Robert M. Young Online Writings
ACROSS THE BORDERLINE
I am here to sound a keynote — not on behalf of any standing I have in the clinical or theoretical domain of psychosis — but on behalf of the impulse which led a group of us from the Guild of Psychotherapists and Free Associations to think it would be worthwhile to convene a conference on psychosis which brought together psychiatrists, psychoanalysts, psychotherapists, various other sorts of therapists and people who are concerned with that which we call ‘the psychotic’. Our first impulse was a simple but regrettably unusual one — the desire to bring ‘the psychotic’ into the same space where people who focus on relationships, words, movements, roles, etc. live and work. I should add that our deeper impulse was to show that it is already there and not ‘dealt with’ and relegated to institutions and drugs, by which I mean classical psychiatry. Our aim was and is to promote dialogue and exploration of parts of human nature which are all too often bracketed off and sequestered in the domain of ‘the Other’. I hasten to acknowledge that they surely are ‘other’ but will argue — as I did at our last conference — that they are ubiquitous and not the inhabitants of some alien, alienated realm which most of us never inhabit and which is tended by people sometimes called alienists.
It has increasingly struck me as odd, inconsistent and even hypocritical that the training of psychoanalysts and psychotherapists (except, as far as I know, at the Arbours Association) carefully avoids work with psychotic patients. I am not saying that the reasons for protecting students from psychotherapeutic work with florid psychosis are insubstantial. I do feel, however, that this protectiveness is strange, since some of the most important ideas in psychoanalysis and psychoanalytic psychotherapy in recent decades — ideas which trainees study assiduously — have come directly from pioneering analytic work with such patients. I am thinking of the work of Menlanie Klein, D. W. Winnicott, Ronald Fairbairn, Wilfred Bion, Harold Searles, Otto Kernberg, Herbert Rosenfeld, Margaret Little, Marion Milner, Hanna Segal, Donald Meltzer, Henri Rey, Murray Jackson, John Steiner. I would add to this list the work of Francis Tustin, Sydney Klein and Anne Alvarez on autistic phenomena and that of Lesley Sohn on the identificate and Michael Sinason and Joscelyn Richards on the co-habitee. This work is not just good; it is profound, moving, inspiring. It has led us to think of the psychotic as integral to our humanity and has changed the range and level of many psychotherapists’ clinical work. I am not here to review this work but to draw attention to certain features and certain aspects of how we think about the psychotic in contrast with aspects of traditional psychiatry and psychoanalysis. It could be said that in concentrating on the form and structure of the unconscious and in using scientistic analogies drawn from nineteenth and twentieth century physicalist physiological concepts, Freud and his orthodox followers have left others to convey the content and the full emotional resonance and impact of the psychotic in all of us.
Which brings me to my title. It took me the longest time to figure out why the title of a Ry Cooder song felt right for this address. At one level the answer lies in an obvious pun between the diagnostic category which most often brings a psychotherapist into contact with material which is obviously psychotic —I am struck by the resonances betrween the diagnostic category ‘borderline personality disorder’, on the one hand, and popular culture, on the other. But the more I thought about it, the more I realised that I was thinking more generally and more ambitiously. I apologise to anyone why has not had the good fortune to hear this song, either in Cooder’s original rendition or the equally evocative cover version recently sung by Willie Nelson. I have printed out the words and will play the song for anyone who would like to hear it. Here they are:
‘Across the Borderline’
by Ry Cooder, Jim Dickinson and John Hiatt
There’s a place where I’ve been told
Every street is paved with gold
And it’s just across the borderline
And when it’s time to take your turn
Here’s a lesson that you must learn
You can lose more than you ever hope to find.
When you reach that broken promised land
Where every dream slips through your hand
Then you’ll know that it’s too late to change your mind
Cause you’ve paid the price to come so far
Just to wind up where you are
And you’re still just across the borderline
Up and down the Rio Grande
A thousand footprints in the sand
Breathe a secret no one can define
The river flows on like a breath
In between our life and death
(Tell me) Who’s the next to cross the borderline?
But hope remains when pride is gone
And it keeps you movin’ on
Calling you across the borderline
And when you reach the broken promised land
Where every dream slips through your hand
Then you’ll know that it’s too late to change your mind
Cause you’ve paid the price to come this far
Just to wind up where you are
And you’re still just across the borderline.
While ostensibly about Mexican wetbacks seeking to improve their lives by getting across the border to America, it has many other resonances. On one side of borderline things are definitely and clearly one way, and on the other side they are expected to be very different, indeed. This is part of a longing of people in one condition to be in a presumed opposite one — a split between misery and the Promised Land which (I hope you will not groan when I say) is of a paranoid-schizoid extremity. The song also conjures up a vivid sense of the internal world, where we harbour splits between the phantasy of the misery of an existing reality and the nirvana of a presumed better place, a place which comes to mind when one hears the sound of ‘A Train in the Distance’, since, as Paul Simon puts it in the song by that name, ‘The thought that life could be better is woven indelibly into our hearts and our brains’. (I listened to this song on my way to analysis for some years). If we could just get across that fence, our longings could be fulfilled, but we’re stuck here — stuck, as John Steiner would have it, between the paranoid-schizoid and depressive positions, stuck in a psychic retreat, a borderland. For those of you who may not be familiar with debates about these matters, Steiner’s concept of pathological organisation is on offer as a Kleinian characterisation of what more orthodox people call borderline personality disorder (Alex Tarnopolsky has written a useful Rosetta Stone translation between the two, in which he points out that only a quarter of British psychiatrists use the concept of borderline personality disorder and half of those are analysts — Tarnopolsky, 1992, p. 78).
Some of the figures associated with the borderline vividly convey the space I am referring to between what one experiences and what one hopes for — a space where it is all to easy to get side-tracked, so much so that we have made cultural heroes of people with borderline personalities. One of the main points of my paper is to suggest that we take this cultural fact seriously as we think about the place of the psychotic in our everyday world. Our sense of certain actors and their typical roles merge imperceptibly. Harry Dean Stanton is one such person. As if to help me make my point, he sings a verse on the Cooder original, just as he acts as the balladeer in ‘Cool Hand Luke’. In his most memorable role he portrayed the haunting, lost, abandoned, bewildered everyman in ‘Paris Texas’ and endless characters of a bemused and alienated visage before and since. Other actors of this ilk are Harvey Keitel (‘Bad Timing’, ‘Alice Doesn’t Live Here Anymore’, ‘Blue Collar’, Reservoir Dogs’, ‘The Bad Lieutenant’), Mickey Rourke (‘Angel Heart’), Nicholas Cage (‘Wild at Heart’) and Sean Penn. The film, ‘The Border’, for which Cooder wrote the music, stars another such iconic actor, perhaps the quintessential one, Jack Nicholson, who most of us saw first as the hippie, dope-smoking dropout lawyer in ‘Easy Rider’, along with two other figures of the sort I am highlighting, Peter Fonda and Dennis Hopper, who has made a career of such parts and lived the part, as well. According to last Sunday’s colour supplement Hopper felt that the villain in David Lynch’s ‘Blue Velvet’ was precisely himself. He has also portrayed a psychotic villain in ‘Paris Trout’.
Connoisseurs of Roger Corman ‘B’ movies will have seen a lot of Nicholson, including a wonderful scene where he leers with masochistic fulfilment when he has had all his teeth pulled by a dentist in one sitting. I suppose he is the most famous of all filmic borderline personalities. He is probably best remembered for his portrayal of Randle McMurphy in ‘One Flew Over the Cuckoo’s Nest’, Ken Kesey’s allegory on what we do to non-conformists whom we consider to be irresponsible and a threat to the established authoritarian social and psychiatric order. (Mention of Kesey points to the whole genre of ‘borderline’ literature which included his work, that of Kerouac and Tom Wolfe’s account of that subculture in The Electric Kool Aid Acid Test. Tony Tanner has reflected more broadly on the genre in a chapter entitled ‘Edge City’, i.e., the borderlands around the boundaries of conventional society, which embraces Ken Kesey and others in fiction (Tanner, 1971, ch. 16). Returning to the cinema, there was a spate of films celebrating such people in the wake of the sixties, notably ‘Steelyard Blues’, about a subculture of misfits, centred on Donald Sutherland, Jane Fonda and Peter Boyle. Mike Lee’s ‘Naked’ is a recent example of a borderline hero. Jack Nicholson has played such a person in many guises: the musician in ‘Five Easy Pieces’, the rustler in ‘Missouri Breaks’ (whose sidekick was Stanton), the used up astronaut in ‘Terms of Endearment’, the criminal Joker in ‘Batman’, the Devil in ‘The Witches of Eastwick’, and, finally and conveniently for my purpose, the properly maniacal werewolf in ‘Wolf’, taking us to the full-blooded image of the split person, the Jeckyll & Hyde of Robert Louis Stevenson and Michael Sinason’s concept of ‘the cohabitee’.
I will say something about the imagery of such notions, but I want to start with the most extreme version. In his papers and workshops on the cohabitee, Sinason maintains that mental illness is ubiquitous, that we are each and all a body with two (and only two) minds. The second personality is not a repository of trauma. It is hard-wired and cannot learn. It can accumulate experience and agglommerate thoughts but cannot think or change in any way (Sinason, 1993, p. 214). He believes that the language of part and whole objects is insufficient to convey the picture of humanity he holds — that a full-blooded other, a whole personality, cohabits with the ‘I’ personality, with all its range of abilities, feelings and irrationalities. We are not dealing here with something madly Promethiam or Faustian like Baron von Frankenstein and his pitiful creature, created by him but a separate being. The correct fictional renderings are precisely Dr Jeckyll and Mr Hyde or the helpless man who turns into a werewolf in the light of the full moon. Both are two minds in a single body, and this is Sinason’s sombre model of human nature. (I am told, by the way, that a Scottosh novel of the early nineteeth-century, Confessions of a Justified Sinner, by James Hogg, has the same Jekyll/Hyde theme, but I haven’t read it yet.)
I am very struck by the ubiquity and popularity of representations of such an Other in popular culture. When I was a boy I had recurrent terrors in the darkness and nightmares, evoked by a whole series of films about Frankenstein, his bride, Dracula, the Mummy, the Invisible Man and the Wolf Man — dozens of them, right up to ‘Abbott and Costello Meet Frankenstein’ in which, as I recall, all of them make appearances. Ask me who is properly terrifying, and I will tell you of Boris Karloff, Bela Lugosi and Lon Chaney Jr. These actors and the creatures they portrayed were far more real to me than any boogie-man of Southern folk tales or any of the fiends in the ghost stories told around the YMCA or Scout campfire. The whole range of them reappeared in Hammer Films with Peter Cushing, Christopher Lee and Vincent Price and are the subjects of a revival and remakes at the moment.
I find this a stark and dispiriting rendition of our humanity, which I am having a tough time coming to terms with after doing my best to assimilate what I took to be a version of human nature which was dispiriting enough, thank you very much. I mean, of course, the equal billing of Eros and Thanatos in Civilization and Its Discontents and in the writings of Melanie Klein, a veritable re-incarnation of Manicheanism, a religion which vied with the (believe it or not) more hopeful doctrine of Christianity, in which man carries the birthright of the slaying of Abel by Cain in the doctrine original sin, whereby we are literally born in sin and, like Bunyan’s Pilgrim, have to work our salvation in a life of good works and repentance. In Christianity the ultimate triumph of the good is assured. In Manicheanism, the forces of good and evil were equally matched, and the overall outcome was very much in doubt and hung in the balance. Mind you, perhaps Kleinianism strikes me, relatively speaking, as a form of optimism, since I was brought up a strict Presbyterian, wherein ‘the elect’ were already chosen, predestined, but one had to behave well nevertheless. I later came to see this as rather like B. F. Skinner’s intermittent reinforcement regime in which the rat got driven mad by the lack of any connection between what it did and the rewards which came its way. It is not surprising that Christianity won out over Manicheanism and that most psychoanalysts and psychotherapists find undiluted Kleinianism — and, I should acknowledge, some undiluted Kleinians - too much to bear.
But there is also a compassionate and forgiving way of speaking about these things. In doing so, I want to return to the concept of a border, borderlines or borderlands It strikes me that although traditional psychiatry and traditional psychoanalysis give plenty of weight to the irrational, they are very keen to draw a line. This is clear in the whole tenor of the American Psychiatric Association’s Diagnostic and Statistical Manual (which, by the way, many of the psychotherapeutic trainees I teach have never seen unless they have worked in mental hospitals). As Robert Wallerstein points out in his review of the recent IPA research conference on Borderline Personality Disorder, the diagnostic criteria used in DSM were quite consciously designed to be ‘atheoretical’ and ‘behaviourally-based’ (Wallerstein, 1994, p. 765). They are avowedly undynamic. Indeed, one makes the diagnosis on the basis of five — any five — of eight criteria. The rubric reads, ‘A pervasive pattern of instability of mood, interpersonal relationships, and self-image, beginning in early adulthood and present in a variety of contexts, as indicated by at least five of the following:’ (I’ll read the rest even though it will be familiar to many, because I want to draw attention to how undynamic a list it is.)
‘(1) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of overidealization and devaluation
‘(2) impulsiveness in at least two areas that are potentially self-damaging, e. g., spending, sex, substance abuse, shoplifting, reckless driving, binge eating (Do not include suicidal or self-mutilating behavior covered in [5].)
‘(3) affective instability: marked shifts from baseline mood to depression, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days
‘(4) inappropriate, intense anger or lack of control of anger, e. g., frequent displays of temper, constant anger, recurrent physical fights
‘(5) recurrent suicidal threats, gestures, or behavior, or self-mutilating behavior
‘(6) marked and persistent identity disturbance manifested by uncertainty about at least two of the following: self-image, sexual orientation, long-term goals or career choice, type of friends desired, preferred values
‘(7) chronic feelings of emptiness or boredom
‘(8) frantic efforts to avoid real or imagined abandonment (Do not include suicidal or self-mutilating behavior covered in [5}.)’ (APA, 1987, p. 347).
There can also be transient psychotic symptoms at times of stress (p. 346). Wallerstein notes that this gives ninety-three combinations which can land one in the BPD pigeon-hole (p. 675) or, to follow my own imagery, on the wrong side of the borderline. It is a list calculated to make most people I know pretty uncomfortable.
I have spelled all this out in order to highlight a contrast on which Wallerstein dwells. He refers to ‘a clash of underlying philosophical assumptions between diagnostic understandings derived from DSM-III criteria and those derived from clinical psychodynamic formulations. What DSM-III rests on in its several hundred categorisations and sub-categorisations is what all the individuals assigned to a particular diagnostic pigeonhole have in common, their common behavioural diagnostic defined class, for example, borderline personality disorders. What psychoanalytic case formulation rests on is the understanding of a unique life history eventuating in the presenting illness picture: what makes this particular individual a unique instance, different from every other individual on earth. This focus on uniqueness is shared, of course, with imaginative literature...’ (p. 766).
This brings me to several dichotomies, some false. First, I want to distinguish between the sort of diagnostic pigeon-holing which characterises DSM-III and classical psychiatry, from the sorts of dynamic formulations which characterise psychoanalysis and related approaches. Medicine and, within it, psychiatry strives to find instances of disease entities which are as near to the natural kinds of natural science as can be managed. The model is the element in chemistry or the species in biology. However, disease syndromes are not natural kinds. They are a coming together of a series of phenomena which lead to an outcome which distresses people or those around them. Even somatic diseases fail to qualify as natural kinds. It only takes a moment’s reflection to see that elements such as iron or sulphur, or a species of beetle are very different from the coming together of a micro-organism and a human to produce measles, a genetic defect leading to a failure of insulin productionl leading to diabetes, various problems in the circulatory system leading to a stroke or heart attack, and that these, in turn, are very different from categories in DSM-II such as factitious disorder, kleptomania, fetishism, trichotillomania (obsessively twizzling one’s hair) or self-defeating personality disorder. It is for this reason that psychiatric diagnosis is so controversial. Syndromes come and go in successive editions of the manual, as homosexuality did. It was introduced in 1953 and removed in 1973. Many of the diagnostic categories spelled out toward the back of DSM-III are pretty dodgy, and some depict people who are merely sad or obnoxious. Others — fetishists and some sexual deviants, for example — are campaigning to get the stigma of having a psychiatric pigeonhole removed from them. Nymphomaniacs and priapists were incarcerated when I was first a psychiatric aide in 1955; they are roaming the streets now. But, then, so are people most of us would agree need more institutional care than is currently available.
I will add here that there is an intriguing literature on the historical relativity of somatic medical diagnoses which lends extra weight to my scepticism about the categories of psychiatric psychopathology, since it makes the classsifications of the parent discipline, medicine, less apparently biological and more conventional and cultural. A series of searching papers by Karl Figlio has made this point vividly with respect to chlorosis (a form of anemia) and miners’ nystagmus (Figlio, 1978, 1979, 1985). The eminent psychiatrist and historian of medicine German Berrios points out that the putative objectivity and neutrality of psychiatric classifications is a will-o-the wisp, relying on the empiricist tradition for its respectability but in fact begging large questions about the theory-ladenness and value-ladenness of its concepts (Berrios, 1991, esp. p. 236). Indeed, he makes the point forcefully in saying that the persistence of psychopathological classifications in British psychiatry can be attributed to an empiricist false-consciousness, seeking theory-neutral descriptions. Its basis — the wish to remain at the level of description — is an effort to be free of the obligation to understand and deal with process, dynamics and aetiology. He also points out that the reliability coefficients of psychiatric diagnoses are not very impressive (p. 241) Borderline Personality Disorder is a striking example of a diagnosis which has been the subject of intense controversy, culminating in a recent, good collection on the validity of the concept (Silver and Rosenbleuth, 1992)
Even the most oft-cited criteria for diagnosing the most well-established psychiatric syndromes are not the exclusive domain of, say, the schizophrenic, the manic-depressive or the so-called true paranoid. I am referring to hallucinations and delusions, the two mainstays of the distinction between normal and psychotic. It could be said that the distinguishing feature of the psychoanalytic tradition which runs from Abraham and Klein through Bion, Segal, Meltzer and Rosenfeld is the stress it lays on the presence of psychotic phenomena in all of us. In her classical paper ‘On the Genesis of Psychical Conflict in Early Infancy’ (which was one of the main documents in the Freud-Klein Controversial Discussions — see King and Steiner, 1991), Joan Riviere bases her claims about the ubiquity of psychotic processes in infants on Freud’s own ‘hypothesis that the psyche is always interpreting the reality of its experiences — 'or rather, misinterpreting them — in a subjective manner that increases its pleasure and preserves it from pain' (Riviere, 1952a, p. 41). Freud calls this process "hallucination"; and it forms the foundation of what we mean by phantasy-life'. Riviere adds that 'this primitive and elementary function of his psyche — to misinterpret his perceptions for his own satisfaction — still retains the upper hand in the minds of the great majority of even civilised adults' (p. 41). Klein notoriously and repeatedly said that the thought that primitive mental processes of infants were like those of adult psychotics. She denied that this was tantamount to saying that they were psychotic, but her loyal disciple, Donald Meltzer, says it is difficult to draw any other conclusion. He says the same thing about Bion’s distinction between the psychotic and the non-psychotic parts of the personality. Some said that this distinction was only being made about the minds of schizophrenics, but Meltzer comes down firmly on the side of saying that Bion means all personalities, especially including those of analytic trainees.
The penchant of Kleinians for finding psychotic processes in all of us is striking. Klein moved from locating the paranoid-schizoid and depressive positions as the starting points for adult psychoses to treating them as developmental stages and finally to seeing them as present in the moment-to-moment shifts in people’s thought processes. John Steiner says of those positions and his own concept of the borderline position, stuck between the two — which he calls a pathological organization or ‘psychic retreat’ — that ‘It is clear that not only the two basic positions but also the borderline position occur in all patients, and the notion of positions can help the analyst to consider where the patient is located at any particular time’ (Steiner, 1993, p. 11). His work is replete with examples of the ubiquity and normality of such processes (see, e.g., pp. 26, 51, 52, 54). The person who puts this point best and most frequently and to whose work I shall revert in a moment is Harold Searles, who says, ‘I became convinced, long ago, that borderline phenomena will be encountered in any deep-reaching course of psychoanalysis or intensive psychoanalytic therapy, for these phenomena are part of the general human condition’ (Searles, 1986, p. xii).
But classical Freudian psychoanalysis tells a different story, a story of well-drawn and well-guarded borderlines. It is, I think, for this reason that Searles says of orthodox psychoanalysis, 'to the degree that it is rigorously classical, it is delusional' (Searles, 1979, p. 458). It has a model based on keeping the irrational at bay. I can best illustrate this by drawing your attention to two psychoanalytic classics, Freud’s The Psychopathology of Everyday Life (1901) and Anna Freud’s The Ego and the Mechanisms of Defence (1936). I want to stress that in drawing attention to the affinities between these two works I am distorting the richness of Sigmund Freud’s work, teasing out a particular strand and emphasising how it got woven into what came to be known as neo-Freudian orthodoxy, a reading of his work which until recently dominated most of the psychoanalytic world.
The model is this. The ego is the guardian of realism and adaptation. It has at its disposal a set of mechanisms which are like mini-neuroses, which work like safety valves, letting off a bit of steam in a parapraxis, a slip of the tongue, a forgotten letter or stamp or name or signature or appointment, a momentary clumsiness. This restores the equilibrium in the same way dreams do. Indeed, he points out the similarities between parapraxes, on the one hand, and dreams and full-blown neurotic symptoms, on the other (Freud, 1901, pp. 277-8). He concludes that in parapraxes ‘the symptoms are located in the least important psychical functions, while everything that can lay claim to higher psychical value remains free from disturbance’ (p. 279).
Anna Freud sought to classify the mechanisms available to the ego to achieve a kind of psychic equilibrium. I my view she lumps together mechanisms of tremendously different levels of significance. projection, introjection, repression, sublimation, and conversion strike me as basic to the deepest levels of mental functioning, while others, e. g., undoing, isolation of affect and turning against the self, are on a different level, and still others such as denial and regression fall somewhere in between. In a fascinating book-length series of interviews with her in which this classic is re-evaluated near the end of Anna Freud’s life, Joseph Sandler makes it clear that the list is far from definitive or complete (Sandler, 1985). Anna Freud explored about thirteen; I was taught nineteen as a medical student. The main point of her conceptualisation of the ego’s mechanisms of defence is to keep irrationalities from erupting into consciousness and to maximise the conflict-free sphere of ego functioning.
This approach depends on a model of the mind where there is a border between the rational and irrational, between ego and id, which is policed by the ego’s platoon of keepers of the peace. How different a conception of the inner world this conveys from one in which we are shunting back and forth between splitting, projective identification and persecution, on the one hand, and integration, depressive anxiety and reparation, on the other. Notice that both of the Kleinian positions include terms which are familiar to the psychiatry of psychosis. Indeed, as I have indicated, they had their origins in her investigations in the 1930s into the origins of manic-depressive and paranoid psychoses. Hence: paranoid, schizoid and depressive in the Kleinian concepts which provide the most basic and common features of our everyday thinking. In a classical neo-Freudian model, the irrational goes on one side of the line and the rational on the other. In the Kleinian model they are jumbled, and we are constantly shuffling between these two basic positions, managing paired emotions — love and hate, envy and gratitude — with constant difficulty, living much of the time near the edge or, perhaps I can say, in the borderlands.
In case you are wondering where we have been and are going, I’ll put up some signposts. I have been reflecting on classification and on the line drawn in psychiatry and orthodox psychoanalysis between the normal and the psychotic. I have been contrasting that frame of mind with some things we experience in our everyday and cultural lives, drawing on a song and some movies, notably ones involving people who get labelled as having borderline personalities when they get incarcerated but who evoke lots of identifications when we see them on the screen and the gossip columns. I have also pointed out the close fit between Mike Sinason’s extreme view of the place of madness in us with another genre of films in which two identities inhabit a single body. My overall aim is to bring the Otherness of psychosis nearer to the rest of life and to draw attention to the ubiquitousness of psychotic phenomena in our development, our inner worlds and our culture in a quite mundane, day-by day and minute-by-minute sense.
Now I want to go onto the opposite tack, because I would be horrified if you thought I was saying that there is no such thing as psychosis or that treating borderline or psychotic people was just like treating anyone else. Having brought the psychotic into everyday life I now want to leave open the question of how we distinguish properly psychotic people from the psychotic parts and themes and moments in the rest of us. My purpose today is to throw doubt on the practice of drawing lines. How we go on to characterise psychotically disturbed people is a problem I suggest we address after we are clear about that. I would rather, for example, speak in terms of relative refractoriness or the extent to which the psychotic is in the ascendant in a given person at a given time.
First, I need hardly say in this company that working psychotherapeutically with psychotic and borderline people is hard, exhausting, demanding, dispiriting and has to be approached with a species of stoicism and with limited goals. All writers make this clear, but Harold Searles makes it clearest of all. He is eloquent in conveying the impact of their projections, the problems of maintaining the transference and, most challenging of all, how excruciatingly tough it is to bear what the patient evokes in the countertransference. I have a psychotic patient who has often been hospitalised and came to me after wearing out a colleague and who regales me in a stentorian voice, always in an expository mode, with long sagas from his multigenerational delusional system, with whom I find it all too easy to let my mind wander and who makes little or no response to most interpretations, ‘I’d say half’ to others and seems for the most part unable to make any conscious connection with transference interpretations. He is so sensitive to others’ projections that he cannot bear drama on television or in the theatre and always feels potentially overwhelmed, just as he was by his parents’. Yet he has improved and holds down a modest job in the helping professions, has maintained a marriage and functions (albeit with lots of jealousy) as a parent.
I have two patients who have pathological organisations who I have seen for nearly eight years each. I would have to say, with some embarrassment, that one has not shifted fundamentally, though I think I can discern signs of movement at the moment. Her reigning symptom is being stuck — in her cosy relationship, sexually and in career terms, and the mood of our sessions is one of passivity, filled with what Betty Joseph aptly calls ‘chuntering’, a constant flow without purchase. She suffers from a kind of wistful longing; everything its muted; nothing will change; she does not expect anything. She has a perpetual sense — unconnected to any concrete plans — that if she could only return to her native country she could live again and had a vivid dream of gazing across a narrow isthmus to a mountain in the distance where all would be well if she could only reach it. She has little or no conscious sense of the perverseness and the destructive narcissism controlling much of her inner world and engendering her severe self-limitation. Yet she perseveres. She once tried to terminate treatment but reacted with such distress that she was back within days. In both of these cases my main task is to avoid collusive patterns of relating where I am the only person in the room interested in change.
My other patient with a pathological organisation is the most challenging person with whom I have worked. Without the supervision and support of Alex Tarnopolsky and Arthur Hyatt Williams, I don’t know what I might have done. She works in a cultural job and is conventionally successful, if by that you mean getting work and having it well-received and widely experienced. But she hates it, hates most of life and despised the work. After many years of saying she wanted to but couldn’t she did manage to do a course and, amid continual claims that nothing mattered or gave any satisfaction, finished it with distinction and was soon tapped for the country’s premier position in her field. Of course, this turns out to be meaningless, too. So much for half of Freud’s goal — to love and to work. On the love side she has never made love; she has only had sex to hurt people and not even that for five years. She envies people in relationships, hates the sun and the spring and greenery and cannot bear it when people have babies. She experiences a perverse delight in despising the good: fair is foul and foul is fair. She acknowledges no relationship with me, does not explicitly grant the pertinence of interpretations (though she often confirms them unconsciously), has no gratitude and cannot hold onto a good experience for a moment after the actual event. And — just as the DSM rubric says — she has transient psychotic symptoms from time to time. She believes that black objects will attack her, that black bags full of offal will be thrown through her car window, that flexes and garden hoses will strangle her and that black men will leap out of the attic and kill her. She once hallucinated a puddle of water in her bedroom which disappeared before her eyes. Yet she works regularly, is admired in her profession, comes regularly to her sessions, makes an effort to make up ones lost through work and conveys — again, unconsciously — a longing and need for containment unequalled in my clinical experience. She often says that if she could only move to Spain or be a waitress or receptionist, life would be bearable across the borderline from where she is at.
I have spoken about these patients to make it clear that I have some idea about the intractability of psychotic and borderline phenomena. But, like Searles, I believe passionately in this work and find it rewarding in a way which cannot easily be characterised. He stresses the need to acknowledge that what the patient puts into one finds a home and evokes distressing feelings of worthlessness, of being non-human and of sheer ennui, with boundaries between the patient’s inner world and one’s own hard to find or maintain, while one has the concomitant responsibility to contain — I want to say ‘to contain like mad’. The patient I have just been discussing is quite literally hopeless, and I am the repository of good experiences, hope and quite a lot of memory.
I’d like to share a couple of passages from Searles which convey the special character of this work. He quotes a patient: ‘I don’t care anything about the way you respond. I care about how I respond. Your feelings don’t mean anything more to me than if you were one of the lines on that wallpaper there’. He comments that it took him years to discern that for such patients ‘the therapist is in actuality of such basic importance that the patient cannot allow more than a little bit of the therapist to be perceived as being outside the patient’ (Searles, 1986, pp. 31-2.). In a later passage he expands on the problem of the borderline patient’s inability to differentiate ‘at a more than superficial level, between nocturnal dreams or daytime fantasies on the one hand, and perception of outer reality on the other hand; between thoughts (and/or feelings) and behavioral actions; between symbolic and concrete levels of meaning in communications; between himself and the other person; between himself and the outer world; between human and nonhuman, animate and inanimate, ingredients of the outer world; and so on’ (p. 58).
I now want to revert to Wallerstein’s distinction between what patients have in common and what is unique about them. This may seem a rather bland distinction, but I think it parallels what makes psychotherapists feel uncomfortable about conventional psychiatry, psychiatric nosology or classification and psychiatric institutions. When I first worked in a mental hospital in the mid-1950s, I felt a real split. When I attended diagnostic interviews and classes I became very adept at making diagnoses according to the official rubric. I was an apt pupil. This was the precise moment when utterly custodial psychiatry was being challenged by the new major tranquillizers, with the effect that people were again beginning to be seen as individuals, and the issue of unlocking most of the wards was coming onto the agenda. When I went out onto the ward, however, my experience of the patients was truly as individuals, but I had the strong impression that if I had stayed there as long as some of the staff I would have lost that sense of individuality and fallen back on perceiving the patient as the diagnosis.
Once again, this is a common feature of socialisation into the parent discipline, medicine. In her classic study of what happens to nurses during training, Isabel Menzies Lyth points out that a major feature of the reification that occurs leads one to refer to ‘the liver in bed 10’ or ‘the pneumonia in bed 15’, thereby depersonalising the patient (Lyth, 1959, p. 52). She analyses this in terms of being socialised into a system of defences against psychotic anxieties which protect the staff from potentially overwhelming primitive feelings associated with life-threatening situations, feelings which re-evoke infantile anxieties. This way of thinking has been applied to all groups and institutions by Bion, Elliott Jaques, A. K. Rice, Pierre Turquet, Eric Miller, Gordon Lawrence, David Armstong, Bob Hinshelwood and others in the so-called ‘group relations’ movement (Bion, 1961; Jaques, 1955; Turquet, 1975; Miller, 1990; Lawrence, 1991; Armstrong, 1991, 1992). It is hell’s own job to remain human in such settings, and Donald Meltzer (1992) has given us a vivid description of the sort of person who rises to the top of them, living in their inner world at the other extreme, the claustrum, the lower end of the psychic digestive tract, desperately defending themselves against schizophrenic breakdown and doing so at the expense of sensitive and thoughtful human relations.
But it can be done, as Searles and others have shown. I am thinking of Searles’ analytic work with psychotics and borderlines, sustained at Chesnut Lodge and elsewhere over many decades, and Peter Barham’s sensitive renderings of the utterances of a full-blown schizophrenic which may appear incomprehensible on the surface but make good sense when properly understood in the context of his life and environment (Barham, 1985, esp. ch. 4). In this context we should also acknowledge the pioneering work of Ronald Laing and Joseph Berke in insisting that we attend fully and patiently to what psychotic people say and mean. What I am suggesting is that, although there are strong unconscious, disciplinary and institutional forces at work which can lead us all-too-easily to draw a sharp borderline between the normal and the psychotic or Other, it really is possible to hold onto the narrative of the individual life and its inner meaning, as it interacts at the deepest level with the inner world of the therapist and other people. It is also possible to conceptualise the primitive processes which we characterise as psychotic, without falling into the well of jaded categorisation which stresses the common features of disturbed thought at the expense — even to the near exclusion — of the individual life stories and idiosyncratic meanings which constitute our humanity. Barham’s writings have been as eloquent as those of Searles in holding onto the meaningfulness of the psychotic without settling for the reifications of diagnostic nosology.
I think the future of relations between dynamic psychotherapy and dynamic psychiatry lies in a shared project of holding onto that individual narrative meaningfulness without flinching at just how distressing and testing it is for the mental health worker. As I think of the art of Bosch and Breughel and van Gogh and Dali and Man Ray, the fiction of John Barth and Joseph Heller — especially the characters of Milo Minderbinder and Yossarian — and recall some of the film actors and characters I mentioned earlier, I know that that shared project would bring us into the mainstream of what the wider culture has always known about ‘the psychotic’, something conveyed in a saying first coined by Terence in the second century BC and worth recalling and striving to hold onto in our daily psychiatric and psychotherapeutic work: ‘Nothing human is alien to me’.
This is the text of the keynote address to the Second International Conference on ‘Psychosis: Treatment of Choice?’, at the University of Essex, Colchester, 23-25 September 1994.
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