Herbert Rosenfeld at Work

The Italian Seminars

Herbert A. Rosenfeld, Franco De Masi, Franco De Masi

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429914492
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Between 1978 and 1985 Dr Herbert Rosenfeld was one of a number of British analysts invited by a group of Societa di Psicoanalisi Italiani members to conduct a series of seminars and supervisions for the purpose of deepening and refining that group's clinical skills and theoretical understanding. This book is an illuminating record of that encounter, and a warm tribute to the significant influence of Rosenfeld's contribution.It is divided into two parts - 'Theoretical' and 'Clinical', and based on a selection of verbatim transcripts recorded at the time. These transcripts, with their dialogical form, succeed in capturing much of the specificity of oral exchange, and thus convey a strong impression of Rosenfeld the man as much as clinician or theoretician. Rosenfeld remained to the end a continuously creative analyst and these 'last thoughts' provide the reader with ample evidence of his undimmed gifts. His subtle intuitions, meticulously close attention to both patient's and analyst's interpretations, and fine appreciation of the intricacies of the analytic encounter, are abundantly present.

PART I

THEORETICAL SEMINARS

ONE

Psychotic transference diagnosis and treatment issues in the analysis of a psychotic adolescent

Ihave selected the case of a 16-year-old psychotic adolescent to cast light on certain aspects of psychotic transference which often remain concealed and therefore insufficiently diagnosed and interpreted in the analysis of psychotic patients. This not only slows down the progress of treatment, it can produce an acute psychotic situation inasmuch as the concealed and split psychotic parts escape control and overpower the non-psychotic elements in the patient’s personality.

The therapist who presented the patient in a seminar was very keen to speak with me about this; the patient’s state had suddenly deteriorated after three and a half years of analysis and after both the analyst and the supervisor thought the patient had improved considerably.

It suddenly became clear that the patient was rapidly producing a schizophrenic situation. This was a real blow to the analyst, and without doubt, to the supervisor as well. Given that the analyst was not in a position to tackle the intense negative transference that had emerged, a transference which did not respond to any interpretation, it was necessary to terminate the analysis. Nevertheless, the analyst continued to be very interested in the patient and was keen to find out if I could somehow explain what had gone wrong with the treatment.

In the analysis of psychotic patients one expects psychotic transference to develop sooner or later, and when this happens it should be diagnosed very rapidly. Often signs of either positive or negative psychotic transference appear early on in therapy, but usually the patient attempts to suppress and conceal the most destructive and violent aspects of his psychosis; it is nonetheless essential as soon as possible to reach the emotions and fantasies connected with the split part of the self, to stop the non-psychotic parts from being overpowered later on by an acute and sometimes delirious psychotic attack.

I do not intend to spend much time on details of the analysis, which had been conducted with skill, sensitivity, and empathetic and affectionate comprehension. Rather, I shall focus on the more significant aspects of the concealed psychotic transference, which progressively became more and more intense until it got completely out of hand, precisely because it had not been recognized and interpreted by the therapist. Another important factor in the analysis was that the patient openly displayed significant aspects of a strong negative transference accompanied by very powerful destructive and sadistic feelings. This, however, concealed the fact that his dangerously destructive aspects were highly split and that there had been an attempt not to reveal them—something in which the analyst was unconsciously colluding. It was very clear from the clinical material, and it is precisely this that I will attempt to demonstrate, that the above factors were responsible for the malignant evolution of the psychosis that took place after the patient had clearly made considerable progress under analysis.

The patient—Bernard, as he is called—is an elder son, with a sister who is four years younger. His American parents went to live in France a year before he was born. His father, a writer and journalist, travels a lot on business and is often away, sometimes for a couple of months at a time. His mother, a rather fragile and infantile woman, does not work. Bernard had previously gone for a consultation with an older psychoanalyst. Bernard says that he came to the clinic because he is unhappy, does not like himself, and feels that he is bad. He would like to purify the world, and he would like to be helped in this. The future frightens him; he is scared of becoming poor and not coping. He fears that he is stupid and that his sister is intelligent. He thinks that the world is mean and nasty to him. One day he leaves a note for his parents: “I hate myself—destroy me.”

He imagines that his parents are going to abandon him; he has hallucinations in which he hears them saying that they are going to abandon him. Bernard says he is very jealous of his sister, but from his mother it is learned that he has never done anything mean to her. He is afraid of cataclysms, and he dreams that he has lost his bearings. On two occasions he draws maps because he likes geography, but then he makes a kind of completely shapeless scribble which he calls the infinite and the eternal. He has a nightmare in which he is attacked by a swarm of bees while his mother tries to protect him.

The conclusion of this consultation is that the boy, aged 11 years at the time, is suffering from depression; also, there is still the problem of an infantile psychosis. It is decided to commence therapy; a psychotherapist is selected for him, to see him three times a week, with the supervision of an older analyst.

The psychotherapist notes that he met the parents together once, and that he agreed that they could meet the supervisor, as they were requesting. According to his report:

“The father struck me as an intellectual, a man rather detached from reality. He is a long way from understanding the seriousness of his son’s condition: for him, Bernard’s problems are down to bilingualism; he considers him extremely intelligent and sometimes encourages him to take part in political discussions with his colleagues. But father and son do not get on well, and the father seems worried, perhaps even hurt and unhappy about this. The mother is young-looking and fragile. She expresses herself with great difficulty in French and starts by talking of the problems that arose after Bernard was born: she acutely felt her inability to speak the language, and the lack of friends and relatives around her was extremely disturbing. She was very anxious and completely disoriented when she left the clinic. She did not know how to look after the child: she looked up books on the topic and fortunately received affectionate help from an American neighbour of hers, a woman of Greek origins.

Her mother had planned to come and stay with her for a few months around the time of the boy’s birth, but she had to cancel the trip due to the unexpected death of a relative. The woman admires her son and protects him a lot.”

In a later meeting, the therapist met Bernard:

“Unlike his parents, he has no accent and expresses himself perfectly in French. He speaks in an unstoppable flood of words, listing all his symptoms, most of which are of an obsessive nature. Every day he bangs his head against a ruler to punish himself. Before crossing the road, he has to count to 12. There are also worrying rituals to avoid poor marks at school, which is one of the main dramas in his life at this time. He is very unhappy and he cries a lot; despite his intelligence, he is not doing well in his studies because he is so disorganized. He sits down and writes political tracts and short stories; he is seeking a style and closely studying his personality; he thinks that therapy might be a rather quick process, because he knows himself so well. Nevertheless, he finds it very tough to fix times for the sessions. My unyielding attitude is of considerable relief to him. I am struck by Bernard’s intelligence and also by his physical restlessness, as well as his need to rationalize everything. One perceives a thousand different things jostling around inside him, a thousand things he desperately tries to control and dominate through a considerable flow of words, which, however, leave little room for a real exchange.”

Observations on the diagnostic interview

It is clear from this account that the mother clearly understands, following the birth of her son, that she does not feel capable of providing him with any security in the initial part of his life. She feels hopelessly lost; she does not know the local language and is overwhelmed by anxiety. His very mother, therefore, feels like a little girl, a little girl abandoned by her own mother who had promised to come and help but could not keep her promise. It really seems that the mother felt that she and her newborn baby were two lost children, until the friendly neighbour came to give them a little help. The child’s birth is obviously very traumatic for the mother, and, we may suppose, for the son too. In this diagnostic interview the patient expresses a fear of being completely lacking in organization, a situation he defines as infinity-eternity. He also recounts the dream that is rather common in psychotic patients of being attacked by a swarm of bees, while his mother tries to protect him.

From these observations one may conclude that the patient is conscious of infantile psychotic anxieties, occurring very early in his personality, and he does not know how to handle them.

Continuation of the therapist’s account

Bernard says that he has come because there is no alternative, but in reality he finds it hard to accept asking anybody for help. In fact, he needs somebody. His refusal to recognize or to experience a dependent relationship or simply his need for help was practically constant throughout therapy. “It really is too humiliating and degrading,” he says. During the positive phase of treating this patient, there is evidence of a psychoanalytic process under way. Nevertheless, the therapist never has the feeling that real internalization takes place. There is still a major risk of the patient’s personality disintegrating; this is confirmed three and a half years later when therapy is broken off. The therapist divides the therapy into four phases. The first lasts roughly a year and a half. There is an atmosphere of violence in the relationship; for the patient, the sessions are a place for expressing his “craziness”—he often says, to reassure the therapist, “Don’t worry, I don’t act as crazy as this out there, but in here I can explode.” For example, he confides that it is his opinion that every fruit has its own personality, an idea to which he subscribes completely. Fruits are actors in his phantasy world: kiwis are like contemptible, sadistic Chinese—they fascinate and scare him; they gang up to attack pineapples, which are weak creatures.

“One day he turns up with a kiwi and asks me to touch it so that I can feel its slightly hairy skin. He feels this need. For me, it is as if I had agreed to touch him. During the sessions he is extremely agitated; he laughs, grimaces, throws chalk and even his school-bag up into the air. On more than one occasion I am forced to protect myself from projectiles. He cannot keep himself under control and he knows it, so he says sorry. He attacks me a great deal with words too.

“He displays a significant paranoid element, and this remains constant. Sometimes even the most positive moments are interpolated with phrases such as, ‘What do you want from me? I don’t want to come any more.’ He feels attacked, threatened, he asks what I do with what he tells me. He thinks I am studying him, examining him to write a book or tell my supervisor. He himself constructs a set of tests to assess his parents and his sister’s intelligence, something he considers to be great fun. He hardly ever speaks about his real life. On the contrary, he invents imaginary countries peopled by extraterrestrial monsters with hooks for limbs.”

Discussion

First, I would like to discuss the structure of the patient’s personality: intellectually he is capable of understanding that he needs to be treated, and yet this need provokes considerable resentment within him. It therefore becomes difficult for him to feel that he must be treated and that he must seek help from somebody. The need to be treated is perceived as being too humiliating and degrading; this narcissistic denial of his need to be treated combines with an attitude of strong paranoid rejection of the analyst, which is expressed in the following manner: “What do you want from me? I don’t want to come any more.” This attitude remains unchanged and is manifestly not analysed at any time during treatment. The patient feels not only not accepted, but also mistreated and exploited by the analyst, who is described as a totally narcissistic personality treating him only for her own ends. It seems possible to link with the projection of his narcissistic organization onto the analyst the fact that the patient feels completely in the hands of a therapist exclusively interested in herself: this is an aspect of the psychotic narcissistic transference. It appears to be vital in this situation to bring more to the surface the patient’s fantasies of omnipotent self-sufficiency, which conceal the infantile structure of a very small and omnipotent child who does not need his mother, and allow him to delude himself into thinking that he can get by on his own perfectly well.

Bernard wishes to prove to himself that he was born without any particular feeling, or difficulty, and to be able to face life without finding himself in the humiliating situation of acknowledging that as a baby and as a boy he needed a mother, and that he has had to face the jealousy deriving from sharing her with another baby, his younger sister.

It is very important to tell such an intelligent boy that it is the voice of his omnipotence within that prompts him to believe that a little baby can do without its mother and be independent and mature. This is obviously an illusion. But if the boy insists on believing what this voice is telling him, he continuously treats himself as being stupid. This is the reason why he feels stupid and why he is concerned with stupidity. It is essential, it follows, to help the boy work through the feeling of stupidity that comes from the absolutely unrealistic claims of his omnipotence. The healthy part of him knows it is unwise to continually follow the suggestions of omnipotence; it is very stupid to do so. Yet Bernard is not strong enough to oppose these continual stupid suggestions. Naturally, if a part of the patient is convinced of the truth of his omnipotent self and what it suggests to him, another part of him understands that it is all evil folly; it is inevitable that great confusion results, sometimes even a total mess, with the result that he feels that he can never know the truth.

Usually, psychotic patients such as this boy feel enormous relief when they begin to understand that there is a conflict between this omnipotent and often completely mad part (which says: “I do not want to be treated, I am perfectly fine and independent.”) and the part that understands that this is madness and that he must learn to stand up to this madness. When, during the course of analysis, he begins to understand this difficulty, at first the patient can admit that there is at least a little truth in what has been pointed out, and he can start to be more honest about this point and acknowledge to himself, not to mention to the analyst, that he is in difficulty with this omnipotent part of himself. Later on, he may recognize that there is no point in continuing to pretend that his omnipotence is always right, as the analyst knows what is going on.

Naturally, this comes a great relief because at this point Bernard wishes to be controlled by the analyst and, if the analyst is helping him with what he knows, he begins to feel that he becomes less stupid and can think with greater clarity. This evolution in the transference relationship is of prime importance because the boy becomes less diffident, much more inclined to listen to the analyst; what emerges is a patient who truly wants to collaborate with the analyst.

It is also important to understand that the humiliation and degradation that are crushing the patient derive essentially from the part of him that is suffering the delirium of omnipotence, that tells him he knows everything and can do everything and therefore does not need to depend on anyone. This is why the omnipotent part of the patient feels humiliated and insulted by everything—situations and people alike—and contradicts his omnipotent assertion that he has always been able to look after himself since his earliest infant days. This part of the patient does not know what it means to learn or take something inside oneself for the purpose of growing. The omnipotence stands in the way of a process of introjection, which would weaken the self-sufficiency thesis. Therefore, a patient dominated by an omnipotent self is not capable of introjection. In describing how analysis proceeds, the analyst shows understanding that the patient is not capable of introjection, but perhaps does not understand the root of this problem, which only becomes clear when the strength of the omnipotent narcissistic structure begins to decline as a result of detailed analysis. The omnipotent structure is also responsible for constructing a false self, given that it has nothing to do with the real process of growth, which takes place when a child grows thanks to a relationship of dependency with an understanding and sensitive mother. Humiliation, degradation, and the idea of going back to infancy also crop up when the narcissistic omnipotence is projected onto the analyst and the patient feels that the dependent and healthy part of himself is incessantly denigrated by the omnipotent parts of his self, which have taken the place of the analyst. But there is also a chance that a real omnipotent adult has produced the same effect on the patient. Naturally, it is very important to distinguish between the patient’s own omnipotence, and the omnipotence of past and present figures, just as it is essential for the analyst not to feel omnipotent and not to act in an omnipotent manner. This is not, however, the case here. It would obviously be silly of the analyst to address an omnipotent patient, who in reality is only an omnipotent child, as if he were an adult: this would only greatly augment his omnipotence. But the omnipotent self cannot be ignored—it too has the right to be helped in analysis, although so very easily it can feel wounded and rejected. It is therefore important, as early as possible, to make the patient aware of the struggle between the part of himself that is rather infantile, closer to the conscious, more inclined to dependency, more realistic, and, therefore, healthy and the omnipotent psychotic aspects of his personality.

If, in the analyst’s position, you feel that all of the different elements of the patient tend to establish a relationship with you, then you can show this to him, and little by little he will feel more secure and better accepted. When the omnipotent part of the patient says to the analyst, “I do not want to be treated,” a possible answer is, “Probably you feel you don’t need to be here, you feel that you know everything and want to stay as you are. But I have noticed that another part of you feels differently; it is this part that perhaps wants something from me, and we must see if it feels free to speak to me.”

It cannot be said that there are hard and fast rules for practically handling this kind of situation, but the analyst should grasp every opportunity to maintain a balance. I’d like to remind you that when the patient said he wasn’t going to come any more, and expressed the idea that the analyst was studying him and perhaps was going to write a book about him, he was working out a set of tests to measure the intelligence of his parents and sister, something he enjoyed enormously. I consider this to be an absolutely certain indication of the fact that he was continually measuring the analyst’s intelligence and the analyst’s ability to understand, using a secret method; this enabled him to feel greatly superior to the analyst and seemed to make her ridiculous. But I am also certain that he was afraid that the analyst would notice and take retaliatory measures. It would have been very important to interpret this situation, for these omnipotent fantasies encompass an intrusion into the analyst for the purpose of belittling her and looking down on her; on the other hand, there is a great fear of talking to the analyst about real flaws, which he may have noted in her way of proceeding. Naturally, many elements of the transference situation were not sufficiently clarified by the analyst.

Continuation of the analyst’s exposition

The analyst continues:

“In the last session before the holidays the patient wants to break everything, for example the telephone-socket connector; he imagines that he is in a satellite which is bombing and destroying galaxies, represented by the walls and ceiling. I tell him that the room represents me and my body, which he prefers to destroy, destroying both of us, rather than tolerating a separation, even if it is a temporary one. In spite of the extreme violence of certain sessions, I am never afraid, nor do I feel that the situation is getting out of hand. The following winter continues much as before. Bernard is fascinated b...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface to the English Edition
• Foreword
• Preface to the Italian Edition
• Introduction
• Part I Theoretical seminars
• Part II Clinical seminars
• References
• Index