a woman meets men who disappear on her. (Freud compared going on a journey to death in the Interpretation of Dreams). Many complain about having a boyfriend who treats them badly and who they ask about his feelings or about his future plans and he gives them no response (he isn't there). They are afraid to demand an answer.

In a previous post I shared a song about the opposite of this "the fade away" in which it is the altruist who disappears on the person they were with for fear of turning the person down. They just ignore phone calls and texts and "fade out of existence" for the person.

I've also written about victimization or spousal abuse as sometimes being traceable to the repetition of the primal scene in which one takes the place of the abused, injured, or humiliated mother.  

In comparison to egoism, the death of the other becomes related to the death of oneself in the deutero stage just as perfection becomes part of oneself. In this case, the death or loss of one's consciousness becomes the central idea. Wanting to sleep all the time, over-eating and dimming consciousness this way, losing oneself in work or scattering oneself with several different projects and things to do or people to help, etc.

This is all still very rough, but something fell into place for me and I thought others might be interested to read it even though it is roughly patched together.

inferiority tensions and superiority/ conceit tensions and self-satisfaction

I'm still struggling to formulate the deutero stage in altruism...

The tension of conceit and people-pleasing and being self-effacing is simple to see and straightforward. Those who want to help the disadvantaged without much gain for themselves and for whom compassion and not pity (in its implication of being above) is present can be contrasted to those who want social honors.  

Similarly, the ambitious/industrious person who is driven for more achievement is simple to understand as well.

In deutero superiority in the egoist the drive element is diminished and the person has a confidence that may be built upon very little achievement.

In the altruist the tensions of conceit that a part of the self-effacement and avoiding presumption, and worrying about others seems to be flipped as well.

There is a self-satisfaction in the deutero subject altruist. There is a relation to a father-substitute in which he is treated with manifest gratitude and idealization but under this there is some sense that in one's assisting him that one has put on the finishing touches or guided in a way that was indispensable or that one knows better. The father must lead and the altruist can't take his place but in the deutero altruist there is something like a masked superhero fantasy.

The echoistic Peter Parker is secretly Spiderman and its not just to protect his family but the inability to be taken for the father-substitute.

In another relation to the depersonalized father in the social realm the deutero subject altruist could maybe be a bit of a "busybody". I think of Jane Austen's Emma and her matchmaking and general meddling.

Another patient referred to "needing to be needed" and the self-pity that went along with feeling that others didn't appreciate what she had given was strongly manifest.

The variety of types is often staggering and it's very difficult to feel like I have a principle or concept that can refract in all the different directions that I see in cultural, personal, and clinical experience.


    

penis envy, the anal castration complex and the anal trito phase

I've had several female patients now who've brought up sensations of wanting to urinate themselves or memories from the past of being embarrassed about their urination. Initially, the first couple patients began to associate boys standing up to urinate, and this idea developed into the pride or "cockiness" of the boys in their penis and ability to urinate this way. The idea has also taken the form of boys having it easier than girls. Instead of an open hatred of cocky men it becomes hatred of men for not "checking their privilege".

One patient exclaimed that she didn't choose to be a girl and it's not fair. Another didn't disparage her sex and had pride in being a woman but I couldn't explore it (her associations took her somewhere valuable and I wouldn't lead her back just to satisfy my curiosity).

In the proto, deutero, nuclear complex, trito model it seems like the trito renunciation hasn't been made in these women (this means that the urethral tendencies didn't become instinctually renounced). This desire functions in combination with the earlier nuclear complex (i.e. oedipus, electra, bellerophon, antigone). In two of them the foot features prominently as a displacement downwards from above. The foot is disgusting, or it is "private" and seems to represent the castrated genital. I say 'seems' because where the discussion of urination led to conscious fantasies of boys and direct statements of hatred towards them, the foot has not yet been explored.

The anal castration complex, the protesting of sexual difference at the anal stage, and the feeling of having "gross" genitals is one side and the urethral impulses that weren't renounced to become the anal trito ego ideal becomes another...

Two of my patients have open murderous wishes they have felt towards others and I don't think they would have these strong reactions if they formed the trito conscience...

There are also very strong, anal ontology, judgments about other people. One client very strongly competes in a subject egoistic way and so her penis envy could very well stem from having a SE fixation here. Another is object altruistic and so her penis envy could stem from this masculine route too.

The problem is that the less dominant part (subject altruistic, or object egoistic) could be the defused so it's hard to say this must be from the masculine fixation.

Also, I can't tell whether expressing this phantasy is what is curative at all. In my current way of thinking, it is the abreaction of the emotion that came up in relation to the father-substitute, which had to be repressed, that is is curative and allows re-fusion with the father-imago through the person of the analyst.      

Then, the longer work of performing the instinctual renunciation and forming the trito stage becomes important so that the person becomes less self-absorbed and more able to whether hardships in the world...   however, part of me rebels against this... part of me feels like the world should change and not the person...

I've decided to post this. Usually I'd see all the doubts and uncertainty and leave it in the collection of pieces to be edited, but after the last post I thought I'd make it public.

Are there any analysts out there who have followed similar references to urination?
Are there any analysts out there who have a stronger sense that change has happened after the exploration of penis envy?

teeth

 I have to share that I often post on this site to procrastinate with other projects or obligations I should be working on.

I also want to share that I have many half started posts and many more moments of just staring at the screen and wondering what to write. I often touch on to something and then feel that I couldn't give it enough poetic flair.

In general, I feel embarrassment about my writing and often open up old posts to see forgotten words or basic mistakes.

I feel like I owe the people who read an apology. I also think often about how I need to take more pride in what I do...

I think I shared in an old post that "I have no guts" and that I do only the outline of things but the movements or the effort to shape things aren't consistent the whole way through.

I picture a magician who conjures up something that is impressive on the surface but on closer inspection you find that the bouquet of flowers he pulls out is lifeless and bland.

This is only on somedays though and if you've read any of what I write then you know it is only one soul, or one chorus of souls, that hum this song.

Still, today I feel like all my teeth should fall out and that, with mouth agape, everyone should see the putrid flesh of my gums (now gnashing with an underbite). Everyone should feel disgust and shun this previously long-toothed villain. All should throw stones or flee.

 

Transactional Analysis and Gestalt Therapy

As I'm at work trying to understand the relationship of the drive and the imagos with my patients, and formalize their repetitions and defenses, I find that using transactional analysis is helpful to explain the phenomenal element.

There's always a game in the stories patients tell...

One will complain about her cheating, lying, threatening,... boyfriend but when she doesn't take an opportunity to leave we see that she has her own reasons for staying with him. She feels like she deserves to be homeless for what she's done to others and she has anxiety on her own and feels to overwhelmed to face the world alone.

One will be a "parent" and mercilessly criticize the partner and put his or her own castration anxiety into them or have them walking on eggshells and feeling like a "child". Then, as the past comes up, they can start to own that this was how they felt in the past themselves with their parents.

I remember reading a gestalt technique about getting the person to do an impression of someone whom they are obviously projecting on. Often having the patient do this will have them acknowledge themselves that they "used to feel like this" or that they're "kinda like this too".

One patient describes her volar castration complex through explaining her sister's "attitude".

"I am...[sister's name]"
"Everyone else is wrong"
"I don't pick and choose my battles [but argue with people every time]"
"I am disgusted with everyone who isn't me"
"no one else is going to be good enough for me"

  

Is extra-transferential interpretation "wild analysis"?

Although some relational psychoanalysts are to commended for wanting to go beyond the simplistic models of ego psychology, the idea that some of them put forward about the unconscious being created in the analytical meeting is silly.

Often they are altruists who don't want to make other intellectuals feel bad and therefore humble their position so that it doesn't upset the understanding of others.

However, once one accepts that the analyst is just one potential father-substitute in the patients life and that he or she may have transference with another and that may be occupying some of their time in the session, the question arises as to why interpretation can't be made regarding that transference?

In an ego psychology model, the view is that the transference relationship is needed with the analyst so that the rational ego can begin to see how it's repeating and hold itself back. The patient gets to see the transference in the room and repeated interpretations by the analyst will strengthen it.

I have a patient who is having a nice defused antigone complex, or subject altruist castration complex. There is a woman in my patient's building who is physically disabled and has nurse assistants who come to her home to assist her with her basic needs. My patient presents the triangle that the nurse assistant is showing up late, not doing her job as well as she should, and she will have anxiety for the disabled woman's well-being as well as resentment towards the nurse's assistant. My patient feels like she is the real caretaker and that the assistant should give her some of the money she makes and that the assistant is generally not doing her job. Of course she doesn't say any of these things to he nursing assistant but will bottle them up until she explodes (except for the satisfaction of complaining to the disabled person about the assistant). Soon the past begins to naturally arise in the conversation. The patient used to "raise" her brothers and sisters and they considered her to be parental figure. However, there was a point in her teenage years when her mother "tried to take back the power" when she hadn't been there as a parent for years.

When one is presented with present and past like this a few times, isn't the situation becoming ripe for analytic action?

Also, isn't the end point having the patient being able to re-fuse with the father-substitute and therefore to clear up the emotional resistance to this? The patient has to process the narcissistic/echoistic injury that causes the defusion and whether it regards the repetition in the transference or out of the transference to be there as a witness to the pain and mourning will set the analyst up as a new father-substitute that can be fused with.

In this case, instead of the patient getting involved in a triangle if the nursing assistant couldn't be a father-substitute who handled the situation then she should have made the relevant calls and trusted in another father-substitute to do the work. Her loyalty to her disabled friend shouldn't so completely overshadow her 'self-loyalty' in giving her own pursuits the time they deserve.


*** a quick note. Not every relationalist is an altruist, just like not every liberal is an altruist. An egoist can also identify with the school because of it being portrayed as the dominant model in his training institute or from what he gleans from the journals or the general psychoanalytic community.

My point is that rather than the psychoanalytic models or ideas expanding to conquer other disciplines,  it appears like they became effaced in order to accept them.

echoistic injury- the need for punishment

I've indicated that there is a step between the oedipus complex and the castration complex.

In fusion with the father imago the individual has good relations with father-substitute. The subject egoist, for example, is able to respect his boss or superior and have friendly relations with others in the group. In defusion, he enters the castration complex and has problems accepting the father-substitute and competition with others in the group may break out.

In defusion, the ego ideal has the imperative for the SE to "be his own father" and he experiences more tensions between his ego and ego ideal. This leaves him open to narcissistic injuries in relation to his image-ego in the social (ego drives) or sexual (object drives) relations. The narcissistic injury will bring about a second defusion and require defensive management of the anxiety.

In the object altruist I've begun to note that the echoistic injury comes from not being accepted by a group of friends. In one patient there is the unmistakable longing for an earlier period when she was included in a group that other's would talk about and seemed special. Another patient had a dream that she was a boy included in a group of 'wild boys' and before she became an outsider she delighted in the irreverence and bawdiness of the group.

The echoistic injury, like the narcissistic, ties the centrality of the castration complex of the phallic stage with the castration complex of an earlier stage. The second defusion of the need for punishment deals with the 'social anxiety' of people in the community confronting one about the shame of one's social humiliation. Rather than expecting punishment or enforcement of the humiliation from others one punishes oneself first. Since the earlier anal, volar, part-object nuclear complexes are open and functioning simultaneously with the phallic, the need for punishment might align with repetitions from these stages.