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Chapter Four: The Infrastructure of the Vertical Split

David Garfield Karnac Books ePub

As we saw in the case of Judith, disavowed action can be seen as the patient's way of trying to hold on to a threatened sense of self agency. Behaviors, actions and a variety of different split off states contain vital elements of an unintegrated self. For Judith, the mirroring selfobject experience, as it deepened, allowed for the reintegration of these various psychotic behavioral states. The key concept here is “threatened.” Given Judith's experience with her grandfather, her very psychological existence was at stake.

This chapter, through two clinical vignettes, explores in greater depth Kohut's (1971) concept of the vertical split. Interestingly, Sullivan's (1953) identification of “selective inattention” as a security operation within a self system can be seen to foreshadow Kohut's concept of the vertical split. Stern's (1985) research on the development of agency within the infant and the important role of caretaker attunement to the felt consequences of intended action add to the clinical understanding of disavowed motor acts. Here, faulty selfobject experiences result in the development of an in-depth sector of the psyche that remains conscious, yet disavowed. We clearly saw this in Judith's psychopathology.

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CHAPTER FOUR: Affect and primary process in psychosis

David Garfield Karnac Books ePub

Dr. Tony Potter wondered whether he could make a go of becoming a psychotherapist. It wasn't so much a philosophical question as it was a pragmatic one. At times, it seemed easier to understand the musing of his psychotic patients than it was to understand the healthier ones.

One of his teachers had commented that people took “normality” for granted and worried a great deal about pathology when, in fact—given the billions of decisions the human organism had to make from applying the right amount of pressure to the toothpaste tube and activating the proper finger musculature to, God forbid, driving a car—it was amazing anyone dared get up in the morning. A psychotic break, in this light, did not seem like such a big deal, nor an unlikely event. The waiter asked him for the second time what he would like to order.

Tony considered that this daydream retreat into his work was a defense against his anxieties about relating to his girlfriend. He determined to focus his attention on their dinner together. The fish market was one of Boston's finest seafood restaurants and Tony andNancy both loved it. As he was looking over the menu on the blackboard on the wall, he saw the entire Mills family file in. He almost choked on his water. Because of confidentiality, he couldn't say anything to Nancy. Nancy looked lovely, she was wearing a black dress and her short red hair stood out in contrast. Maybe Amy wouldn't notice them. The waiter seated the family far back behind them.

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CHAPTER EIGHT: Shame, pride, and paranoid psychoses

David Garfield Karnac Books ePub

Tony's work with Robert Meyer began in a fairly unremarkable way. Yet, it was an experience that was to imprint itself indelibly on the young psychiatrist's mind. Meyer had been admitted to Mount Sinai with a delusional disorder of a persecutory type. After his introduction to the subject through Jack Barnes, Tony was ready and interested to go to work. Psychotherapy with Robert was easy. This was an articulate, intelligent, 29-year-old married man who had worked in his father's lighting business.

Tony discovered that Robert had an invigorating and developmen-tally advanced childhood. He had been an active boy, played sports, had lots of friends, and revelled in his job as older brother to his two younger sisters. However, early in the therapy, Tony picked up that Robert's childhood had not been completely smooth. Robert had to defend his father from the jeering of neighbourhood children. The Meyer family was the least affluent on the block and Robertwould make up stories about how wealthy and powerful his dad was when other children would ask why their car was so old or why their house was so small. Robert simply told them that although his father was rich and well known, those things were not important in their family. Robert even remembered one or two fistfights around this issue.

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CHAPETR NINE: Emotion and self-esteem in psychosis

David Garfield Karnac Books ePub

Amy seemed depressed. Somehow being in the hospital for two months had taken some of her dramatic style out of her. Tony could relate to that; his initial enthusiasm, the mission to cure, had certainly taken its lumps as well. His experience with Robert Meyer almost did him in. Where was that bubble of omnipotence that was supposed to protect us from the harsh realities of day-to-day life? It seemed nowhere to be found.

Amy was now “graduating” to outpatient status. Her rapid, pressured speech had been tempered by lithium. Her oratory and dramatic flair were now more subdued. Although Tony didn't believe in the syndrome of “postpsychotic depression,” he knew that it could be the beginning of the down part of her bipolar affective disorder. Perhaps, she was just exhausted from the whole ordeal. Tony reassured himself that the Lithium would help protect her from becoming neurovegetative. But it couldn't protect either of them from the distasteful choices of day-to-day living. He hoped that the old adage of “depression shared is depression halved” was true. Yet, would it be hers or his?

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Chapter One: The Opening Phase—The Case of Judith

David Garfield Karnac Books ePub

Judith was a lithe, petite, blue eyed blonde woman in her early twenties when Dr. Steinman first met her in a psychiatry emergency room; blood oozed from four deep self inflicted cuts on her left forearm. She was sitting demurely in an uncomfortable wooden chair, her face bland and remote. Dr. Steinman began….

“What happened?” Dr. Steinman asked her.

“Nothing.”

He persisted: “Surely something happened.”

“I don't know” She remained impassive.

“Did something bother you?”

“Uh huh,” she responded in a meek, barely perceptible voice.

“What was it?”

“I didn't feel good.”

“Where?”

“Here,” and she pointed to her abdomen.

Dr. Steinman wanted to continue this developing line of exploration. Why, he wondered, would she cut herself? There must be a lot bothering this very young looking woman; even though her voice was calm and timorous, cutting herself was an emotion filled act—or one intended to stop emotions.

But the blood was seeping onto the floor of the shabby emergency room Dr. Steinman had begun to work at three weeks earlier at the end of his psychiatry residency. He had trained at a hospital that had a rather large staff for the psychiatry emergency room. But now, trying to support his young family, he was working with only a nurse's aide on duty with him. Before the blood became a problem, Dr. Steinman walked Judith across the street to a fully operational hospital emergency room where her wounds were sutured and butterflies applied.

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