mkt
 

  Book Review
 
 Psychic Retreats:
 Pathological Organisations in Psychotic, Neurotic
 and Borderline Patients
 John Steiner
 

     
Writing with practising psychoanalysts and psychoanalytic psychotherapists in mind, John Steiner draws on new developments in Kleinian psychoanalysis to enable analysts to understand the problems of treating severely ill patients.
He examines how psychic retreats are constructed and, by using detailed clinical material, explores how analysts can treat patients who withdraw from reality in this way.

0-415-09923-4 1993 176pp. £55.00 / $96.00 hbk
0-415-09924-2 1993 176pp. £19.99 / $31.95 pbk

Hardback, Separate volumes are available in hardback and in paperback.
London/New York: Tavistock/Routledge, 1993. 176 pp.

 
Review by Chris Mawson

This is a very clearly and concisely written book about patients who are very difficult to reach. Its great strength lies in the way that Steiner convincingly brings together detailed clinical description and the theoretical concepts informing his work. Although drawing centrally on Melanie Klein’s concept of projective identification, and on recent Kleinian developments, this is by no means a piece of work which will be useful only to those who work daily with Kleinian concepts. Meaningful links are made to the work of other authors and the whole emphasis is on the ‘fine grain’ of maintaining close contact with the patient’s need to involve the analyst in creating psychic retreats,- sanctuaries and bastions against unwanted and painful reality. There are findings here which will be of use to practitioners of different orientations. The book begins with an outline of the theory of psychic retreats as being manifestations of underlying pathological organisations of the personality. In three chapters the account is extended to include more detailed clinical examples of how these processes operate. Steiner reviews the specific kinds of mental pain evaded by subordinating oneself to these organisations. Essentially both depressive and persecutory anxieties are avoided, but at a devastating cost.

In Chapter 4 Steiner extends his review to work done on narcissistic structures, and in the following chapter he discusses the important role in movements towards recovery of what Bion has called "projective identification in reverse’. This is a very interesting discussion of the likely processes involved in psychic repair, linking the recovery of parts of the self lost through violent omnipotent attacks on thinking with the work of mourning. This theme is picked up again in Chapter 7, and there is an intervening chapter in which problems of psychotic catastrophe are explored.

In Chapter 8 Steiner discusses perverse aspects of psychic retreats, making connections with Freud’s ideas concerning fetishism, and in the following chapter he follows this up to explain how the hold of the psychotic part of the personality is strengthened by perverse, lying relationships forged between disparate parts of the self. There is then a description of psychic retreats found in literature, from the Oedipus stories. Particularly interesting here is the notion of ‘turning a blind eye’ as an important perverse mechanism, permitting psychotic retreat from reality by allowing a simultaneous acknowledgement and disavowal of the truth of an experience.

In the final chapter Steiner concludes with a discussion of technical problems relating to the nature of interpretations and how they are likely to be received by the intensely frightened and hostile patient, who fears the abrupt and permanent loss of the psychic retreat. In this chapter Steiner offers some ideas which are of real help to the beleaguered analyst or therapist in his or her attempts to stay with the patient, and to understand more clearly ‘what the stakes are’ at critically difficult points in the work. Although John Steiner’s ideas have largely been honed in his work with severely damaged individuals, a major aim of this book is to assist us in recognising similar, less extreme variations in less disturbed patients, so that we might better understand what is going on, and be more open to those moments in which we become drawn in to supporting the patient’s pathological organisation. I think this is a major strength of this book and I wholeheartedly recommend it to a wide readership.
 

Chris Mawson
Psychoanalyst

 

Review by David Morgan

When reviewing a classic text like Psychic Retreats it hard not to look for clues to understanding the current world crisis. Psychoanalytical theory should in the main be restricted to elucidating the dilemmas of the consulting room. However some theories seem to offer profound insights not only into the workings of the unconscious and its manifestations in
analysis, but also into events in the external world. What makes people turn to superficial and simplistic ideas of life which although they may provide certainty are at best inadequate and at worst dangerous? What it is that makes a young man fly into a building and destroy lives in the name of a religion? These questions seem at least to this reader irrevocably connected to the attractions of pathological organisations, or psychic retreats, as conceived of by Steiner, organisations which can come to feel more important than life itself.

Freud (1937) in 'Analysis Terminable and Interminable' tried to understand why his patients resisted change, preferring their own versions of reality in the face of understanding, even though this impoverished and crippled their lives. As a result he reluctantly turned toward an emphasis on the role of the 'death instinct'. Its purpose was to attack life and all its hateful conflicts, involving a wish to retreat to an anxiety-free state. This primitive hatred of reality and all its problems, and a wish to regress to a tensionless state akin to death, was the basis of the death instinct. We have come to see that this can be the result of factors internal to the personality. Traumatic external experiences can also lead to disturbed and violent object relations, which then become attached to an individual's own destructive capacities.

The history of Steiner's thinking owes its development to Abraham and his exploration of narcissistic states of mind in the transference of his patients. This was later extended by others including Herbert Rosenfeld. Rosenfeld's view of destructive narcissism includes the idea of a Mafia-like gang that can dominate the unconscious world of the patient, offering a corrupt haven for otherwise impoverished object relationships. It is as if these pathological organisations, in return for one's devotion, offer protection from all pain. Steiner extends the idea of these pathological organisations to a wider range of patients -neurotic, perverse, borderline and psychotic patients alike may all have such structures in the personality. Steiner uses the more sympathetic and explanatory term, 'psychic retreat'.

Many sorts of individual may in different ways adopt a psychic retreat at different points and for different reasons, during psychic development. For example some patients, existing mainly in a paranoid schizoid modality, need to manage extremely persecuting states of mind and object relations. Others, nearer to the depressive position, need to avoid what they experience as potentially overwhelming and unbearable guilt. What is always involved is the avoidance of conflict and working-through, and their replacement with pseudo-understanding, self-sufficiency and over-compliant or seductive ways of dealing with reality. All gradations of dependence on the psychic retreat are found clinically, from the completely stuck patient at one extreme to those who use the retreat in a transient and discretionary way at the other. The range and pervasiveness of the retreat can vary and some patients are able to develop and sustain adequate relationships in some areas but remain stuck in other aspects of their lives.

Our conflicts around difficult external and internal realities -the profound struggle to deal with anxieties of living and dying, can at times seem so unbearably painful and non-resolvable that there is a retreat to more simplistic understandings. These can often be shallow and insubstantial but offer a restricted certainty that defies reality. If I am an impoverished peasant with apparently little or no future, I may understandably hate my reality. One way of managing this hatred would be to use it to empower myself. I get rid of my human feelings and join a fundamentalist sect or Mafia-like gangster organisation. This seems to offer some hope and inspiration to me, though really it is a way of avoiding pain by inflicting it on others- it is the other who now becomes robbed of their life and reality. Steiner is talking about the individual, internal version of such external organisations. The same sort of processes are involved, although the degree of acting-out in the world is less, or at least less visible. The reversal of suffering and alienation is managed through projective identification. I split off and violently project the vulnerable aspects of myself. I identify with the hatred and violence of the internal 'gang' and feel that I triumph over adversity, even though it is ultimately at the cost of my humanity.

Such manoeuvres in the external or the internal world can put one in the position of holding an absolute certainty about one's rightness which can be used to triumph over others, so it is they and not oneself who has to bear uncertainty. The difficulty of leaving an organisation like this after an allegiance has been agreed is enormous. Giving up the safety of the organisation involves acknowledging and facing the pain and vulnerability that led to the flight from reality in the first place. It involves a huge loss of certainty. It also involves facing the guilt about what one has done to the self and others in the process of the violent splitting and projection. The consequent gain from living in the real world, and the possibility of real human relationships to replace the organisation, can seem poor substitutes to the apparent safety offered by the superficial certainties of these retreats.

In this substantial work Steiner is addressing these areas of internal retreat that, like religious sects or Mafia-like organisations, have offered patients at times of particular emotional poverty an escape from suffering. They may have been turned to rather in the manner of a Faustian pact- in return for loyalty, selling of the soul, insulation is given from unbearable experiences at various stages of life. An omerta-like allegiance is required, to a sado-masochistic structure that attempts to exclude all awareness of human vulnerability. This vulnerability is projected into others, while the psychic retreat, hardened up by hatred, prevents any awareness of this vulnerable self returning into the subject. Ordinary reality is attacked, and a resulting 'virtual reality' is idealised. These patients' psychopathology, involving as it does the impoverished certainties of omnipotence, cruelty and sado-masochism, and the illusion of eliminating of human vulnerability, make them unavailable and difficult to analyse. After all what we are offering as analysts and therapists are all the disadvantages of the 'ordinary' human interaction that has been eschewed.

As Steiner puts it:

'The relief provided by the retreat is achieved at the cost of isolation, stagnation and withdrawal, and some patients find such a state distressing and complain about it. Others, however, accept the situation with resignation, relief and at times defiance or triumph, so that it is the analyst who has to carry the despair associated with the failure to make contact. Sometimes the retreat is experienced as a cruel place and the deadly nature of the situation is recognised by the patient, but more often the retreat is idealised and represented as a pleasant and even ideal haven. Whether idealised or persecutory, it is clung to as preferable to even worse states which the patient is convinced are the only alternatives.' (p. 2)

Steiner writes sensitively about these patients' emergence from and withdrawal to these states. These retreats offer an apparent sanctuary from anxiety and are therefore difficult to analyse. This is because the analyst's work threatens a return of the anxiety. The patient may deal with this by trying to neutralise the analyst's contributions and incorporating them as part of his own mind, and his own retreat, avoiding dangerous change. The analyst needs to help the patient feel that he is neither siding with, nor attacking the retreat, but is fully aware of how difficult it is for patient to let go of his apparent 'lifeline'. Only then may the patient be helped to become aware of the real poverty of his situation. The capacity of the analyst to avoid using psychoanalytic theory itself as a sort of psychic retreat at these times seems to me be an important part of what Steiner is talking about.

Where psychic retreats dominate analytic treatments they give an opportunity for close study and engagement. It is Steiner's long experience of working with borderline patients that enables him to begin to break these organisations into their components. His work has helped us to think more clearly about these clinical manifestations, and his important book is at the cutting edge of contemporary Kleinian thinking and clinical advance. Steiner through his careful and detailed understanding enables us to think of how to engage even with the most stuck patients. He demonstrates a profound sensitivity to the patient's psychic equilibrium, and a recognition of their desperate need for the retreat for long periods during the analysis. The retreats by their nature need to pervade analytical treatment until trust in an object makes it possible for emergence into painful reality.

As this emergence begins, the analyst is experienced as having a separate mind, capable of thinking different thoughts from the patient. The patient experiences a profound sense of loss and consequent mourning. As the role of the psychic retreat diminishes, awareness dawns for the patient of his impoverished life. Awareness of the dependency on the analyst emerges, with the fear of loss that accompanies all deep human relationships. A real relationship with the object allows for ambivalence and the painful awareness of co-existing loving and hateful feelings. The undoing of the power of the psychic retreat
involves the analyst helping the patient understand the perversity and seductiveness of the 'propaganda' he has been subject to for so long, and which has led him away from reality. The awareness that real comfort and succour can come from an object outside the self, an object who is different and human like oneself, and therefore limited, is painful. One of the seductions of the psychic retreat is that it appears infinite and therefore omnipotent. It triumphs over the human condition, so that it is others who will die whilst the perverse state of mind in phantasy goes on forever. This is reminiscent of suicidal states of mind. The fundamentalists who destroyed the lives of so many in the World Trade Centre believed that they would live forever after they died, and thus triumph over their victims.

Steiner has contributed helpfully to the continuing debate about how and when to interpret the transference relationship to the analyst. There is agreement that such understandings can only be communicated to patients when they are ready to receive them, and that we need to gauge this from careful observation of
the patient's communications. The differences in focus in the debate seem to me around the exploration of the patient's capacity to understand what it is they are doing; whether or not the projection first has to be taken up in the analyst. Once the perceived nature of the object is explored, the conditions for deeper understanding can become possible. Difference in emphasis deeply influence how one intervenes. Steiner shows how we must take into account whether or not the patient sees the analyst in the first place as someone who can provide understanding. Otherwise we may too-readily assume a shared understanding that may in a way resemble the patients own retreat into certainty.

Steiner beautifully outlines the subtle use of the counter-transference with these patients, as a method of understanding and elucidating the patients' use of projective identification. His use of what he calls 'analyst -centred interpretations' enables the patient to explore his disturbed perceptions of reality first of all outside himself, located in his analyst. This avoids the problem of the patient's withdrawal and retreat when confronted by patient-centred interpretations that forcibly return projections to him -threaten him with too much awareness too quickly. Steiner understands the importance for the patient of at first being understood in the position he is in now. He suggest that the patient often has a profound feeling of not having an understanding object. Steiner recognises that part of the need to organise a psychic retreat is in response to a world lacking in objects who can distinguish between one's own and their own reality. When the analyst allows himself to be thought about in this 'analyst centred' way, he provides a different sort of object, and enables the patient to begin to think about himself too.

That pathological organisations can be a defence against a world of apparently unthinking objects makes sense to me. What seems important is the analyst's ability to allow the patient's reality to be projected onto him, without either immediately rebutting it, or too-readily allowing himself to be blamed. The skill in containment is in being able to suspend issues of blame, and instead to encourage exploration- getting to know reality. This can in its turn allow the patient to start thinking about what may be being projected, and to discern between his view of his analyst, and his analyst's independent reality.

This in my view is a tremendously important and exciting book from a really accomplished clinician. His wide experience as a consultant in the National Health Service and as a psychoanalyst makes it essential reading for analyst and non-analyst alike. I consider it one of the most important recent books by a contemporary psychoanalyst of any orientation.



David Morgan
Psychoanalyst
Consultant Clinical Psychologist
Tavistock and Portman NHS Trust
London


 


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