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On understanding projective identification in the treatment of psychotic states of mind: The publishing cohort of H. Rosenfeld, H. Segal and W. Bion (1946–1957)

2009; Taylor & Francis; Volume: 90; Issue: 1 Linguagem: Inglês

10.1111/j.1745-8315.2008.00115.x

1745-8315

Joseph Aguayo,

Mental Health and Psychiatry

Abstract A publishing cohort of Kleinian analysts – Rosenfeld, Segal and Bion – implemented Klein's (1946) notions of projective identification and the 'paranoid ' and 'schizoid ' positions in the understanding of a group of psychotic disorders. The author differentiates Klein's (1946)Notes on some schizoid mechanisms paper from its revised version of 1952, maintaining that it was Rosenfeld's clinical work during this period that helped to centralize Klein's redefinition of projective identification. The stage was set for Segal 's contribution in terms of 'symbolic equations,' where the psychotic's attack on the breast left him incarcerated in internal torment and persecution, where things‐in‐themselves were confused with what they symbolically represented. Segal in turn linked psychotic to normal, paranoid–schizoid to depressive positions, where by means of projective identification and symbolic imagination, the patient could arouse feelings in the analyst related to sadness, guilt and loss. Bion assumed that psychotic pathology reflected disordered thinking, when the severely disturbed used language as a mode of action. The psychotic was profoundly confused between the use of thought and action in the natural world – where thought was required, he preferred action and vice versa. Bion also drew upon projective identification in a new, broader way, so that analysis could now become more of an intersubjective, bi‐directional field of projective and communicational influence between patient and analyst. The paper concludes with the impact of the work of Rosenfeld, Segal and Bion and variations on the technique of analyzing psychotic states in terms of the patient's early history, transference and countertransference.Key words: countertransferencehistory of psychoanalysispsychoanalytic techniquepsychosisreconstructionresearch AcknowledgmentsAn earlier version of this paper was delivered at the 'Hanna Segal Today' Conference at University College London on 1 December 2007 (Mary Target, Chair). The author also here gratefully acknowledges the support of the International Psychoanalytical Association's Research Advisory Board – through its fellowships granted in the area of the history of psychoanalysis, a number of publications (Aguayo, 1997, 2000, 2002, 2008; Spielman, 2006) as well as research trips to the Melanie Klein Archives housed at the Wellcome Institute in London and to the archives of the British Psycho‐Analytical Society have been made possible. The author also recognizes the helpful support of a number of colleagues: Robert Hinshelwood, Riccardo Steiner, Robert Westman, James Grotstein and Jon Tabakin. The responsibility for the final paper is, of course, the author's own.Notes1. Both Rosenfeld (1952b, p. 457) and Segal (1950, p. 275) directly referred to Freud's bleak view of the analyzability of the psychotic disorders. While Klein's (1946) paper certainly hypothesized that psychotic patients could form a treatable transference in analysis, she also emphasized in the Appendix to her 1946 paper how continuous her work was with Freud's and in many ways agreed with his analysis of the paranoid Dr Schreber (Klein, 1946, pp. 108–10) This continuity was also a remnant of the era of the Controversial Discussions (1941–44), during which time she took pains to show how her work was completely consistent – indeed, extended from that of Freud (Steiner, 2000, p. 73). Klein's (1946) paper, however, left it open to her students to provide case material that might justify her claims to have made an innovative contribution to the treatment of the psychoses. Their effort also addressed a central ambiguity of Freud's (1911) analysis of Schreber: how could Freud explicate the unconscious dynamics of paranoid psychosis yet maintain that these types of cases were psychoanalytically untreatable?2. I have briefly set out the importance of a textual analysis of Klein's two versions of the Notes on some schizoid mechanisms paper in a Letter to the Editors (Aguayo, 2008). In contrast to other works in this area (e.g. Goretti, 2007), one clear implication of comparing these texts is that they allow us to measure how far the Kleinian analysis of psychotic states had come between 1946 and 1952. It is also a reflection of how the work of the Klein group had become consolidated during the post‐war period into a school of thought, complete with its own specific terminology and celebrated in a 1952 issue of the International Journal of Psychoanalysis (1952,33, part 2). This entire issue was dedicated to a consideration of Klein's work on the occasion of her 70th birthday – and included a congratulatory Preface from Ernest Jones (ibid., p. 83). It is also significant that the editor during those years (1947–1959) of the Journal (Willi Hoffer, a Freudian) was assisted by Marjorie Brierley (an Independent) and W.C.M. Scott (a Kleinian), which also represented the three recently established training tracks at the British Psycho‐Analytical Society.3. I think that it was also during this early period that the term 'Kleinian' also originated. From the slightly pejorative use of the term 'Kleinist' by Winnicott, he seemed to differentiate the creative work of Melanie Klein from what he thought of as the relatively moribund language employed by some of her followers during that time. Acting on his freedom to state his analytic findings in a language of his own, he wrote a letter to Klein on 17 November 1952: "I personally think that it is very important that your work be restated by people discovering in their own way and presenting what they discover in their own language & If you make the stipulation that in the future only your language shall be used for the statement of other people's discoveries then the language becomes a dead language, as it has already become in the Society. You would be surprised at the sighs and groans that accompany every restatement of the internal object clichés by what I am going to call Kleinians" (Rodman, 1987, p. 34; also Rodman, 2003, p. 176).4. In Notes on some schizoid mechanisms, Klein (1946) wrote about her own treatment experience with both a manic‐depressive patient (ibid., p. 106) and a schizoid patient (ibid., p. 107). She had of course treated a childhood schizophrenic earlier on (Klein, 1930).5. During this time when the London Klein group treated psychotically‐disturbed patients, it is important to bear in mind the broad diagnostic distinctions within which they worked. Their diagnostic categories were in effect 'psychotic' versus 'non‐psychotic' (Bion, 1957), and did not include the diagnoses that would be of greater interest to subsequent generations of practitioners – the so‐called borderline, narcissistic and sexually perverse disorders. While the post‐war Kleinians treated and subsequently theorized about their work with briefly hospitalized schizophrenics and non‐hospitalized schizoid and paranoid disorders, their findings and conceptual methods have been more usefully applied to patients with near‐psychotic or borderline/narcissistic diagnoses. The Klein group also did not subsequently provide much by way of follow‐up data to substantiate enduring treatment changes in the patients seen. In this sense, their overall findings are broadly comparable to those of the American Interpersonal School: H.S. Sullivan. F. Fromm‐Reichmann and H. Searles also treated hospitalized schizophrenics, but also found that their long‐term results were more beneficial to those less disturbed than chronically hospitalized, poor pre‐morbid schizophrenics. One broad measure of this change can be seen in the shift by analysts such as Searles, who moved from working with hospitalized chronic schizophrenics (Searles, 1965) to patients with borderline conditions (Searles, 1986). Needless to say, the Klein group also did not factor into the treatment or explanatory equation the effect of psychiatric medication, another variable that would take on greater significance amongst subsequent generations of psychiatric and psychoanalytic practitioners.6. A brief clinical illustration: in Rosenfeld's (1947) treatment of 'Mildred,' who was depersonalized, withdrawn and paranoid, she manifested confusional states, phantasizing being kept prisoner in a dungeon by a devil. In a paranoid psychotic transference, she concretely thought her analyst needed to keep her captive, forcing her to think his way to the point of no longer knowing what she herself thought. In Rosenfeld's (1947, p. 134) words, "& the central anxiety was a phantasy of the persecuting analyst forcing himself into her to control her and rob her, not only of her inner possessions, for instance, her babies and her feelings, but her very self." For a time, she warded off persecutory fears that rendered him not only invasive, but attacking and controlling as well. When reminded of her "& sadistic envious attacks of the devil who in her phantasy, always attacked the good objects &", it then became easier to demonstrate that she herself behaved like a sadistic devil: it was in fact the patient's own denied intrusive attacks that were levied against the analyst as a productive, envied and admired mother (ibid., p. 135).In Riccardo Steiner's (2008) analysis of this case, he also emphasized an erotized aspect of her delusional paranoid transference, but at a primitive, part‐object level, reflecting a concreteness of functioning rather than a whole object, genital–oedipal conflict. Because of this concreteness, she often misheard the analyst's interpretations as an invitation to act, a seductiveness that frightened her and sometimes caused her to miss her sessions.7. When the names of these contributors are added to existing footnotes, which included the work of D.W. Winnicott and M.G. Evans, there is only one exception, W.D. Fairbairn, who was not a close collaborator of Mrs. Klein. This coterie of colleagues is vividly represented in photographic form – as all the above‐mentioned analysts were present at a dinner party celebrating Melanie Klein's 70th birthday on 30 March 1952 at Kettner's Restaurant in London (Grosskurth, 1986, photograph between p. 372 and p. 373; also, cf. p. 392).8. R. Steiner (2007, p. 242) has pointed out that Hanna Segal (1950) in her initial paper on the treatment of a schizophrenic did not use the term 'projective identification.' I agree with his conjecture that Segal did not use this term because Klein was still working out its definition. On the other hand, Rosenfeld did develop and expand the definition of projective identification, but also emphasized the 'quantity of the self' invested in its use, thus leading to the forcefully violent manner in which the psychotic patient projected into his objects. In 1952, Rosenfeld noted en passantSegal's (1950) initial use of symbolic equation and, in R. Steiner's words, "Rosenfeld stressed that the capacity to form symbols was very present in his patients, and also temporarily lost, due to the violence of the projective identification" (Steiner, 2007, pp. 242–3). In different words, the forcefully violent projections that resulted in the patient's fragmentation and splitting were fundamental, in Rosenfeld's view, to why the psychotic patient fell into symbolic equations and could not often rise above concrete thinking.9. In his reconsideration of countertransference, I conjecture that Bion also had in mind his 1950 membership paper for the British Society and his new view made it possible to publish it later on as the first paper in a collection of papers from this period (Bion, 1950). In effect, Bion's 1950 case of a middle‐aged schoolteacher who had lived an unacknowledged 'pretend' existence in and out of analysis had unwittingly created a fetid and stale atmosphere in his analysis. It was only with Bion's belated understanding of the existence of the patient's 'counterfeit' self that helped to enliven the analysis. Yet it was based on his comprehending a maddening psychic quadrille, where there was a stale‐making potential for meaninglessness at the juncture where the pseudo‐patient encountered a pseudo‐analyst. This folie à deux finally became clear to the analyst: he was in fact experienced by his patient as an 'imaginary twin.' In different terms, I think Bion recognized the importance of the patient's role as an unreliable and self‐subverting narrator. Once this was understood, Bion could in turn grasp more clearly his own unconscious collusion with the patient, thus giving impetus to the importance of the active consideration of the countertransference later on. It was from this countertransferential web that the analyst had to extricate himself. By 1955, Bion came to the fuller realization of the broader importance of the countertransference, and he indicated as such in a much revised version of his 1952 paper on Group dynamics (Bion, 1952): "The experience of countertransference appears to me to have quite a distinct quality that should enable the analyst to differentiate the occasion when he is the object of a projective identification from the occasion when he is not. The analyst feels he is being manipulated so as to be playing a part, no matter how difficult to recognize, in someone else's phantasy" (Bion, 1955b, p. 446).