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Herbert Rosenfeld at Work

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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.

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

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I have 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.

 

2. The relationship between psychosomatic symptoms and latent psychotic states

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Such has been the boom in literature on psychosomatic illnesses that it is impossible to summarize it, let alone even read everything that has been written on the subject. A number of authors have attempted to describe specific psychic conflicts or specific character structures for each individual psychosomatic illness (Franz Alexander and Flanders Dunbar). Others, such as Felix Deutsch and Adolph Meyer, posit the existence of strong interactions between body and mind in all psychosomatic conditions. There are also those who highlight that multiple factors underlie psychosomatic illness, including genetic factors, the existence of traumas at an early age, inability to resolve a situation through behaviour, symbolic representation and even psychosis. The ideative level can lead to a direct physiological expression manifested via the autonomous nervous system. In 1964 I hypothesized that mental conflict, especially early con-fusional conditions (which are particularly intolerable for the infantile ego), tend to be split and projected, evacuated into the body or internal organs, in such a fashion as to cause hypochondria or psychosomatic illness, or sometimes a combination of the two. Given that there are many factors capable of bringing about a psychosomatic illness, only a detailed analytic inquiry into the specific psychosomatic problem can clear up what has caused the psychosomasis in an individual.

 

3. Communication problems between patient and analyst in psychotic and borderline patients

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The analyst’s ability to support the analytic role greatly depends on understanding patient communications. During the course of his analytic training, the analyst gradually learns to observe the way in which the vast majority of neurotic patients communicate, the way they speak, and their emotional tones of voice, in order to grasp the patient’s emotions and relative defences; narrative style and non-verbal communication also offer precious pointers.

Psychotic and borderline patients require a particularly attentive study of forms of communication. Here, I shall attempt to illustrate some of the phenomena that often considerably impede progress of analysis and can cause its failure. For example, it is likely that manifestations of transference psychosis, which so often hinders the treatment of borderline patients, are due not just to a lack of comprehension, but also to a growing misunderstanding between patient and analyst. One of the most significant causes of incomprehension lies in the difficulty of picking up on non-verbal communication contemporaneous with verbal communication: the two may contradict or complement one another. In parallel, the patient may pick up on non-verbal features of the analyst’s communicative style, which can actually alter or twist what the analyst consciously intends to communicate. A number of insufficient communication issues between patient and analyst have been studied and described in detail by Robert Langs and others.

 

4. The analyst’s use of phantasy

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On the issue of the analyst’s use of phantasy in the treatment of narcissistic, borderline, or psychotic patients, I would like to refer firstly to the work of Pierce Clark, then subsequently to the work of Donald Meltzer. Twenty-five years ago, Pierce Clark (1933) described the way he treats these particularly serious cases. The analyst actively encouraged patients to express not just free association, but their fantasies, and in this way almost succeeded in stimulating their imaginative activities. This therapeutic procedure was subsequently abandoned because the analyst did not consider it to be of use. In fact, it should be noted that even when encouraged or prompted to verbalize their fantasies, patients did not succeed in doing so, precisely because their ability to fantasize was inhibited. The problem, indeed, is not so much understanding the patient’s fantasies, but rather why their fantasies are not florid and vivid, why they are so inhibited. What emerged from the collusion of these two people who agreed to produce fantasies was of dubious worth because the problem was the greater or less degree of inhibition of fantastical activity. In parallel with this later, abandoned therapeutic approach, Clark developed his own theory of psychotic disturbances, a theory that took for granted faults in primary mothering, a deficit of availability by the original maternal object. It was therefore a matter of giving the patient everything he/she wanted, to counter the lack of affection during the earliest period of life, with the consequence that an artificial and false environment was created in which the patient was treated like a spoilt, little baby. The hope was that by compensating in this manner, the initial painful frustration would disappear. This approach was also abandoned because it did not prove to be effective; Clark’s attempts did not meet with success, and a number of psychotic patients treated this way did not demonstrate any changes at all.

 

5. Traumatic infancy

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In this supervision, Rosenfeld highlights how the past can mould the present, how it may be deformed by memory or, on the contrary, how it may manifest itself in order to be understood.

Infantile traumatic experiences may in reality be used victim-istically as a defence against insight, or they may be communicated and relived in the analytic relationship in order to be transformed. The analyst’s taking on of the patients past, when it is manifestly traumatic, helps to configure the developmental blockage, the distortion of development, and the patient’s difficulties, which will certainly make the analytic relationship difficult and distressful. The presentation of traumatic infancy described in this seminar is something that Rosenfeld takes very seriously.

The session material here certainly sheds light on the analyst, but it also tells the story of the past. This emerges in part in the content and atmosphere of the first dream; the present and the analytic relationship are the locus in which the basic supportive objects and emotional experiences lacking in infancy emerge only to rapidly decay, giving the analyst a perception of a frustrating and tantalizing working situation.

 

6. Transference in psychosis

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The following case was presented to Herbert Rosenfeld in Milan by a psychoanalyst in 1982 and again in 1983. We have chosen to publish the 1983 seminar because it is so full of comment illustrating Rosenfeld’s contribution to the psychoanalytic theory of psychosis and the theory of technique.

The case history regards a young woman who has her first psychotic breakdown during the consultation interviews, at the end of which her analysis begins.

Rosenfeld comments on the evolution of the analytic relationship, He focuses on the patient’s changing perception of the analyst, and he distinguishes between various types of projective identification.

He highlights the importance of showing the patient healthy aspects and areas of functioning, which can contribute to the analytic process, and counsels against an all-absorbing concentration on transference: the analyst must distinguish the transference relationship from other relationships that exist in the patient’s inner world. This is all the more important with psychotic patients, who might misunderstand transference-related interpretations.

 

7. Persecutory anxiety

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The patient presented in this seminar initially appears to be a mysterious geometric object During the course of the presentation the patient frees himself from the nebulous atmosphere in which he has enveloped himself to reveal a way of mental functioning that may be understood, reached, and touched. But being touched can represent a danger, a source of persecution. Rosenfeld shows how one may handle this delicate situation in such a way as to access the relationship. This requires great wisdom and the ability to wait: wait for the patient to perceive the value that the analyst figure takes on for him and, above all, wait for the patient to achieve the ability to keep things together when he connects with his emotions and with people, moving away from his world of geometric figures.

This case presents additional interest in its illustration of the difficulties of tackling the particular depressive anxiety that emerges from analytic insight, associated with the painful and intolerable perception of how much life has been wasted in the psychotic state. Drawing upon prophetic words from Pirandello’s Henry IV, the patient describes this pervasive anxiety in a touching manner; this is something that often appears during the course of improvement in the analysis of psychotic cases.

 

8. A primitive psychic structure

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What is interesting about this seminar is the attempt to put the patient’s complex personality structure into focus; an attempt to understand the difficulties of handling a particular analytic relationship.

In this case, Rosenfeld refers to a psychic structure that though highly primitive must not be confused with an infantile structure, something with which we psychoanalysts are more familiar

The patient in question is so much lacking a sense of separate-ness that he is almost physically interpenetrated with the analyst; for him, separations are perceived as lacerating occurrences affecting his body.

Defences against perceiving a relationship of dependency are so violent that they impede normal modes of communication and transference.

Resulting from a condition of traumatic birth, the patient nurtures a desire to return to the womb; he employs defences and communications in which projection of the self onto others predominates, here becoming a special form of intrusion into the analyst’s mind and body.

 

9. Crisis situations

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This clinical situation here regards a young man who has his first psychotic breakdown three weeks after beginning analytic work, and who then makes a horrific suicide attempt

The analytic events covered go up to the sixth year of analysis, including material from two sessions.

These sessions are followed by a dream the analyst had which— we later find out—occurs at the same time as a manic explosion by the patient, who is taken into a psychiatric hospital.

Rosenfeld emphasizes how useful it is for the analyst to build up a preliminary picture in his mind, which can then be modified as analysis proceeds, to serve as a fallback when a hard-to-manage crisis situation occurs.

An example for similar situations may be found in the analysis of this patient, revealing the need to rapidly become aware of the existence of a serious risk of suicide or of a psychotic crisis, fed by omnipotent guilt and identification with a destructive mother.

A great deal of caution must be used in the treatment of manic conditions. If handled precipitately, the patient’s depressive state may worsen and push him to suicide.

 

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