This paper was originally addressed to a convention of independent group members of the British Psychoanalytical Society who had gathered to consider whether common, theoretical and technical issues shape, or contribute to, an independent group identity. I shall be describing some aspects of my understanding of psychotic patients, and some of the techniques I have utilised in working with them.
An interesting question could then be: were people in this original audience more likely to agree with my comments, share my views and understanding, likely to be using my techniques, or feeling that they want to use them, than if the audience were comprised of members of either of the other two societies (the Kleinians and the Contemporary Freudians)? And if so, what common theoretical or technical view points are members of the independent group sharing with me to make it more likely that my comments will resonate within this group, when compared with members in the other two groups?
My own supposition is that there are these common issues. My clinical work has been significantly influenced by the work of Balint, Winnicott, and Klein, and I believe this is probably more true of the majority of members of the independent group than in the other two groups. The reader may want to consider these matters once he or she has read a little of how I go about things with psychotic patients.
Paul Williams, in his paper on psychotic developments in a sexually abused borderline patient, presented an excellent portrayal of the treatment of a severely disturbed female patient, in which, for long periods of time, he was confronted with the problems of an analysis of a state of mind in which the psychotic part of the personality was in the ascendancy over the non-psychotic. The patient had created a dissociated, projected, delusional pseudo-object to govern her thoughts and actions as a protection against the panic of confusion, fragmentation, and annihilation. Here I comment on my experiences with similar patients who were not so much borderline as psychotic, in which the same types of problems apply but to a different degree.
For these patients, I have found it necessary to have them in analysis four or five times a week and to maintain a firm setting in order to hold and contain them. The maintenance of boundaries and limits represents a crucial aspect of treatment. The analysis is particularly of the here-and-now of the transference and occasionally of the there-and-then, when the relevant past is known. This is more easily said than done, because the hating of both external and internal reality together with the denial of its recognition makes secondary process or sane thought extremely difficult. In these patients, there are delusional objects that may be dissociated and projected and experienced as coming from external sources, or that may be internalised and experienced as different personalities. For example, a patient of mine knew he was God or Moses or even an ancient rock in the desert. These delusional...