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Chapter Six - The Superego in Difficult Patients

De Masi, Franco Karnac Books ePub

“The attitude of the superego should be taken into account – which has not hitherto been done – in every form of psychical illness”

(Freud, 1924b, p. 152)

The superego in difficult patients is often tantamount to a negative force, opposing mental growth, which exerts its power with threats and intimidation. In this case it is a structure that has inverted its protective function and has been transformed into a malicious, delusional, or envious figure. While the primitive superego can gradually be transformed through the analyst accepting it, understanding it, and interpretatively returning it, its pathological organisation requires specific interventions that help clarify to the patient its nature, its objectives, and its pathogenic action.

In his Los Angeles discussions, Bion (1978, p. 5) notes that one need only look at a child and say “Ah!” in a reproving way to see him wince guiltily before he has any language knowledge whatsoever—or so one would think. He adds that, in order to understand the moral system, we must resort to the term “super-ego”, which suggests something above everything else, whereas, in fact, it very probably belongs underneath everything else. In asserting that the power of moral behaviour is based on threats and fear, Bion is drawing attention to the equivocal position of the superego, as both the expression of the moral system and an early organiser of pathology.

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CHAPTER TWO: A precursor

De Masi, Franco Karnac Books ePub

The study of deviant sexuality began at the end of the nineteenth century with the publication of the first edition of Krafft-Ebing’s voluminous treatise Psychopathia Sexualis (1886-1902), in which the sexual aberrations were for the first time deemed an object worthy of psychiatric study. The book contains an abundance of case histories covering the entire range of sexual deviations, including the most extreme.

It has been pointed out (Grossman, 1986) that the definition and scientific study of the sadomasochistic perversion predated the birth of psychoanalysis by a decade and decisively influenced the development of that discipline.1

For Krafft-Ebing, whose oeuvre resembles a huge fresco many times revised and extended, the fundamental form of all deviations was reflected in sadism and masochism, which represented the active and passive aspects respectively of the drive of subjugation. The choice of perversion was always latent, even where its onset could be documented in specific episodes in infancy. Krafft-Ebing believed that an event in infancy, such as the young Rousseau’s excitement when he was beaten (which Freud also mentions), was only a secondary factor in the aetiology of masochism—the occasion for its emergence rather than its cause.

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Chapter Eighteen - The Problematic Position of the Transference in the Psychotic State

De Masi, Franco Karnac Books ePub

“Delusional production positions itself in a space that is neither the inner space of the psyche, nor external space, and not even intermediate or transitional space…”

(Racamier, 2000, p. 873)

The psychotic transference results from a pre-existing delusion that invades the analytic setting and relationship: the analyst becomes an object of the delusion and his interpretative function vanishes. The psychotic part that has overcome the rest of the personality destroys the patient's intuitive and self-observation capacities and obstructs the analytic work.

This chapter discusses the onset of psychotic episodes during analysis and, in particular, the delusional transference which, once established, tends to bring the analytic process to a dangerous impasse.

This subject is not widely discussed in contemporary psychoanalytic literature, and neither do many recent papers deal with the analytic therapy of psychotic patients.

Past contributions

In earlier psychoanalytic literature, the onset of a psychotic state during therapy was often the object of close examination and produced many differing contributions.

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CHAPTER FOUR: Sadomasochism and depression

De Masi, Franco Karnac Books ePub

A ccording to Abraham’s contributions on depression (1912,

/\ 1916, 1924), the suffering of melancholia arises out of the

J. \. patient’s perception of a self capable of hating rather than loving. That is why melancholia, unlike mourning, includes conscious hate for the subject’s own self.

In “Mourning and melancholia” (1916-1917g [1915]), Freud takes up this essential aspect of unconscious hate and places it in the perspective of a sadomasochistic relationship that is both internal and external.

Unlike a bereaved person, the melancholic feels not only that his world has become meaningless but also that his ego has been emptied out. In confirmation of his own unworthiness, he attributes to himself not merely guilt but all the negative qualities of the world, too. Freud points out that, in melancholia, it is not just the relationship with the lost love object that is altered, as in mourning, but in addition the relationship with the subject’s own ego. Whereas in mourning the loss concerns the object, in melancholia it is the ego itself that is affected.

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CHAPTER FIVE: The meaning of dreams in the psychotic state

De Masi, Franco Karnac Books ePub

“The god created dreams to show the way to the dreamer, whose eyes are in darkness”

(Egyptian Papyrus Insinger)

Imprisonment in psychosis

The Schizophrenia Bulletin of the US National Institute of Mental Health includes a section, “First Person Account”, open to patients and their families. In some of these articles, patients diagnosed as psychotic discuss the way they live and their problems. (A collection of accounts by these patients and members of their families has been published in Italian by Bertrando [1999].) One of these descriptions seems to illustrate particularly well the state of mental imprisonment in which some patients live even when they have succeeded in recovering a part of their social capacity.

The patient concerned writes:1

“Over the years I have had many‘mad’ thoughts, but my main delusions, of grandeur—mediumistic phenomena—and persecution, have remained constant. These delusions are supported by such vivid hallucinations that I cannot usually distinguish them from reality, except by saying to myself that none of this is real, that what the people I love and trust tell me is true, that I am unusual only because I am schizophrenic, and that everything I think about the supernatural is due to an illness.”

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