Catch Them Before They Fall: The Psychoanalysis of Breakdown

Christopher Bollas

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781135087302
• Edition: 1
• Topic: Psychology
• Subtopic: Psychoanalysis
• Index: Psychology

In this exploration of a radical approach to the psychoanalytical treatment of people on the verge of mental breakdown, Christopher Bollas offers a new and courageous clinical paradigm.

He suggests that the unconscious purpose of breakdown is to present the self to the other for transformative understanding; to have its core distress met and understood directly. If caught in time, a breakdown can become a breakthrough. It is an event imbued with the most profound personal significance, but it requires deep understanding if its meaning is to be released to its transformative potential.

Bollas believes that hospitalization, intensive medication and CBT/DBT all negate this opportunity, and he proposes that many of these patients should instead be offered extended, intensive psychoanalysis.

This book will be of interest to clinicians who find that, with patients on the verge of breakdown, conventional psychoanalytical work is insufficient to meet the emerging crisis. However, Bollas's challenging proposal will provoke many questions and in the final section of the book some of these are raised by Sacha Bollas and presented in a question-and-answer form.

Broken selves

DOI: 10.4324/9780203069547-1

Psychiatrists, psychoanalysts, psychologists and those working in the field of mental health have developed nomenclature over the decades that identifies people according to types of disorder. Even though there is pressure to adopt one manual across all the professions—DSM IV or V—psychoanalysis has its own classical diagnoses: hysterical, obsessional, schizoid, depressive, and so forth.

The underlying assumption is that a person can be fundamentally defined according to a particular character type; that they have always been this way, their psychodevelopmental fate determined by a combination of innate mental structure and those axioms developed during early life. And for many people, this is true. However, analysts often find that once they get to know the patient the initial diagnosis of hysteria or schizoid disorder seems to be of limited value. As the analysis proceeds, with the intrinsic therapeutic efficacy of the analytical process, a single disorder becomes a complex psychodynamic picture. It was Wilhelm Reich who argued that character disorders were like frozen psychodynamic puzzles that, when analysed, would reanimate. The character armour established by the person would dissolve under intense psychoanalytical interpretation.

In other words, if a person has formed his character gradually, over a long time, then through analysis his defences and character positions can be analysed and transformed. It is not a question of miracles. It is long, difficult work which may result in varying degrees of success – and failure.

Not until recently, have I realized that in my own practice I have missed something rather obvious. Sometimes when I see a new patient present as, for example, schizoid or depressed, what I am actually noticing is that something seems to have happened to that person; they seem to be a broken self. By ‘broken self’ I am not referring to a specific diagnosis, nor am I suggesting a new category of pathology. The term is intended to apply to a broad spectrum of people, including those whom we would call ‘normal’. The only common denominator between them is that they have had a breakdown, often in early adulthood, during which they were left without adequate therapeutic care. Whatever the travails of their childhood, or the inherent weaknesses of their ego or their mental structures, it is this breakdown in adult life that has left a distinguishing scar upon their being.

I came to discover in what ways these people differed from those with traditional character disorders as I supervised many cases in different parts of the world. People who have previously suffered a breakdown—that may have been predisposed because of schizoid, depressive, hysteric, or obsessional patterns—present a greater challenge than usual to clinicians.

Over time it seemed to me that certain patients, typically arriving for therapy in their thirties or forties, could not respond to analytical therapy (or anything else) because they had simply given up on life. They were without the sort of organized Mafia gangs within the self, described so astutely by Rosenfeld; they had no such edge to them.¹ Therapists would describe working for years with such people, to no end other than occasional expressions of gratitude. For the most part the patients were functioning way below their capacities, often intermittently unemployed or in positions substantially below the level suggested by their academic achievements. The analyst or therapist usually presented the person for supervision because it was a matter of despair for them in the countertransference. They saw nothing efficacious taking place and questioned whether there was any point in continuing the work.

Gradually I came to see that there was a pattern to be found amongst these people: a great many of them had suffered previously from non-psychotic breakdowns.

Some of these can be precipitated by external trauma. The breakdown might occur at university, going unnoticed in the shuffle of agitated circumstances that come with life in that environment. Or, after graduation when a person would expect to enter the workforce there might be a series of rejections and, after a struggle to keep pushing forward with life, a collapse. Or perhaps a relationship that had endured during student years ends suddenly, leaving the individual abandoned, bereft and unable to recover from the loss. Or maybe a parent, sibling, or close friend dies, leading to a catastrophic grief.

More often than not, however, the precipitating event is something so subtle and seemingly innocuous—a credit card being declined, a parking ticket, an unkind comment by a stranger—that only through analysing the unconscious meaning of the event can its toxic effect be understood.

Whatever causes the onset of the crisis, those in attendance fail to meet the person’s needs adequately during the breakdown. If the person is in therapy they may be unable to afford an increase in sessions, or the anxious therapist might refer them immediately for medication, anxiety management or group therapy. All too often this is followed by a period of hospitalization as the patient’s crisis deepens.

At this point the breakdown becomes structuralized. The personality reforms itself around the effects of breakdown, reordering the self in order to function and survive under significantly reduced circumstances. This heralds a meagre future existence.

This restructuring of mental life means that axioms by which the person has lived are altered. With a mental breakdown of this kind there is a shattering of one of the core assumptions instilled by a good-enough childhood; that when we are in need we will receive help. Various new assumptions take its place: A broken person is characteristically indifferent to their life. They are passive and resigned to their situation. In that they have decathected from their object world one might think of them as aligned with the death drive, but they lack the force of hate, envy, denigration or cynicism that is so often seen in characters that inhabit the hell of the death instinct. Their indifference may be accompanied by unrealistic plans—writing a novel, becoming an entrepreneur—but no actions are taken towards accomplishment in their field of dreams. Instead, these plans function as projections of the broken self: broken dreams that exemplify the impossibility of success.

It’s best not to seek help from any other.

If I am vulnerable, I must kill off feelings.

Only a fallback position can be safe.

I must disinvest in the object world and abandon a relation to reality.

I will give up on ambitions, plans, hopes and desires.

I must find people who are in a similar situation and live within a new society of fellow broken selves.

The broken person’s affect is significantly reduced. They rarely show emotion and are not driven to anger, anxiety or euphoria by events in life. Instead, they maintain a steady remove from affective shifts; nothing is worth the effort.

They may identify with celebrities that they see as having fallen on hard times owing to some negatively transformative event in their life. Such interest is significant as it stands out in a mentality otherwise uninterested either in politics, cultural affairs or environmental issues, or in diet, physical fitness or anything to do with the self’s health. The fallen celebrity seems to be a reflection of the person’s own catastrophe.

They do, however, have a hidden ideal self. It lives on in the unrealistic dreams of success, but it also functions as a defensive imaginary companion, as if the person is trying to hold on to aspects of the self that existed before the breakdown. Winnicott might suggest that the false self is protecting a remnant of the true self. I think this hidden self is a ghost; a sad representative of what the person had thought they could become. Psychotherapists and analysts working with someone who is broken can feel annoyed by this object relation to the ideal self, with its unrealistic, grandiose expectations. Occasional impulses towards achievement— purchasing a book on writing a novel, or surfing the Internet in search of business ideas—are never pursued for long. And it is important to note that such dreams are not accompanied by enthusiasm, but are stated as if they can be realized easily.

When the therapist makes an interpretation there are various typical responses. Often the patient does not reply, is silent for a while, and then continues to talk as if nothing has been said. If confronted they may reply with ‘I don’t know’ or ‘maybe’, showing little evidence of introspection. Instead, they perseverate about someone at work who is asking too much of them, or recount how they are planning a holiday but are unsure where to go. They radiate a low-level mental pain, a quiet depressive despair, but show no interest in what this might mean. It is purely evacuative.

Although the patient remains detached in many respects from their therapist they adhere to ‘the therapy’ or ‘the analysis’. I have come to understand this as a fear that they will have another breakdown and, therefore, need to be connected to a therapist as an insurance policy against future trauma. These patients form a kind of neutral transference to the clinician, one that expresses their negative restructuralization, and analysts feel that they are treading water and getting nowhere.

Almost all clinicians with whom I have discussed these people argue that this is a form of attachment to a non-human other, and they will reach for terms like ‘autistic enclave’ or ‘Asperger’s’ or ‘psychic retreat.’ I suspect that the increasing prevalence of the diagnosis of ‘mild Asperger’s’ may include some people who acquired these characteristics only after a breakdown that reshaped the self’s mental structure.

A common reason why breakdown results in a broken self is the use of psychotropic intervention. Although such medication may help relieve the person in the immediate situation, the ingestion of such drugs negates meaning. Discovery of the unconscious reason for the breakdown, and the opportunity for sentient understanding and tolerance of it within a human and therapeutic situation, are denied to the person. The patient may visit the doctor for repeat prescriptions, they may see a psychiatrist briefly every few weeks, but all this does is to seal over the structuralized breakdown and unwittingly ensure its permanence.

Many ‘serial patients’—people who continually seek different forms of therapy—bear the scars of breakdown throughout their lifespan. They may appear as depressed, with relational difficulties, problems with motivation and a generally lacklustre interest in cultural object use. When they present to their therapists they often have a deep conviction that it is too late to gain help, or they may make unrealistic demands that therapy work right away, their subsequent disappointment causing them to abandon the treatment, or to move from one therapist to another, in which case the scars of breakdown are projected into the abandoned clinicians, who are given an intense experience of being dropped by the other, left to get on with life bearing a wound within the self.

When I realized how many people fell into the category of broken selves I wondered if and when this had occurred in my own practice. Several people came to mind.

Tim had come to a clinic where I worked following a break-up with his girlfriend. He was desolate and in deep trouble, and had been on sick leave for several weeks. Still, he was a highly cooperative patient who entrusted me with his feelings and his existential crisis, and we had reason to believe that he would emerge from his breakdown. I had the opportunity to increase his sessions, which I did not do, and indeed I left the clinic about a year after we began our work. I learned later from colleagues that he continued to attend for a few months after I moved on, and then he left.

Seven years later, I received a phone call out of the blue. Tim wanted to visit me. He did not want to resume therapy; he simply wanted to meet up. The man I encountered was a broken human being. Although he had a job and was in a tenuous relationship with a woman, the signs of life I had seen in him years before were all gone.

I think too of Lila, a woman in her early thirties who came to me for five-times-a-week analysis. I saw her for four years before she moved to another country. I have etched in my memory a period of several months in the second year of her analysis. Ordinarily an articulate and reflective woman, now she was unusually agitated, and could not gather her inner experiences into speech. I knew she was in difficulty but I stuck to our pattern of five-times-a-week analysis. I have little doubt now that a breakdown was taking place and that, had I offered her additional sessions, she might have been reached and her life changed. At that time it simply did not occur to me.

By the early 1980s, however, I was determined to change my practice in working with people on the verge of breakdown. I did not consciously connect this to work with Tim or Lila or other previous patients, but unconsciously I must have been aware that I had failed them, and that something else was needed.

Signs of breakdown

DOI: 10.4324/9780203069547-2

Psychoanalytical work has as much to do with how the analyst receives the analysand as with what they say to them.

If the analyst has worked with a patient for a year or more they will have begun to internalize their character form. It is hard to define this, but think of how after listening, over some time, to the music of a particular composer we begin to feel within ourselves the shape of their musical personality. Our unconscious receives, organizes and recognizes patterns, and these patterns constitute the form that any content may take, whether it be a musical idea, expressed in the pattern of a particular harmonic and melodic idiom, or a poet’s idea taking form in the rhythm of their characteristic syntax that shapes the sequence of images.

Psychoanalysts are trained to be ‘impressionable’; a term Freud used many times to describe the way the analyst registers the analysand. They allow a person’s way of being and of relating to affect them. They need to be as open to this as possible and even though they may begin to notice patterns early on, they should suspend early judgements in order to continue to be open to the form of a person’s character.

When the analyst’s unconscious communicates to the patient’s unconscious that the other is open in this way to character communication, the patient will become more expressive, often more difficult, certainly more specific in the release of personal idioms of being and relating, and over time, the psychoanalyst will begin to feel the shape of the patient within themself. Just as we can conjure the feel of Mozart within our consciousness, even when we are not listening to his music, we know the feel of the many impressions created by the impact of the patient.

The sort of receptiveness assumed here is, however, not characteristic either of psychoanalysts who regard it as mandatory to be constantly interpreting the transference in the here-and-now, or of those who enter into a dialogue with the analysand, offering the analyst’s personal response to what has been said. Both these approaches offer a very different type of analysis from that based on neoclassical principles, and I want to emphasize that understanding this book, and certainly contemplating using the ideas presented here, will be highly problematic for clinicians who work in either of these two ways.

That is not to say that analysts working within those traditions do not have strategies for working with patients in breakdown, but my own work, within the Freudian tradition, operates from the crucial assumption that the analyst must be quiet and recessive for long periods of time, in order that the analysand’s free associations and character moves are offered ample freedom to articulate themselves. If psychoanalysts are actively interventionist then these associations will not establish their patterns of meaning, and the person’s character will be absorbed by the analyst’s construction of the transference, as the selected object of focus.

Within the context of Neo-Freudian classicism, the psychoanalyst engages in a negative capability; they suspend their own views and immediate responses, in order to facilitate the incremental establishment of the analysand’s idiom of being. Within this interformal context, if the analysand unconsciously introduces a nuanced difference from their idiom of being it will be registered by the analyst.¹ This registration will be subliminal to begin with, but as it repeats itself over time the difference will assert itself as a pattern, and this will raise a certain signal anxiety in the analyst, rather as though a snippet of Brahms were to appear in the middle of a Mozart sonata.

Let us move on now to think about the forms of breakdown with which the psychoanalyst may be confronted. To oversimplify somewhat, there are two fundamentally differ...

Table of contents

• Cover
• Halftitle Page
• Title Page
• Copyright Page
• Contents
• Introduction
• 1 Broken selves
• 2 Signs of breakdown
• 3 The guidelines
• 4 Emily
• 5 Anna
• 6 Mark
• 7 Histories and the après-coup
• 8 Time
• 9 Emotional experience
• 10 Reflection, explanation and working through
• 11 Psychic change
• 12 Conclusion
• 13 Questions
• Notes
• Bibliography
• Index