Murray Jackson is a Psychoanalyst and former consultant psychiatrist of the Maudsley Hospital, London


When Henri Rey’s book ‘Universals of psychoanalysis in the treatment of psychotic and borderline states’ appeared in 1994 it was introduced by John Steiner as containing ‘some of the most original and creative ideas to be found in the interface between psychoanalysis, psychiatry and other disciplines’. Steiner recommended it as expressing ideas of fundamental importance, and advised that ‘all psychoanalysts as well as many in those neighbouring fields will find it fascinating to read, and will emerge enriched and also encouraged to broaden their own points of view’. At the same time Kernberg judged it as ‘demanding but highly rewarding for those interested in expanding their understanding of severe psychopathology’.

In the following year a formal tribute to Rey’s work was made at the Tavistock Clinic by Steiner (1995), who expressed his indebtedness to Rey and outlined some of his ideas, and by Rhode (1995), who explored the relevance of his work on psychosis to the understanding of the mind of the autistic child. Rhode was particularly struck by Rey’s views on the ‘maternal space’, and saw a link between the primitive terror that the threat of separation might provoke in a vulnerable small child, and the anxiety experienced by Rey’s adult patient on leaving the session, a fear that Rey explained as the consequence of the patient having equated his self leaving the room with his faeces coming out of his body.


Having worked with seriously disturbed patients in close collaboration with Rey for many years at the Maudsley Hospital, and ( like Steiner and very many others) having been inspired by his remarkable work and therapeutic skill, I think it may be useful to offer some personal comments and reminiscences at this time on his views about psychotic conditions, and his particular understanding of severe and near-psychotic anorexia.

Although I believe that the implications of Rey’s ‘post-Kleinian’ work have not yet been fully explored, recent publications by analysts with special interest in anorexia nervosa have thrown much light on this obscure and complex disorder (see Lawrence 2002), and some have found inspiration in Rey’s views on the organisation and symbolisation of the maternal space, and the ‘claustro-agoraphobia-philia’ syndrome. Sarah Flanders (July 2002, unpublished talk at British Psychoanalytical Society) has compared Rey’s views on the maternal space, disturbances of identity, and the schizoid dread of separation with Glasser’s ‘Core Complex’ and its relation to the psychogenesis of sexual perversion. In focussing on the anal stage of development (Mahler’s ‘separation-individuation’phase) she referred to Glasser’s understanding of his perverse patient’s faecal incontinence as a defensive identification of his body with his mother’s and himself with the stool in his bowel. It is this theme of maternal space and part-object identifications that has been explored by Rey in great detail.

Cyril Couve, in the same meeting (July 2002) spoke of his personal experience of Rey’s capacity for making deep emotional contact with psychotic patients and how this led him to a new understanding of the nature of pathological part objects and the concrete and space-centred quality of much psychotic experience. Although a great deal has been written about mental space (Rosenfeld, 1987, Resnik,1990, Meltzer,1992, Young,1994), Rey’s work conveys the spatial structure of the psychotic mind in a particularly vivid way. Whilst Rosenfeld has described the mechanisms that lead to the ‘feeling of living inside the object’, Rey has enlarged on this theme and illustrated how this experience can range from a not necessarily abnormal existential awareness, to a completely delusional belief leading to complex psychotic thinking and bizarre behaviour.

I have reported numerous examples of what Rey called the ‘ kaleidoscopic’ character of shifting part-object identifications (Jackson& Williams 1994, Jackson 2001) which underlie delusional body imagery. Such shifts may result in oscillating patterns where, for example, paranoid or hypochondriacal delusions may alternate with episodes of claustrophobic panic.

One schizophrenic man lived in recurrent terror that extra-terrestial forces were about to kill him by telepathic means. He had long suffered from intractable colitis and when he became engaged in individual psychotherapy he revealed that he had long been using highly irritant enemas to abort the baby that he believed was inside the pregnant woman who was inside his body. This man had had an emotionally traumatic early life, marked by recurrent losses including the death of his mother from cancer when he was six years old. His case exemplifies an unstable delusional state (responding, incidentally, to psychotherapy) in which oral phantasies typical of the female anorexic have been displaced from mouth and stomach to anus and rectum.

An anorexic patient may refuse food to save the life of the mother inside her body who, in her unconscious phantasy, is pregnant. This baby is highly dangerous because it contains the patient’s own infantile split-off destructive wishes towards her mother’s’ inside baby’, wishes which have been defensively hidden since childhood by projective and introjective processes. For such a patient to starve means to prevent the baby from growing in strength, and thus to spare her mother. For another anorexic, food may be symbolically equated with a baby who must be preserved from cannibalistic attacks, or with a penis containing (thus unconsciously having the qualities of) a nipple, teeth or poison (as in the common snake imagery). When such phantasies enter into the therapeutic transference the patient may insist on chewing sweets in the session.

It is important to recognise the difference between the infantile wish to retreat into the (assumed) safety of a primal unity with the mother’s body, and a wish to invade and colonise her body and to destroy her inside-baby/ies. Many anorexic females struggle to rid themselves of a non-existent suprapubic ‘bulge’, which is the expression of a phantasy of pregnancy which is sometimes clearly delusional.

Such cases also illustrate Rey’s dictum that in schizoid or psychotic states ‘even the containing object is itself contained somewhere’. The retained stool may represent the realisation of a symbiotic phantasy of the dependent self residing safely inside the mother’s body, defaecation representing a catastrophic separation variously experienced as annihilation, loss of self, being abandoned and cast into outer space to die. Saving up urine in bottles and hiding them in secret places is a not uncommon variant. Many other dynamic patterns may be found, and in less severe cases envy of the providing mother may be a simple explanation – ‘biting the hand that feeds’. Oedipal pathology marked by sexualised intrusion into the parents’ relationship, if not based on significant developmentally earlier and more primitive (dyadic) pathology, is likely to take the form of hysterical disorders, sometimes becoming briefly delusional under specific stress. If the earlier pathology is prominent the disturbance may take the form of hysterical psychosis.

The shifting and complicated nature of such part-object identifications present the therapist with the task of deciding which of a multiplicity of meanings may be relevant at a particular moment. This is not a matter of undisciplined imagination on the part of a therapist, for whom anything can mean anything, but rather is the nature of the material with which he must work, in seeking an answer to Rey’s question –

‘What part of the subject, situated where in space and time is doing what to what part of the object, situated where in space and time, with what motivations and with what consequence for subject and object?’

The attempt to answer the question involves a sorting-out of part-objects and motivations, interesting the patient in meanings, attempting to reclaim lost parts of the self (Steiner, 1993), reducing the intensity of projective identification, and undoing the processes of splitting. This is easier said than done, but given the right patient and the necessary resources is not impossible, nor even at times particularly difficult.

Rey believed that it was as much of a mistake to underestimate the capacity of psychotic patients to use a proffered cognitive framework, (a way of thinking usefully about the meanings of their experiences and tolerating the associated affect), than to over-estimate it. It can be impressive to see the positive response made by a competent psychotherapist to the right patient at the right moment to a direct confrontation such as,

‘you are afraid that you want to eat me and you chew sweets in order to protect me’

or

‘you believe that electricity is coming out of the bath taps and threatening to kill you. You have misunderstood the situation. Thought is not electricity! What you dread is that thoughts will come into your mind bringing feelings that you have never been able to bear, and you feel it will kill you if I expect you to try to think about your thoughts’.

Such an intervention could only be safely given by a therapist experienced in such work, with a particular patient with whom he has worked for a sufficiently long time, a therapist who is comfortable with thinking in part-object term. Otherwise it could represent the worst contravention of all the rules of psychoanalytic technique.

What is the nature of this work? Rey’s extremely active, sometimes very direct, and often very effective method of talking with psychotic patients, either in a therapeutic-consultative-assessment or a psychotherapeutic mode is a far cry from the practice of the average psychoanalyst. It could perhaps be considered as psychoanalytic psychiatry, using a technique that has been found to illuminate confusing or bizarre psychotic thinking, and to allow effective psychoanalytic psychotherapy to be employed with certain selected psychotic patients, acute, relapsing or chronic, on a once or twice- weekly basis, with attention to the transference but not necessarily working primarily with it. It requires special resources that are currently beyond the reach of most psychoanalysts, especially in the British NHS. Rey would never conduct an exploratory consultation with a patient unless there was a supportive psychiatric setting, and an interested individual who could carry on in a psychotherapeutic manner if necessary.


Some implications for psychoanalysis and for psychotic patients

Since the Cassel hospital ceased to provide a supportive resource for the handful of pioneering psychoanalysts who specialised in work with psychotics, the ending of the tradition of psychosis psychotherapy at Netherne and Napsbury hospitals, and the dispersal of Ward 6 at the Maudsley hospital, the therapeutic milieu necessary to contain the seriously disturbed patient who requires hospitalisation and medication, whilst psychoanalytic psychotherapy is pursued, is no longer to be found. The work of the late Tom Freeman was an inspiring exception, as is that of Richard Lucas today, but very few psychoanalysts can hope to gain much of this sort of experience, nor can mental health professionals of all disciplines benefit from psychoanalytic thinking.

One consequence is that this impoverishment has left an empty space that has been vigorously colonised by (short-cut) cognitive-behaviour therapists, and this has in some quarters created a state of rivalry between psychoanalysis and CBT. This depressing state of affairs is partly responsible for the opinion of many psychiatrists that psychoanalysis has nothing to offer them in their management of psychotic patients. Without a comprehensible theory of psychosis and a ‘realistic’ method of psychotherapy these psychiatrists feel they have no choice but to turn to CBT’s for help with their huge load of psychotic patients. Such CBT work can be helpful to some of these patients, but without a psychoanalytic input it has an uncertain future. However, some CBT workers are beginning to realise that the short-term work they offer to psychotic patients is not appropriate, and are seeking help to understand what happens in the longer term.

Teaching in Scandinavian countries for many years I found that resources for individual analytically-based psychotherapy of psychotic patients within a supportive psychiatric setting was much more readily available than in the UK, where such patients could rarely hope to receive psychotherapy. However, despite what seems to be a general decline of psychiatric interest in psychoanalytic thinking about psychosis there is good reason to hope that the widening gap may eventually be bridged.

The input of Scandinavian, American and Australian psychiatrists and psychotherapists into the newly-expanded International Society for the Psychological Treatment of the Schizophrenias and other psychoses (ISPS) holds great promise, and a few British psychoanalysts, in particular Brian Martindale and Paul Williams, are actively committed to preserving the original psychoanalytic base of this rapidly-expanding organisation and have launched regular meetings at the Institute of the analytic section of the ISPS. Valuable theoretical bridges between psychiatry and psychotherapy are being elaborated in attachment theory (Holmes,1998) and in research into the development of the infant mind.

Conclusion

Although it may at the present time be difficult or impossible for interested psychoanalysts to treat such patients personally, they can make a crucial contribution by encouraging psychoanalytic psychotherapists to try to secure the necessary support from sympathetic psychiatrists, and supervise their work, as some are already doing.

Henri Rey emphasised that treatment of the psychotic patient requires understanding of the psychotic mind: that the psychotic will not be understood unless the mental mechanisms that he is employing are understood: and that it requires psychoanalytically-informed training to understand these mechanisms. Rey’s highly original work on part-object pathology, the associated part-identifications, and the space-centred thinking of the seriously ill psychotic patient, offers an important contribution to what is already known by psychoanalysts. It also offers guidelines to a psychoanalytic approach which is sophisticated and effective, and could bring psychoanalytically- based psychotherapy to many of those psychotic patients who are the major concern of mental health services everywhere.


References

Holmes, J. (1998). The changing aims of psychoanalytic psychotherapy: an integrative perspective. International Journal of psychoanalysis. 79,2,227-240.

Jackson, M. (2001). Weathering the Storms: psychotherapy for psychosis. London:Karnac.

Jackson, M., & Williams, P. (1994). Unimaginable Storms: a search for meaning in psychosis. London: Karnac.

Lawrence, M. (2002). Body, mother, mind: anorexia, femininity and the intrusive object. International Journal of psychoanalysis 83, 4, 837-850..

Meltzer, D.1992). The Claustrum:an investigation of claustrophobic phenomena. Perthshire: Clunie Press.

Resnik, S. (1990). Mental Space. London. Karnac.

Rey, H. (1994). Universals of Psychoanalysis in the Treatment of Psychotic and Borderline States. London : Free Association Books.

Rhode, M. (1995). Links between Henri Rey’s thinking and psychoanalytic work with autistic children. Psychoanalytic Psychotherapy. 9, 2 ,149-155.

Rosenfeld, H. (1987). Impasse and Interpretation. New Library of Psychoanalysis.no.1. London:Tavistock Publications.

Steiner, J. (1993). Psychic Retreats. New Library of Psychoanalysis.no.19. London: Routledge.

Steiner, J. (1995). The influence of Henri Rey’s work. Psychoanalytic Psychotherapy. 9, 2 ,145-148.

Young, R.M., (1994). Mental Space. London: Process Press.