Would-Be Wife Killer, A Clinical Study of Primitive Mental Functions, Actualised Unconscious Fantasies, Satellite States, and Developmental Steps - Volkan

WOULD-BE WIFE KILLER
WOULD-BE WIFE KILLER

A Clinical Study of
Primitive Mental Functions,
Actualised Unconscious
Fantasies,
Satellite States, and
Developmental Steps
Vamık D. Volkan
First published in 2015 by
Karnac Books Ltd
118 Finchley Road
London NW3 5HT
Copyright © 2015 by Vamık D. Volkan
The right of Vamık D. Volkan to be identified as the author of this work has
been asserted in accordance with §§ 77 and 78 of the Copyright Design and
Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored

in a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior written
permission of the publisher.
British Library Cataloguing in Publication Data
A C.I.P. for this book is available from the British Library
ISBN-13: 978-1-78220-279-0
Typeset by V Publishing Solutions Pvt Ltd., Chennai, India
Printed in Great Britain
www.karnacbooks.com
CONTENTS
ABOUT THE AUTHOR vii
ABOUT THIS BOOK ix
CHAPTER ONE
A beginning therapist meets a would-be wife murderer 1
CHAPTER TWO
A man with three penises and two vaginas 11
CHAPTER THREE
My first three months with Attis 23
CHAPTER FOUR
A childhood injury to a body part that stands for a penis and
actualised unconscious fantasy 33
CHAPTER FIVE
Thoughts on personality organisations 47
v
vi CONTENTS
CHAPTER SIX
The psychotic core 57
CHAPTER SEVEN
Beginning outpatient therapy 65
CHAPTER EIGHT
Linking interpretations, a flesh-coloured car,
and emotional flooding 75
CHAPTER NINE
Turkey dinners and identification with
a therapeutic libidinal object 83
CHAPTER TEN
Internalisation–externalisation cycles and the
alteration of the psychotic core 89
CHAPTER ELEVEN
Workable transference 99
CHAPTER TWELVE
Satellite state and therapeutic play 107
CHAPTER THIRTEEN
Crucial juncture experiences 117
CHAPTER FOURTEEN
Physical illnesses and psychic freedom 125
CHAPTER FIFTEEN
Sunset 131
REFERENCES 135
INDEX 147
ABOUT THE AUTHOR
Vamık D. Volkan, M.D., is an emeritus professor of psychiatry at the

University of Virginia School of Medicine, Charlottesville, Virginia; an
emeritus training and supervising psychoanalyst at the Washington
Psychoanalytic Institute, Washington, D.C.; and the Senior Erik Erikson
Scholar at the Erikson Institute for Education and Research of the
Austen Riggs Center in Stockbridge, Massachusetts. He served as the
Medical Director of the University of Virginia’s Blue Ridge Hospital
and the director of the University of Virginia’s Center for the Study of
Mind and Human Interaction. He is a past president of the International
Society of Political Psychology, the Virginia Psychoanalytic Society, the
Turkish-American Neuropsychiatric Association, and the American
College of Psychoanalysts. He holds Honorary Doctorate degrees from
Kuopio University, Finland (now called University of Eastern Finland);
from Ankara University, Turkey; and from Eastern Psychoanalyti-
cal University, St. Petersburg, Russia. He served as a member of the
Carter Center’s International Negotiation Network, headed by former
president Jimmy Carter. He was an Inaugural Yitzak Rabin Fellow,
Rabin Center for Israeli Studies, Tel Aviv, Israel; a Visiting Professor
of Law, Harvard University, Boston, Massachusetts; a Visiting Pro-
fessor of Political Science, the University of Vienna, Vienna, Austria
vii
viii A B O U T T H E AU T H O R
and Bahcesehir University, Istanbul, Turkey; and a Visiting Professor

˖
of Psychiatry, Ankara University, Ankara, Ege University, Izmir and
Cerrahpasa Medical Faculty, Istanbul, Turkey. He chaired the Select
˖
Advisory Commission to the Federal Bureau of Investigation’s 1996
Critical Incident Response Group; was a Temporary Consultant to the
World Health Organization in Albania and Macedonia; and a Fulbright
Scholar in Austria. Dr. Volkan received the Nevitt Sanford Award from
the International Society of Political Psychology, the Max Hayman
Award from the American Orthopsychiatric Association, the L. Bryce
Boyer Award from the Society for Psychological Anthropology, the
Margaret Mahler Literature Prize from the Margaret Mahler Founda-
tion, Best Teaching Award from the American College of Psychoana-
lysts, and the Sigmund Freud Award given by the city of Vienna in
collaboration with the World Council of Psychotherapy. He has been
nominated four times for the Nobel Peace Prize in the mid-2000s and
in 2014 with letters of support from twenty-seven countries for exam-
ining conflicts between opposing large groups, carrying out projects
in various troubled spots in the world for thirty years, and develop-
ing psychopolitical theories. At present he is the president of Interna-
tional Dialogue Initiative, a non-profit organisation that brings together
unofficial representatives from various parts of the world, including
Germany, Iran, Israel, Russia, Turkey, United Kingdom, United States,
and West Bank to examine world affairs from a psychopolitical angle.
He is the author, co-author, editor, or co-editor of dozens of books, and
has served on the editorial boards of sixteen national or international
professional journals. He lectures internationally.
ABOUT THIS BOOK
This book tells the story of a man who became my patient soon after I
began my psychiatric residency training over five and a half decades
ago. The evening before I met him for the first time he had attempted to
chop off his wife’s head with an axe, but stopped himself from becom-
ing a murderer by entering a catatonic state. He was then a thirty-
nine-year-old Methodist minister and I was fourteen years his junior.
For nearly five years I saw him every workday during his first three-
month-long hospitalisation, during a second hospitalisation of over a
month’s duration, and then once a week as an outpatient. Following
this treatment period I moved to a new location nearly 300 miles away
from him, but since I believed that he needed further psychotherapy,
I gave him the name of a psychiatrist who had an office not far away
from where he lived. He refused to see my colleague, however, and
instead drove to my new place and continued to see me once a month
for some years. Gradually, he came less frequently—four to six times a
year for a decade or so and then once or twice a year—until his physical
health started to decline when he was in his mid-seventies. Although I
did not see him after this, we spoke on the phone several times before
he died in his early eighties. By giving details of my understanding of
ix
x ABOUT THIS BOOK
the mind of this Methodist Minister, I will illustrate the appearance of

some primitive mental functions in the daily behaviour of a person who
almost became a murderer.
Psychoanalysts have written psychobiographies of historical figures
such as Adolph Hitler (Langer, 1972; Dorpat, 2002), who caused unim-
aginable human tragedy, including mass murder. In the United States,
especially after 11 September 2001, there was psychoanalytic interest in
examining what makes a person a terrorist, home-grown or otherwise
(Volkan, 1997, 2013; Olsson, 2014). The appearance and psychology of
murderers and attempted murderers within routine societal conditions,
with some exceptions (Duncan, 2002; Fonagy, 2001; Stone, 1989, 2009),
have not been studied in depth by psychoanalysts. One obvious reason
for this is that persons who commit homicide, or who are serial or spree
killers, or attempted murderers do not come for psychoanalytic treat-
ment and do not spend years on a psychoanalyst’s couch. Peter Fonagy’s
paper that describes in great detail the inner world of a killer and
her years-long psychoanalytic treatment is most unusual. His patient
Henrietta, a young woman, had killed her boyfriend by stabbing him
during a violent quarrel (Fonagy, 2001; Fonagy & Target, 2002).
After twenty-year-old Adam Lanza shot and killed his mother and
then went directly to Sandy Hook Elementary School in Newton,
Connecticut on 14 December 2012, I could not stop thinking about why
a person would commit mass murder. This event led me to write Animal
Killer: Transmission of War Trauma from One Generation to the Next (Volkan,
2014b) to examine the role that certain humiliating childhood events
combined with transgenerational transmission of trauma played in
turning a man whom I named Peter into a mass killer of animals. Peter
would fly in a helicopter over a herd of deer, machinegun the animals,
and watch their bellies explode. Peter also killed not only enemy com-
batants, but also women and children during the Vietnam War. When
Peter was a very small child his biological father abandoned him, and a
man who would become his stepfather entered his life and “saved” him
from a smothering, humiliating home environment. Peter’s stepfather
was a survivor of the 1942 Bataan Death March and Japanese war camps
in the Philippines. He deposited his self-representation, severely trau-
matised during World War II, into the developing self-representation
of little Peter and tasked him with being a vicious hunter instead of
one who is hunted. Peter had a prestigious job in the American weap-
ons industry and friends who were high-level politicians. But when he
ABOUT THIS BOOK xi
faced a humiliating event, such as perceived rejection by his wife or

disappointment due to a work situation, he needed to kill animals.
Common to both Peter and the potential wife killer I describe in this
book are experiences of shame, humiliation, repeated helpless rage, and
consequent aggression in their struggles to achieve psychological sep-
aration from the mental representations of their smothering mothers,
in Peter’s case also a grandmother. Even so, their personality organi-
sations were different: Peter had a malignant narcissistic personality
organisation and the Methodist minister had a psychotic one. Peter’s
motivation to be an animal killer was quite specific and unique to him,
with no similarity to the Methodist minister’s motivation to cut off his
wife’s head. We can say that each murderer’s, or potential murderer’s,
psychodynamic processes need to be understood on individual bases.
The most effective way to learn and/or teach psychodynamic con-
cepts, including those that may explain extreme sadism and deadly
violence in a person, is to illustrate their appearance in clinical work,
especially when experienced psychoanalysts describe them through
relating a patient’s treatment from its beginning to its termination.
After I became a psychoanalyst in the early 1970s, owing to my admin-
istrative and teaching duties and my involvement in psychopolitical
projects in different parts of the world (Volkan, 1988, 1997, 2004a, 2006,
2013, 2014a), I devoted what limited time I had for clinical practice pri-
marily to conducting psychoanalysis. I seldom saw patients less than
four times a week in psychotherapy. Throughout the decades I have
written total psychoanalytic processes of several of my analysands
who had different personality organisations, in order to illustrate how
detailed clinical observations are needed to explain theoretical con-
cepts clearly (Volkan, 1973, 1974, 1987, 1995, 2010; Volkan & Ast, 1997;
Volkan & Fowler, 2009). Even though the potential wife killer I describe
in this book was one of my psychotherapy cases and was not on my
couch, I follow the same tradition here and detail stories of my work
with this patient over four decades starting from the first day I met him.
The content of this book, besides illustrating why one individual almost
became a murderer, includes:
• Description of the psychology of severe physical injury in childhood

on a boy’s body part that stands for a penis
• Observation of the appearance of “actualised unconscious fanta-
sies” due to such an injury, and the utilisation of such a fantasy in
xii ABOUT THIS BOOK
adapting to life and developing a variety of symptoms, including

hallucinations and delusions
• Presentation of a conceptual system that emphasises psychic struc-
ture (personality organisation) that expands our evaluation of
intrapsychic conflicts in understanding psychopathology
• Visualisation of the image of a jelly-filled doughnut to define a
“psychotic core” and explore its fate
• Investigation of primitive transference and countertransference
manifestations that primarily exhibit themselves through fusion-
diffusion or internalisation–externalisation processes of various self-
and object images accompanied by introjective-projective cycles of
affects and thoughts
• Illustration of how patients with a psychotic core tolerate “emotional
flooding”, how they begin to utilise anxiety as a signal of a psycho-
logical conflict, and how they accomplish identification with the
therapist as “a new object” while developing new and more adaptive
ego functions
• Definition of how patients with psychotic-level personality organi-
sation begin to comprehend a “symbol” and how they change their
internal psychological structure and develop more ability to test
reality
• Evaluation of “linking interpretations” and “therapeutic plays” in
which patients repeat in action the story of an unconscious fantasy
but, with therapeutic help, finish it in a more adaptive way, illustrat-
ing their new and more adaptive ego functions
• Conceptualisation of “satellite state” in which individuals find a bal-
ance between experiencing individuation and remaining dependent
on the Other, like a small child who can enjoy playing in a room alone
or with other children as long as she can, now and then, rush to the
kitchen and briefly touch her mother
• Description of “crucial juncture” experiences: an adult patient
learning to integrate his self- and object images
• Realisation of how traumas caused by severe surgeries can open
up previously healed psychological wounds
• Attention to cultural and religious differences in the backgrounds
of two persons, the patient and the therapist, working intimately
together for a long time.
ABOUT THIS BOOK xiii
In this book I also hope to illustrate my nostalgia for times when many
clinicians worked hard to understand the inner lives of very severely
disturbed persons and tried to make them more functional instead of,
as is unfortunately too often the case now, simply medicating them
into submission, even sometimes “throwing” many of them out in the
streets.
While this book primarily focuses on my relationship with one indi-
vidual, the Methodist minister, stories of other persons in treatment are
also presented in order to better illustrate certain theoretical and techni-
cal concepts.
Decades after his attempt to kill his wife, the subject of this book
became a beloved leader of his community. His case is most fascinat-
ing. Since I knew him over many decades, he was part of my life. I am
dedicating this book to his memory.
CHAPTER ONE
A beginning therapist meets a would-be

wife murderer
I
was born to Turkish parents in Cyprus, a Mediterranean island
located south of Turkey. I left the island for the first time in 1950 when
I was eighteen years old and went to Turkey to study medicine at
Ankara University. I graduated in June 1956 and in early February 1957
I came to the United States with only fifteen dollars in my pocket and
my violin under my arm. In Ankara, besides attending medical school,
I was a member of an amateur orchestra that performed concerts now
and then. Before leaving Turkey I had secured an internship position at
the Lutheran Deaconess Hospital in Chicago, where I began working as
soon as I arrived. I was part of what was nicknamed the “brain drain”
in the 1950s, when many young physicians from foreign countries were
lured to the United States to compensate for the shortage of medical
professionals there.
The evening after my arrival in Chicago, without any orientation
and without even knowing the American names of basic medicines,
even simple pain killers, I found myself on-call to respond in my bro-
ken English to emergencies for about 600 inpatients. Orientation to the
work at the hospital took place two weeks later. A soft-spoken elderly
surgeon kindly collected eight much younger physicians, all newcomers
1
2 WOULD-BE WIFE KILLER
from foreign lands, for an orientation. He began by pointing to a

telephone and informing us of the name of the instrument, “telephone”,
and that it sometimes rings. Upon hearing the sound, he told us, we
should lift up the handle and before saying “hello” we should smile.
Although some in Turkey and Cyprus may not have been able to afford
a telephone, I certainly knew what one was and how to use it, and
I felt that our host had treated me and the others—all doctors—as
poor, ignorant, uncivilised persons. This was my somewhat bewilder-
ing introduction to the United States. However, I still feel grateful to
the American nursing personnel who were working at the Lutheran
Deaconess Hospital at that time for helping and protecting me until I
began adjusting to my new surroundings. Later I would learn that the
physical plant of the Lutheran Deaconess Hospital was deteriorating,
and by 1968 it would be closed and relocated to the northwest in Park
Ridge, Illinois.
In the 1950s, most foreign physicians who wanted to become psy-
chiatrists had a tendency to seek work in state mental hospitals follow-
ing their internships. There were rumours about the governor of one
state bragging that there were thousands more emotionally disturbed
patients in one of his state’s mental hospitals than there were in the
largest state mental hospital in a neighbouring state. These hospitals
paid physicians from foreign countries higher salaries than they would
have received at university hospitals. I come from a family of teachers.
My parents, my sisters, my brothers-in-law, my uncle, and other rela-
tives were at that time teaching at all levels, from elementary schools to
a medical school, and I was determined to be a teacher too. To prepare
for a position in a medical school, I wanted my training as a psychiatrist
to take place at a university hospital. Therefore, I was happy when I
learned that I had been accepted as a psychiatry resident at the Univer-
sity of North Carolina’s North Carolina Memorial Hospital in Chapel
Hill. After spending one year in Chicago, a big city, I went to Chapel
Hill, then a village.
My experiences as a psychiatry resident at North Carolina Univer-
sity’s Memorial Hospital were very different from those of young phy-
sicians in training in psychiatry at university hospitals in the United
States today. In the mid-1950s psychoanalytic influence was dominant
at university hospitals. Many chairpersons and most senior teachers
at such places were psychoanalysts, and North Carolina Memorial
Hospital was no different. As trainees, we were intensively taught how
A BEGINNING THERAPIST MEETS A WOULD-BE WIFE MURDERER 3
to interview a patient, make sense of psychodynamic formulations,

notice transference manifestations, and make interpretations. I recall
being on-call one evening during my first year of residency when one
hospitalised patient complained of a severe headache. I prescribed
aspirin. The next morning my supervisor learned about this and was
upset about my giving the patient a headache pill without first talk-
ing with him and finding out the psychological causes of his headache.
Part of our education included conducting therapeutic sessions with a
patient while being observed behind a one-way mirror by our supervi-
sors and fellow residents in psychiatry. Sometimes the trainees were
asked to conduct sessions with patients without asking a single ques-
tion. This was done to “force” us to learn how to talk and interact with
our patients, instead of “machine gunning” them with questions and
receiving only short answers. In those days, psychiatric patients could
stay at university hospitals for many months if necessary.
After finishing my residency training I worked at two state mental
hospitals in North Carolina: one and a half years at Cherry Hospital in
Goldsboro and six months at Dorothea Dix Hospital in Raleigh. I was
obliged to do so because the state of North Carolina had paid me an
additional small salary during my training to become a psychiatrist if
I agreed to work at state hospitals for two years after completing my
residency training. There were thousands of inpatients in each state
hospital with various social and economic backgrounds. My interac-
tions with them and their family members taught me in a most direct
fashion about American culture, at least as it expressed itself in the
American South. Cherry hospital was a segregated one, and it housed
only African-Americans with mental problems. Working there for a
year and a half informed me a great deal about the incredible racism
and race problems in the United States (Volkan, 2009). At that time no
one could have imagined that five decades later an African-American,
Barack Obama, would be elected president of the United States.
Most physicians at the state mental hospitals in North Carolina and
neighbouring states in those days were physicians from different
countries—Lithuania, Philippines, Greece, Korea, among others. Look-
ing back, another benefit of working at Cherry Hospital and Dorothea
Dix Hospital was getting to know colleagues from different cultures
and religions around the world. While working at each of these two
state hospitals, I returned to Chapel Hill once a week and continued to
benefit from more education and supervision.
After spending five years in North Carolina, in 1963 I moved to

Charlottesville, Virginia and became a faculty member at the University
of Virginia and a physician at the University Hospital, where I stayed
until my retirement in 2002. I became a United States citizen in 1968
and also a candidate at the Washington Psychoanalytic Institute in
Washington, DC. I travelled about 120 miles between Charlottesville
and Washington, DC again and again for some years to undertake my
training analysis and education to become a psychoanalyst.
Let me return to my psychiatric residency days at the North Carolina
Memorial Hospital. One day, a few months into my psychiatric
training, while I was attending a seminar, a secretary gave me a hand-
written message from the head nurse of my psychiatric inpatient unit.
She wanted me to come to the unit right away. This was very unusual.
I found a telephone, called her, and told her that I was attending a semi-
nar. She sounded very anxious and demanded that I join her right away
because I was assigned to work with a new patient and that two police-
men who had brought him to the hospital needed to talk with me.
The two policemen looked to be in their mid-twenties, as was I. They
seemed to be uncomfortable when they told me that they were from a
small rural community about an hour from Chapel Hill and that the
man they had brought to the hospital had been their own Methodist
minister for the last year. They knew him well since they had attended
his church on Sundays rather regularly and heard his sermons. One
mumbled: “He is the minister who conducted my marriage ceremony
seven months ago.” I learned that the minister and his wife had no chil-
dren. Apparently, they were living in the church parsonage, close to
the church and to a cemetery. Not far away stood a Southern Baptist
church. There were more Southern Baptists in this region than there
were Methodists. I sensed that there was competition between the
two churches—both white-only congregations—and these two young
policemen wanted to “protect” the reputation of their own minister.
However, they had no choice but to tell me about the circumstances
leading to the patient’s admission to the hospital.
After receiving a call in the wee hours of the morning from the minis-
ter’s wife, the head policeman, a Southern Baptist, and one of the young
policemen who was talking to me, rushed to the minister’s house. They
found the Methodist minister in the family bedroom standing over the
bed he had been sharing with his wife, in a “frozen” state, holding an
axe above his head as if he were ready to chop something. The door
to the backyard was open. His wife told the policemen how, when she
and her husband had both gone to bed the evening before, he had been
upset because he had conducted too many funeral ceremonies during
the previous weeks. He told his wife that he might kill her and also
conduct her funeral ceremony. She stated that she had not been alarmed
because she had not believed him. Very early that morning she awoke
to find her husband in his pyjamas standing over her with an expres-
sion of rage on his face, the lifted axe in his hands. After she screamed,
her husband said nothing and seemed to “freeze”. She quickly got out
of bed and called the police. When they arrived, the head policeman
took the axe from the hands of the minister who remained in the same
position, motionless. Because of this strange state of mind, instead of
taking him to the police station or jail, they called a local physician to
come and evaluate him. Prior to bringing him to Chapel Hill, the two
young policemen had changed the Methodist minister’s clothes from
pyjamas to dress clothes, complete with a bow tie, to make him more
presentable.
At one point I noticed one of the policemen turn to the other, the
newlywed, and whisper, “I used to think that the Baptist pastor was
spreading a rumour that our minister was crazy. But, you know, our
minister is crazy. Remember my telling you two weeks ago about my
seeing him in the cemetery next to the church. I swear that he was talk-
ing to dead people! The Baptist guy’s rumour is true. Our minister talks
to ghosts! Our congregation tries to hide it just so the Baptist pastor, that
son of a devil, won’t be pleased.”
The two policemen gave me a two-page handwritten note from the
local physician who had “committed” the patient to the university
psychiatric unit, authorising the policemen to take him to Chapel Hill.
The note said that the patient was thirty-nine years old, and a brief
medical examination showed that he was in good physical condition.
The physician was aware that the Methodist minister had previously
had some “mental problems”. Apparently, authorities of the Methodist
Church had been routinely assigning him to small rural churches. The
physician’s diagnosis of the patient’s condition was “acute catatonic
schizophrenia”, and the physician had given him a strong sedative
prior to his transportation to North Carolina Memorial Hospital.
Soon after the policemen left, the minister’s wife arrived at the
hospital and I joined Rebecca, an experienced social worker much older
than me, to hear what the woman had to say. Gloria was a beautiful,
well-dressed woman with a smile on her face. She did not seem to be
frightened or in a panic state. She told us that she was an elementary
school teacher and school administrator in the town where she and her
husband lived. We learned that she was a few years younger than her
husband and they had been married for twelve years. She described
how her husband had had on and off “psychiatric problems”. Several
times he had been given leaves of absence from work, been hospital-
ised, and had received medications, each time returning to his duties as
a Methodist minister. After being away from work, he would often be
reassigned to a new church, always in a rural area. In fact, since their
marriage they had moved to a new location every three years or so.
Gloria was grateful to the Methodist Church authorities for protecting
her husband.
Gloria told us that the patient’s father had died from a heart con-
dition when the patient was twenty-two years old, five years before
they married. His mother had died a year ago when he was thirty-eight
years old. Apparently his mother’s death had made him very anxious.
His wife believed that her husband was not able to grieve and mourn
his mother’s death in the usual way. Sometimes he called his wife by his
dead mother’s name. She had the impression that, as the first anniver-
sary of the mother’s death approached, he had become preoccupied
with the cemetery next to the church. He would tell his wife that his
mother and his father might come to their house from the cemetery.
In reality, his parents were not buried there. Gloria admitted that her
husband had informed her of his plan to cut her throat when they were
getting ready for bed, hours before he actually went out, fetched an
axe, and then “froze” standing next to their bed. She imparted all this
information without exhibiting emotion, as if she were reading news
from a newspaper.
Rebecca and I thought that Gloria was in shock from this life-
threatening experience. We also thought that as a “good wife” of a
Methodist minister she did not wish to speak too much about “bad
things” and wished to present her husband as harmless. She was will-
ing to remain with him after his discharge from the hospital, and she
did not think that he would try to kill her again.
I then went to see the patient. He was a tall, handsome man with blue
eyes. With his nice clothes and bow tie he looked as if he was ready to
give a sermon or attend a social event. His brown hair was well combed,
and I imagined that either one of the policemen or Gloria had combed
it before he was taken to Chapel Hill. He sat on a chair in his hospital

room with a forced smile on his face. After I introduced myself he spoke
to me, saying things such as, “God blesses us all,” and “Today is sunny
and nice.” He quoted several passages, apparently from the Bible. He
then asked me if I was sent by Pastor Johns to take him to the eternity
of hell. I suspected that Pastor Johns was the Baptist minister from his
community. The patient insisted that everyone is entitled to God’s grace.
He made many references to Jesus Christ and informed me that Christ
died for all humanity, and that even criminals and African Americans
and foreigners were entitled to his love. I am sure he had noticed that I
was foreign, but he made no reference to my accent.
When I was growing up, Cyprus—populated by Greeks, Turks, and
small minorities such as Armenians and Phoenicians—was a British
colony. The Greeks are Christians and the Turks are Muslims. During
my childhood and teenage years, in most areas of the island they lived
next to one another. My parents were under the influence of the first
Turkish President Kemal Atatürk’s modernisation efforts in the new
Turkish Republic, which was established in 1923 after World War I
ended and after the Ottoman Empire collapsed. Because, as Cypriot
Turks, they lived outside of mainland Turkey and longed for their
“motherland”, I believe that my parents, like most other Cypriot Turks,
invested intensely in Atatürk’s cultural revolution. Their exposure to
Greek culture and the British administration also played a role in their
acceptance and assimilation of Atatürk’s modernisation and Westerni-
sation efforts. Many intellectual Cypriot Turks of that time perceived
the extreme religious influences in the Ottoman Empire as having kept
the Turks from embracing modernisation and as having played a cru-
cial role in the fall of the Ottoman Empire.
Due to my parents’ guidance I grew up with very little investment in
practising religion. I did not even learn to recite a prayer. As a young-
ster, when I watched Greeks going to their churches and Turks going
to their mosques, I would wonder why people were involved in rituals
and beliefs that reflected, in my mind, magical thinking. I was only a
cultural Muslim and as a child celebrated Muslim religious days with-
out knowing the reasons they were considered “holy.” I was also taught
to be respectful towards all religions. During my childhood and teenage
years I did not read the Quran and knew little about its stories except
the ones I learned from people I met in daily interactions or from books
and movies based on religious stories. Therefore, while working with
the Methodist minister I had to learn some Bible stories from fellow
residents or friends. I would read much of the Bible and the Quran
many decades later when I was studying Christian cults and extreme
Muslim religious terrorism, because I wanted to know the stories and
passages used to support destructive actions (Volkan, 2010; Volkan &
Kayatekin, 2006).
In 1958 at North Carolina Memorial Hospital I was facing a man who
wanted to cut off his wife’s head and who, when we met, constantly
mentioned Jesus Christ, God, and quoted passages from the Bible. I felt
ignorant about things that he was “throwing” at me and thought that I
would not be able to work with him. However, I had never met an indi-
vidual who actually wanted to cut off his wife’s head, and I was very
interested in knowing the mind of an attempted murderer.
The next day, when I received supervision from the psychiatrist who
was in charge of the inpatient services, I expressed my reservations
about working with this patient. My supervisor, who was Jewish, told
me that my patient’s references to religion, Jesus, and God, might be in
the service of his search for an object to stabilise him, an external super-
ego. He added that my patient had not developed an integrated super-
ego and that his uncertainty about finding a harsh versus benign
superego was confusing to him.
After listening to my account of some of the patient’s statements
from the day before, my supervisor added that the patient was most
likely comparing Southern Baptist and Methodist belief systems, and
was assessing which one was better suited for a needed superego,
while wondering if I was a follower of the Baptist pastor, an enemy.
I was advised to provide a benign superego model for my patient, sit
with him in his room each working day for fifty minutes, tell him that
I wanted to get to know him and that whenever he was ready he could
share his thoughts and feelings with me. If I noticed that something
made the patient very anxious I could share my observation of his con-
dition with the patient, advising him that I was not in a hurry and that
he could take his time to let me get to know him. With this approach,
I would slowly collect data about his life story. My supervisor also dealt
with my anxiety by telling me that he was not in a hurry to hear my
formulation about the patient’s mental condition. I accepted the case
assignment without making any further fuss.
Soon after the patient was admitted to the hospital he was given
psychological tests. The experienced psychologist stated that it was
difficult to administer psychological tests to the patient because of

his inattention. She also admitted that she was afraid of him because
she had been told he was a potential murderer. Nevertheless she con-
cluded that he was suffering from “chronic schizophrenia”. Later in this
book I will return to the diagnosis of the Methodist minister’s mental
state and examine it closely. In those days there were no sophisticated
tools to look at patients’ brain functions and so no intensive neurologi-
cal examination was performed.
During our first meeting I had noticed that the index finger of the
patient’s right hand was missing. I would learn the story of his missing
finger later. He had lost it when he was four years old, and this event
turned out to be a most significant event in his life. In the next chapter
the reader will learn this story and why, when I wrote about this patient
in my first book decades ago (Volkan, 1976), I called him “Attis”.
CHAPTER TWO
A man with three penises and

two vaginas
T
he repressing function of Attis’ ego was not strong. He would
recall events in his early and late childhood in detail and describe
them without expressing affects. Once he informed me about
seeing his mother’s vagina at the age of nine months. Obviously this was
a fantasised “memory”. On other occasions he described his mother’s
vagina when he saw it while she was urinating in a field after harvest-
ing vegetables when her son was only three or four years old. Of course,
I could not be sure if these recollections were real events or imagined
ones. He could also recall certain wishes that most men do not possess
or totally repress. For example, in his early teens Attis had wishes and
dreams of having sex with his mother even though he considered such
acts as frightening. In spite of his interchanging or mixing his fantasies,
wishes, and dreads with realities, having delusions and hallucinations
that I will illustrate later, and sometimes becoming preoccupied with
uttering religious quotations, during the first year or so of our work
together I was able to collect significant data about his real-life experi-
ences and connect their impact on his adult mental state.
Attis was the fourth child of a rather poor uneducated rural fam-
ily. Both his father’s and mother’s ancestors had come to the United
States from middle Europe long ago and had Germanic names, but
11
while Attis was growing up the family did not seem to have an obvious
investment in any specific ethnic identity. There were no pictures of
ancestors hanging on the walls of their farmhouse. A print in a wooden
frame showing a bleeding Jesus on the cross stood on the mantle of the
fireplace in the living room. Attis’ parents were Methodists, Southern
Americans who went to church on Sundays. Their church services
were only for white people, and they blamed African-Americans for
unsolved crimes. When they had time, they listened to country music
on the radio. Attis’ father earned his living by selling vegetables and
fruit raised on the family’s small farm, and his mother stayed home
raising her children, although she also was required to help her hus-
band by working in the fields.
As far as Attis knew, he had been a healthy infant. He was born
on Groundhog Day, 2 February, which is also known as Candlemas
Day. Attis knew that on Candlemas Day, forty days after Jesus’ birth,
his mother Mary presented him to God at the Temple in Jerusalem.
When Attis was a child, however, the focus in the family was not on
him becoming a future light as baby Jesus was. The focus was on the
groundhog story that began as a Pennsylvania German custom in the
United States in the eighteenth century (Yoder, 2003). It is said that on
2 February the groundhog comes out of hibernation. According to tra-
dition, if the animal sees his shadow, he is frightened and retreats into
his hole for another six weeks of winter weather. If he does not see his
shadow, spring will come soon. When Attis was born, there was a ter-
rible and devastating storm; the groundhog could not see his shadow
and he did not return to his hole. But, in this case, the winter was not
over. Attis’ mother, by often repeating the story of the storm during his
birth, made her son feel that the circumstances indicated a malignant
destiny. Occasionally, child Attis identified himself with a groundhog
and he was often filled with a sense of doom, which, in fact, was not
incompatible with the events of his childhood.
Attis had two older brothers and one older sister. When he was
twenty months old, his mother bore twins, a boy and a girl. As luck
would have it, two other women in the neighbourhood gave birth to
twins at about the same time and the three women became highly com-
petitive about their offspring. His mother’s preoccupation with the
twins and with a deaf girl born a year after the twins arrived served
to deprive Attis of adequate mothering in early childhood. Attis could
not recall if he was breastfed or bottle fed when he was an infant. But
A M A N W I T H T H R E E P E N I S E S A N D T W O VAG I N A S 13
he knew that, for a time, he carried a bottle with him and stayed in
diapers along with the babies. Attis recalled how, while growing up, he
had been regarded by others in the family as unduly tied to his moth-
er’s apron strings, but their “togetherness” was filled with tension and
sadistic attacks by the mother, such as her screaming and telling him
that he was a nuisance and that she was tired of his whining. He could
not remember ever being hugged by his mother. Between the ages of
three and four, Attis was involved in several severely traumatic epi-
sodes. His mother’s role in these events further complicated her son’s
response to them and his finding his own healthy psychic individua-
tion. On two separate occasions there were fires in his house, once while
he was sick in bed with a high fever; his mother rescued him each time.
When he was growing up his mother would remind him often that she
was his “saviour” and that without her he would be dead.
Listening to Attis, I developed an image of his mother as a lonely,
angry, and confused woman with seven children. She, I sensed, felt
overwhelmed with mothering activities and work on the farm, espe-
cially after Attis’ birth when she became pregnant with the twins and
a year after their birth when she had a deaf baby. Attis’ mother might
have had an unconscious wish that Attis had perished in these fires. This
way she would have had more time for herself and the other babies.
This might have been the reason why she would tell Attis, again and
again, that without her presence he would not be alive. She might also
have had unconscious guilt over her deficiencies in mothering Attis, as
well as the possibility that her unconscious wish for his disappearance
could become a reality. I concluded that Attis’ mother was not able to
help her son differentiate clearly between his internal state and external
reality, to develop a sufficient capacity to “mentalise” (Fonagy & Target,
1996; Target & Fonagy, 1996). Attis could not accomplish a sufficient
separation–individuation (Mahler, 1968) from the mental representa-
tion of his mother and he could not integrate the caring mother image
with the image of his mother’s frequent yelling at him. His mother
would tell him that she would give him to an ugly, unmarried old
woman in the rural area where they lived. This old woman was appar-
ently a fortune teller and had a reputation for being a “bitch”. Adult
Attis imagined her as an ugly woman with a big nose and ugly teeth.
He often thought that the “bitch” was an extension of his “bad” mother.
Child Attis came to the oedipal age with mentalisation and unresolved
separation–individuation problems.
The following story further illustrates Attis’ mother’s role in his

difficulty differentiating between reality and fantasy, and in his
separation–individuation issues. When he was four, Attis was help-
ing his second older brother chop wood. With his right index finger, he
pointed to a spot where he thought his brother should strike the axe. His
brother chopped off his finger. When this happened, his mother put Attis
in the family truck and rushed him to a doctor whose office was some
distance away to have the severed piece sewn back in place. Her oft-
repeated account of what actually happened indicated that in her panic
she “forgot” to take the severed part with her; had she done so, the child
might have had his finger restored. Instead, when they returned to the
farm, she preserved the severed digit in some kind of liquid in a bottle.
I can only imagine Attis’ mother’s motivation for keeping her son’s
severed finger in a bottle. Perhaps she had a wish to get rid of her son/
his finger but also wanted to deny her guilt for “forgetting” to take the
cut segment of the finger to the doctor’s office. Perhaps she was over-
whelmed by having a handicapped baby daughter and did not wish
to have a physically handicapped son and thus denied Attis becoming
handicapped. Perhaps she had sexualised unconscious fantasies
about the finger segment. Of course, I will never know for sure her
psychological reasons for her unusual decision to keep the cut finger
in a bottle.
Because the glass was transparent, anyone, including Attis, could see
what was in the bottle. The mother was “proud” of this grim object,
which she kept in the guestroom and often displayed to visitors.
Because of how his mother related to the finger in the bottle, as a child
Attis perceived it as “alive”. His mother, just as she had had his life in
her possession when she rescued him from the house fires, also pos-
sessed his “alive” finger. The child’s finger stump was not yet healed
when he had his first experience with surgery—a tonsillectomy. In the
same year in which he had his first tonsillectomy, Attis fell off a ladder
into a bin of cottonseed. On this occasion he could have suffocated and
died. This time he managed to save himself.
When Attis described his father I surmised this man to be a sadistic
individual who did not pay much attention to his children and who did
not express love. He did not drink and only rarely physically abused
his children, but he had frequent temper tantrums. Attis was afraid of
his father’s temper and often saw his father in a fury forcing a stick
up a donkey’s anus when the animal disobeyed his master’s orders.
I concluded that the father did nothing to help little Attis become
“unglued” from a “crazy mother”, as Attis referred to her on several
occasions.
When he was of oedipal age, Attis was told how a worker at a nearby
farm went into a cave and severed his penis with a knife. When he
told me about this event as an adult he trembled. In general he would
not allow himself to express his emotions openly. As an oedipal-age
child, he was preoccupied with the account of the farmworker’s self-
castration and felt menace in the environment. I suspected that in his
mind the farmworker’s self-castration was linked with his losing a
segment of one of his fingers. Attis continued to believe that the finger
in the bottle was “alive” and also stood for a penis. Since this time he
had had fears about sharp objects. At the age of eight he sustained a
back injury that not only left a physical scar on his hips but supported
his belief that life is full of physical danger.
When Attis reached puberty, in the midst of his second individua-
tion (Blos, 1979), his father had an appendectomy. Apparently, Attis’
mother went to the hospital and managed to acquire her husband’s
appendix. She put it also in a bottle filled with the same kind of liquid
that was supposed to preserve Attis’ finger. She placed this bottle in
the parental bedroom, brought Attis’ finger from the guestroom and
displayed them together. Again, I do not know what her psychologi-
cal motivation was for doing such a thing. Attis gazed at the father’s
appendix and his own finger and concluded that the appendix was
larger than the finger segment. He clearly recalled how he wished that
the larger appendix belonged to him. He sometimes wished to eat his
father’s appendix and imagined that he had. Then he would have a
stomachache or think that his father’s eaten appendix would turn into
a penis in his stomach.
I allowed my mind to wander and thought that Attis’ fantasy to eat
his father’s appendix/penis, which was bigger than his finger segment,
illustrated his wish to identify with his father in a most primitive fash-
ion, by introjecting the father’s penis in a concrete fashion, by “eating”
it. His method for finding a way to unglue himself from his mother
by introjecting (eating) his father/the father’s penis, his “reaching up”
(Boyer, 1961, 1983; Volkan, 1976, 1997, 2010) from pregenital conflicts
to oedipal issues, would not work because of the father’s scary sadism,
especially his penetrating a donkey’s anus with a stick; the internalised
father might put a stick in his son’s butt too!
Attis was good at athletic activities when they required no

teamwork, such as running, competing individually. He was aware
that he was different from his classmates and this prevented him from
doing well scholastically. He had thoughts that he would not share
with his friends. For example, sometimes he would “believe” that he
had three penises. The first one was his real penis between his legs.
The second one was represented by his finger segment in the bottle.
It was not just a symbol for his penis, it was his castrated penis, but
“alive”. The third penis was in his stomach, his father’s appendix.
Sometimes he also thought that he had two vaginas, his two armpits.
His vaginas, resembling his mother’s vagina that he had seen, were
divided into a “good” one and a bleeding and “bad” one. In short,
he was a hermaphrodite being.
I imagined that his having three penises responded to a variety of
things. The more penises Attis had, the more he could still possess one
after being “castrated” by his brother/mother’s agent and after expect-
ing castration again, this time by his father. If he remained regressed
and “fused” with his mother he should at least have two vaginas sepa-
rating the “good” mother he wished to have from the “bad” one he
had experienced again and again. He could not integrate his mother’s
mental representation. Perhaps he also wanted to have an extra vagina
in case his father mutilated one by putting a stick in it.
As a teenager, after having dreams or fantasies of having sex with
his mother, Attis would think of being sent to hell. He would easily
associate his image of being in hell with his memories of the horror
of twice being in a burning house and the feeling of suffocation from
being buried alive in a bin of cottonseed. He recalled being so interred
in his adult phobia. When Attis was twenty years old, he had severe
pains in his stomach. He told me that, looking back, he was not sure if
the pain was due to his fantasy of eating his father’s appendix or due
to a medical issue. His physician decided that Attis was suffering from
acute appendicitis. He had surgery and his appendix was removed (but
not saved by his mother). After his father died from heart failure when
Attis was twenty-two years old, Attis believed that his father was bur-
ied alive and that he might come back and castrate him. Once when he
was twenty-four and again when he was twenty-six Attis had throat
surgery. In his mind the stomach-ache, the appendectomy, and the two
throat surgeries seemed to be linked to the images of his childhood
experiences.
His continuing fear of going to hell and being consumed by fire

inspired Attis’ wish to seek God. I sensed that “God” stood for parent
figures that could not be “killed” or damaged by his rage against
them. By turning to God he could save himself from experiencing
overwhelming guilt feelings and fear of “bad” parents’ retaliation. He
seemed to have no religious calling in the usual sense and was very
much conflicted in relating to the church, the image of which, I thought,
was also fused intermittently with the mental representation of his
mother. After much difficulty in a well-known college, he left for a
second-class divinity school, and graduated at age 25. He was then a
Methodist minister.
From what Attis told me and from reading his detailed medical
records from a hospital where he had been taken two years after his
graduation, I could piece together the story of his first major dramatic
psychotic episode. At that time he had a ministerial position in a lit-
tle country church. Listening to him, my thinking was that obtaining
this position forced him to think of himself as an adult. But he could
not function as an individuated male adult without identifying with a
strong father figure or, at least, being an extension of him. His biologi-
cal father was already dead. One Sunday while he was preaching in his
church he felt that the congregation was looking at him in adoration.
This was a “sign” informing him that he could turn into Jesus, God’s son
on earth. As the Virgin Mary presented her son to God on Candlemas
day he himself could be presented to God as Jesus. There was only
one woman in the church, a “bitch”, who was the devil’s agent. But,
by becoming Jesus he could deal with her. On Monday morning Attis
walked into the nearby deep woods, climbing to the mountaintop. As
he walked, he tore his clothing from his slender, well-muscled body;
there should be no barriers between him and his God. He was slashed
by branches as he walked naked, and oozing blood made him look as
though he had been savagely whipped. On the mountaintop, he threw
out his arms as though he were nailed to the cross and stood motionless
to receive his Father, whose power he felt in the rays of the hot summer
sun that began to burn his torn body.
When it was realised that the twenty-seven-year-old minister was
missing, a search party was sent after him. He was found three days
later, naked, dehydrated, and nearly dead. Covered with dried blood
and badly sunburned, he looked so much like an animal that the man
who found him seized his right hand to make a positive identification,
as it was common knowledge that the young minister had lost a finger
on that hand.
Attis was taken to a hospital where he was diagnosed as suffering
from schizophrenia. Following this hospitalisation, he was eventu-
ally allowed to return to his job. He was assigned to another rural area
where, I surmised, religious belief and customs were unsophisticated,
good and evil were seen as issues of black and white, and signs from
beyond taken seriously. In such a milieu, Attis could conceal his delu-
sions most of the time, making an adjustment to his environment. By
this time his older siblings had moved away from North Carolina and
married. The twins stayed near their parents and were involved in
farming, but eventually they married as well. His deaf sister stayed in
the same house with her mother and never married. As an adult, Attis
had minimal contact with his siblings.
His mother wanted Attis to marry a woman she approved of. He
met a schoolteacher, Gloria, in the new community where he was sent
by the church after his dramatic psychotic episode and hospitalisa-
tion. His new location was not far away from the rural area where his
mother still lived. His mother visited him, met Gloria, interviewed
and approved her. She told her son that the younger woman would
be a good wife to a Methodist minister as she seemed obedient, silent,
and devoted to Christ. Until this point Attis had not made any sexual
advances towards a woman. (Even though he had two “vaginas” he
was never interested in sexual relationships with men.) He made plans
to marry the schoolteacher, learning just before the marriage took place
that she was not a virgin. She had had an affair with an older man, just
as Attis suspected or fantasised that his mother had done in her girl-
hood. Attis recalled, even at this time, having the feeling that his mother
and Gloria were interchangeable. Gloria confessed that indeed she had
been an older man’s lover before and while courting Attis, and that this
man had later rejected her. While protesting the marriage in his mind,
saying to himself that he was trapped, Attis went through with the mar-
riage ceremony.
Attis would sometimes feel the presence of his father in the house he
shared with his wife, locating this presence particularly in the closets,
which at times he refused to open on this account. Sometimes he hal-
lucinated his father’s grinning face and adopted more psychological
defences, shouting three times to it to leave him alone and becoming
temporarily catatonic if the face remained. Attis was unable to leave
home without dread of having left something burning inside the house;
he compulsively checked the stove and all the locks each time he went
out. As a married man he had a recurrent dream, reflecting his child-
hood accident in which his finger was cut off. In it, he saw a door drop
like a guillotine on a snake and cut it into two pieces. Sometimes he
hallucinated and saw guillotines and snakes in the house.
Attis’ mother kept the severed finger in the bottle until her death
when Attis was thirty-eight years old, a year before he became my
patient. After his mother’s death, Attis took the bottle with the finger in
it to the home he was sharing with Gloria. He kept it in a dresser drawer
and sometimes thought of it as living. The father’s appendix in the bot-
tle was left behind and was later lost. By this time, the finger in the
bottle was mummified and shrunken; it was a dark piece of hard mate-
rial. About six months after I had first met him Attis brought the finger
in a bottle to one of his sessions in a heavy briefcase. He opened the
briefcase, took out a bottle and showed the morbid item to me. There
was no longer any liquid in the bottle, and indeed the thing in the bot-
tle was an indistinguishable dried-up, dark object. I did not touch the
bottle. He put it back into his briefcase and made sure that the briefcase
was tightly closed. Later, Attis would tell me that after showing me the
finger in the bottle he had returned it to the same dresser drawer. Its
magic apparently continued.
After his mother’s death and his possession of his dried-up finger
segment, Attis’ swings from extreme dependency upon his wife to
extreme, but unexpressed, rage towards her increased. He began to
show more signs and symptoms related to fusion of self- and object
images or representations and/or one object image with another. While
his experiences with fusion with other images or mental representa-
tions had existed before, they were temporary. (Here I am using the
term “mental representation” as a collection of mental images.) Now,
he could hardly differentiate Gloria from the mental representation
of his mother. He was, however, able to differentiate himself from the
mental representation of his wife. On occasions during the sex act he
would think that he was his father. On many other occasions, making
love to Gloria seemed to him as if he were involved in an incestuous
relationship.
During sex, his body perception would change. Before orgasm, he
would experience himself as a frog between Gloria’s legs facing the
mouth of a walrus, which I thought represented the concept of vagina
dentata, a vagina that contains teeth. Putting a penis in a vagina that

contains teeth might result in castration. I thought that the symbolism
of the frog was connected with his idea of a detachable penis (the finger
or the appendix in a bottle). Luis Cortés (1978) has noted a connection
between frogs and genitalia in numerous paintings and sculptures from
medieval and Renaissance Europe. When not intimate with Gloria, Attis
was preoccupied with a longing for “freedom” from wife/mother. He
wanted to divorce Gloria but never actually initiated such action.
When his primary process thinking dominated, in his mind his
divorce/separation from his wife/mother as well as mourning over a
person (his mother, who in reality had died) could be accomplished
through the death of Gloria or himself. The psychological separation
could only be achieved by the physical death of one of the partners.
Mourning means a preoccupation with the mental images of the lost
person or thing (Freud, 1917e; Volkan, 1981a; Volkan & Zintl, 1993).
As long as a person is alive he will maintain the images of important
lost objects. However, when there are no complications the mourning
process comes to a practical end: the mental representation of the lost
person or thing becomes “futureless” (Tähkä, 1984, 1993). The mourner
no longer remains preoccupied with the images of the lost object. Attis
could not mourn as a “normal” adult. For Attis, as the first anniversary
of his mother’s death approached, “finishing” his mourning over the
dead mother literally meant “killing” the wife/mother. He was experi-
encing a complicated, psychotic “anniversary reaction” (Pollock, 1989).
During this time he was called upon to perform an unusually large
number of funeral services as a minister. He became more preoccupied
with graveyards and the return of his dead parents. Sometimes at night
he saw lights moving among the graves.
The night prior to the two policemen bringing him to North Carolina
Memorial Hospital, as Gloria lay sleeping next to him, Attis recalled
having the strongest impulse to kill her. Getting out of bed, he went
to the backyard of the house and fetched an axe. He was very careful
not to be seen by his dead father who might come from the cemetery.
His finger was cut off by an axe and the brother who had cut off his
finger was his mother’s agent. Now, he aimed to do to his wife/mother
what his brother had done to him. As he approached his sleeping wife,
apparently he went into a catatonic state. He did not remember how he
had stopped short of being a murderer.
Some years after I first met Attis, when I was a psychoanalytic

candidate at the Washington Psychoanalytic Institute, one of my
beloved teachers was Edith Weigert. She had studied various ver-
sions of the Attis (or Atys) myth (Weigert, 1938). When I wrote about
my patient for the first time (Volkan, 1976) I gave him the name of
Attis because this mythological figure’s story focuses on the preserva-
tion of body parts, especially keeping a finger alive after death. Other
themes of the myth of Attis also preoccupied my patient’s mind, such as
castration, hermaphroditism, incest, and drinking (eating) the Other’s
blood.
There are different versions of the myth of Attis, according to my
reading of Greek mythology. As the story is told by Carl Kerényi
(1980), the Agdos rock assumed the shape of the Great Mother. Zeus
fell asleep on it and his semen caused the rock to deliver Agdistis,
a hermaphrodite being of great savagery. In an effort to tame Agdistis,
Dionysos turned water into wine, which the thirsty Agdistis drank
until he fell into a deep sleep. Dionysos then tied the male member
of the sleeping Agdistis to a tree, so that, when he sprang up from his
sleep, he castrated himself. The earth drank the blood and ate the torn-
off member and from these grew a new tree. Nana, the daughter of
Sangarius, the river god, placed its fruit in her lap. She conceived a
child of it and Sangarius left the infant out in the open to die, but a
he-goat tended him and he survived. His name was Attis and his beauty
was such that Agdistis, now without a male member, fell in love with
him. Midas, King of Pessinous, sought to separate Attis from Agdistis
and, to this end, gave the boy his own daughter in marriage. Agdistis
appeared at the wedding and drove the guests mad with the notes
of a syrinx, whereupon Attis castrated himself and died. Repentant,
Agdistis besought Zeus to return the boy to life but all that Fate would
allow was to grant that his body would never putrefy, his hair would
continue to grow and his smallest finger would remain alive and capa-
ble of movement.
My patient’s finger in the bottle was “alive”, kept so, not by Zeus,
but by the patient’s mother. His mother was a soul murderer (Shengold,
1991) and had “killed” her son’s soul, but made sure that his finger/
penis would remain “alive”.
CHAPTER THREE
My first three months with Attis
E
arly in my training in psychiatry I developed a habit of keeping
notes on my work with patients whose cases, I thought, would
give me illustrations of psychodynamic concepts and whom I
considered as “special”. Attis was certainly a special patient for me.
While writing this book, decades after my first meeting with him,
I primarily depended on my notes and what I had written about him in
my two previous books, Primitive Internalized Object Relations (Volkan,
1976) and The Infantile Psychotic Self and its Fates (1995). I do not have
extensive notes on my work with him during his first hospitalisation at
the North Carolina Memorial Hospital, which lasted three months, but
I do have some vivid memories.
During his hospitalisation I visited Attis every working day and
spent fifty minutes with him each visit. During the initial three weeks
of his stay at the hospital, except on the first day of his hospitalisation,
he did not talk with me. Whenever I entered his room I found him sit-
ting on a chair hiding beneath the blanket he had taken from his bed
and pulled over his head. According to the nurses he spent most of his
time hidden in this manner. The nurses told me that Attis would leave
his room for meals, but he would suddenly scurry back.
23
The psychiatrist in charge of the inpatient unit would meet with

psychiatry residents who had patients in the inpatient unit, nurses, and
social workers every day except on weekends. I would also see my older
colleague once a week for private supervision. At the direction of my
supervisor, I was having full fifty-minute sessions with Attis even when
he did not speak. I was supposed to listen to my patient’s “silences”. For
an inexperienced therapist this was difficult, and it was much later when
I would learn about different types of “silences” that patients exhibit on
the couch. Peter, the animal killer, whose case I referred to in the intro-
duction to this book, had gone through a very long silent period during
his analysis, session after session. Patients like him who possess a nar-
cissistic personality organisation often escape into a “cocoon” (Modell,
1975; Rudden, 2011) or a “glass bubble” (Volkan, 1979a, 2010, 2014a) on
the couch as an expression of their grandiose fantasy of living alone in
a kingdom and needing no one. Sometimes while inside their “glass
bubble” they do not need to speak. Another type of patient, an overtly
dependent one, may stay silent, comfortable, satisfied, and secure when
he develops an intense transference of being like a baby in the arms of a
loving analyst/mother (Volkan, 2014a). Other times, a patient with rage
does not speak when she feels that her words will act like bullets.
Attis did not have a narcissistic personality organisation with a lonely
kingdom, but a psychotic one. His silences did not indicate that he was
feeling comfortable, satisfied, and safe in my arms. My supervisor and
I concluded that Attis’ hiding behind a blanket and remaining silent in
the foetal position was primarily a concrete illustration of his regression
into a womb. Because of his difficulty with reality testing and differen-
tiating between thoughts/affects, he would stay in a “womb” in order
to deal with intolerable anxiety. He also feared that once more he might
surrender to his murderous impulses if he believed that his words, as
bullets, might harm me.
The supervisor helped those working with Attis to remain non-
intrusive, and we tried to present a safe environment for the Methodist
minister. I recall being told how a new therapist should always remem-
ber that being together with a patient is not like being with someone
in a social setting and that the therapist needs to develop a “thera-
peutic identity” or, in Stanley Olinick’s words, become a “therapeutic
instrument” (Olinick, 1980). Trying to develop a “therapeutic identity”,
following my supervisor’s advice, I would tell Attis that I was in the
room listening to his silences and that he could speak whenever he
M Y F I R S T T H R E E M O N T H S W I T H AT T I S 25
was ready to do so. I added that he and I would be curious about his
thoughts when he verbalised them. I was not directed to give any kind
of medicine to patients, but to learn about their psychological conflicts
and deficiencies, and respond to them psychotherapeutically. In fact,
throughout the decades that I would work with Attis I never gave him
any medicine and he never asked for any. I followed my supervisor’s
suggestions and after three weeks the Methodist minister started to tell
me about himself, at first in a piecemeal and bizarre fashion.
This began in the following way. One day, after I told Attis that I
would not harm him if he would emerge from beneath the blanket,
Attis put his fingers out from under the blanket and wiggled them. He
then began talking while still hiding. I thought that he was showing me
that he was missing a finger. At that time I did not know the story of
how he had lost it. As he had during our first meeting, he began citing
biblical passages, none of which were familiar to me. The next day he
began talking to me without hiding behind his blanket. He referred to
himself as a “monster” with three penises and two vaginas. He hallu-
cinated snakes in the room; he did not fear them but feared their being
hurt. He talked about a guillotine cutting a snake into two pieces. Such
observations convince a beginning therapist that a snake is a symbol of
a penis.
One day Attis began to insist that he was a groundhog. At that time
I did not know enough English and I did not know what a ground-
hog was. It would take many months before I learned the folklore of
Groundhog Day and of Attis’ birth on that day. Today, I appreciate the
hard task that many International Psychoanalytic Association supervi-
sors face when they supervise candidates from countries where psycho-
analytic training is new. Not knowing the language, history, folklore,
and mythology that exist in places such as China, Korea, Turkey, or
Bulgaria where the establishment of psychoanalytic training is still
ongoing, makes supervision of local candidates’ therapeutic work a
challenge. Looking back I think that my not knowing biblical references
and what the word groundhog meant was most likely useful during the
very initial phase of my work with the Methodist minister. I was liter-
ally a “blank slate” to which he could externalise aspects of himself and
project his affects and bizarre thoughts without my complicating them
and then returning them to him.
During Attis’ three-month stay at the North Carolina Memorial
Hospital Gloria came to see Rebecca once a week with the aim of
understanding her husband’s illness and to learn to “manage” him

better after his release from the hospital. The social worker would meet
with me regularly and tell me about her meetings with Gloria. I learned
that Gloria had no close relatives nearby, but had several female friends
whom she could call on quickly when she needed support and advice.
She also had a direct line to an authority in the Methodist Church. Hav-
ing a steady profession seemed to give her self-esteem, but Rebecca and
I sensed her masochistic tendencies; she seemed to express guilt feel-
ings for having had an affair with an older man. This affair apparently
continued even after she was engaged to be married to Attis. Rebecca
explained to me how when she had her affair Gloria was “acting out”
her childhood oedipal fantasies which were overtly stimulated and
complicated by her childhood experiences, including having had a
father who sometimes drank and walked around naked at home while
making sexual remarks about his pre-teenage daughter. Rebecca sensed
that Gloria was still feeling guilty and was determined to be a “good
wife” to the Methodist minister, even though he was strange and dan-
gerous. Gloria did not want to have children and made sure that she
would not get pregnant. Each time she came to visit Rebecca she would
also spend time with her husband.
The combination of nurses’ and my efforts to create a secure envi-
ronment for Attis at the university hospital, and Gloria’s visits helped
him to become more relaxed. Sometimes he appeared to be a “normal”
individual and exhibited social skills in relating to other inpatients and
hospital personnel. During our sessions he described his life experi-
ences in a routine way, but would still sometimes suddenly ask me if I
were Pastor Johns, his father, or his mother in disguise. Sometimes he
would behave as though I was Pastor Johns, his father, or his mother.
His various object images would become fused and interchangeable.
Occasionally, he would give me murderous looks and threaten to kill
me. I guess I was too naïve or inexperienced to feel frightened.
Much later in my career I would write about establishing a “real-
ity base” (Volkan, 1995, 2010) during the initial part of a therapeutic
relationship with individuals who have psychotic conditions and break
with reality. Anna Freud (1954) noted that neurotic patients’ attitudes
toward their analysts as they enter analysis are already based on real-
ity. A person suffering from a neurosis has fantasies about the therapist
(and in turn the therapist has fantasies about the patient) even before the
two meet for the first time (Volkan, 2010). But a patient with a neurotic
condition has no difficulty in separating what is real from what is not

real. She knows that her therapist or analyst is not her mother, father,
sibling, or another important individual. Making practical arrange-
ments for meeting times and payments will be enough to establish a
reality base. Later, such a patient will build a transference neurosis on
this reality base. A person suffering from psychosis has overt and covert
extreme transference distortions as treatment begins. The therapist or
the analyst needs to establish a reality base from the beginning.
When Attis fused my image with his dead mother or father I would
simply remind him that I was not his mother or father. A therapist’s
reliance on what Finnish psychoanalyst Veikko Tähkä (1984, 1993)
called “empathic description” supports the development of a reality
base for patients like Attis at the very beginning of their treatment.
Tähkä re-examined the classic concept of “interpretation”, defined as
bringing to the patient’s awareness mental conflicts and their contents
that were previously unconscious. He stated that the classical defini-
tion of interpretation links it with the phenomena of repression and
dynamic unconscious. Therefore, interpretation as a therapeutic tool
can be utilised only for those patients with neurotic pathology whose
main defence mechanism is repression. Interpretation in the classical
sense could not correspond to the subjective experience of a patient
like the Methodist minister, even when he might grasp an interpreta-
tion intellectually. An individual like the Methodist minister will not
respond to interpretation. Such a patient will most likely respond to
the therapist’s catching and describing the patient’s way of experienc-
ing in a method that is analogous to a primary developmental object’s
(i.e., mother’s) understanding of her offspring and conveying that
understanding to the patient (empathic description). I would explain to
Attis that he was bringing his unfinished psychological struggles with
his parents to our relationship and then feeling as though he were actu-
ally reliving his childhood. Even though he did not really understand
what I was describing, I noticed that he felt more at ease by sensing
that I knew what his trouble was. I tried to remain as a steady “Other”
who would help him to test the reality, especially when he seemed to be
frightened of being flooded with high anxiety and murderous feelings.
I will now report on some events in my own background and make
some remarks about my supervisor in the service of illustrating how
a therapist’s and even a supervisor’s personal issues contaminate a
therapist’s interactions with a patient, as aspects of the patient’s history,
behaviour patterns, and symptoms awaken some psychological issues

in the therapist. For three months I sensed or fantasised that my super-
visor stood by me and supported me more than other fellow psychiatry
residents on the same inpatient unit. I liked this and also found it a
familiar situation. Let me explain. The Ottoman Turks conquered the
island of Cyprus in 1571. My mother’s family belonged to the Ottoman
elite when Cyprus was still an Ottoman island, and her wealthy grand-
father was the kadı (religious chief judge) of Nicosia, the capital city. In
1878 the Ottoman Sultan “rented” the island to the British in order to
secure British support for the Ottomans’ struggle with the Russians.
The British wanted to be in Cyprus to protect their interest in the Suez
Canal. Although Cyprus remained nominally Ottoman territory dur-
ing this period, it was formally annexed by the British in 1914 at the
start of World War I, in which the Ottoman Empire allied itself with
Imperial Germany. Modern-day Turkey formally recognised British
rule in Cyprus in 1923, and the island became a crown colony the
following year.
In 1878, after the island was rented and British administration was
established in Nicosia, my great-grandfather lost his position, and this
lead to marital difficulties. His son, my maternal grandfather, obvi-
ously frustrated, did not follow in his father’s footsteps to become a
well-known respected and highly intellectual figure of the community;
instead, he lived on comfortably using the family’s existing financial
assets until they dwindled. Slowly the family lost its prestige and also
its financial status. One of my mother’s brothers was named after his
kadı grandfather. I suspect that unconsciously he was given the task to
bring back the family’s prestigious name and fortune. He was thought
to be, whether true or not, a “genius”. When he was a young univer-
sity student in Istanbul his dead body was found in the Marmara Sea
some fifty days after he had disappeared. After I became a psychoana-
lyst I suspected that my “genius” uncle was under great pressure to
bring back the family’s prestige and that this pressure was one major
reason for his committing suicide. When I was born, the family gave
me the name of my dead uncle and my kadı, great-grandfather. What
was important was my being a “replacement child” (Cain & Cain, 1964;
Legg & Sherick, 1976; Green & Solnit, 1964; Poznanski, 1972; Ainslie &
Solyom, 1986; Volkan & Ast, 1997).
My mother and grandmother deposited into my self-representation
the idealised mental representation of my dead uncle and tasks
originally given to him. Depositing (Volkan, 1987, 2010; Volkan, Ast &
Greer, 2002), like identification, is utilised by a child for the develop-
ment of his personality characteristics. In identification, the child is the
primary active partner in taking in and assimilating an adult’s men-
tal images and owning this person’s ego and superego functions. In
depositing, the adult person more actively pushes specific images into
the developing self-representation of the child and assigns psycho-
logical tasks to the deposited images. In other words, the adult per-
son uses the child (mostly unconsciously) as a permanent reservoir
for certain self- and other images and psychological tasks belonging
to such images. Melanie Klein’s (1946) “projective identification” can
explain such a process. However, I wish to use the term “depositing”
to illustrate how parenting individuals create a psychological DNA in
the child. Anne Ancelin Schützenberger’s (1998) “ancestor syndrome”,
Judith Kestenberg’s (1982) term “transgenerational transposition”, and
Haydée Faimberg’s (2005) description of “the telescoping of genera-
tions” refer to depositing traumatised images.
An adult’s depositing an image in the developing child’s self-
representation, as well as a child’s identification with an adult’s image,
takes place silently. Nevertheless, there were some visible signs of my
being a replacement child. For example, I had to be “number one” in
my class at the end of each school year while attending middle and high
school, otherwise my mother and grandmother would have “depres-
sion” during the summer. Usually I was able to achieve this. Transgen-
erational transmission of a psychological task forced me to develop
a strong and, I believe and hope, healthy narcissism. I learned of my
being a “replacement child” partly during my personal analysis and
later through self-analysis and collection of historical data about my
family. I believe that as a child I assimilated the combined idealised
images of my uncle and my elite Ottoman ancestor, traumatised by a
historical event, into my self-representation. My being driven to be a
“rescuer” of my family’s fame or fortune, and my ability to sublimate,
I believe, played a role in my becoming a psychoanalyst (Volkan, 1985).
So, in the late 1950s my supervisor’s attention to me and his interest in
me as if I were “number one” among my fellow psychiatry residents,
and my becoming a “rescuer” of Attis felt familiar. All I needed to learn
was to “rescue” a patient through a therapeutic methodology.
There was another, most likely a more important, reason for my
initial devotion in Attis’ case and later for my keeping him as my patient
for decades. I became fully aware of this reason only years after I started
to work with Attis. Here follows the story of my second motivation for
my devotion to Attis’ case.
During the last two and a half years of my life in Ankara before I
came to the United States in early 1957 I shared a small room in an
apartment complex with another Cypriot Turk named Erol Mulla. He
had come to Ankara, as had I, for his medical education and was two
classes below me at the same medical school. He called me abi meaning
“my big brother”. Since I only had sisters and no brothers, I consid-
ered him to be my brother. During the time we were roommates ethnic
conflict began between the Cypriot Turks and Cypriot Greeks. Three
months after my arrival in the United States I received a letter from my
father. In the envelope there was a newspaper article with Erol’s picture
describing how he had gone to Cyprus from Ankara to visit his ailing
mother. While trying to purchase medicine for her at a pharmacy he
was shot seven times by a Cypriot Greek terrorist. This person killed
Erol, a bright young man with a promising future, in order to terrorise
the ethnic group to which he belonged.
After receiving the news of Erol’s death I felt numb. I did not cry.
I was in Chicago in a foreign environment in which I was close to no
one, so I did not share the news of Erol’s murder with any other per-
son. Even when I was undergoing my personal analysis some years
later, I did not dwell on losing Erol. My “hidden” mourning process,
I believe, largely remained just that—hidden. As a young analyst I
felt close to the late William Niederland and, in a sense, I thought of
him as a mentor even though he lived in New York City and I lived in
Charlottesville, Virginia. At the time it never occurred to me that my
seeking out William Niederland who had coined the term “survivor
syndrome” (Niederland, 1968) as a mentor might have something to do
with my losing Erol and my own “survival guilt”. I published a book
called Cyprus: War and Adaptation (Volkan, 1979b) in which I briefly
described Erol’s murder. During the same year I began my involvement
in international affairs (Volkan, 2013). Then, after working with Arabs
and Israelis for over six years, I was involved in bringing together
Soviets and Americans, and later Russians and Estonians, and repre-
sentatives of other opposing large groups to find peaceful solutions for
their large-group problems. At the same time, I was trying to under-
stand the psychology of ethnic, national, religious, or ideological con-
flicts that are associated with massive losses. Without being aware of
my motivation, early in my career as a psychiatrist and psychoanalyst

I devoted years to studying ethnic conflicts, mourning, and adaptation
(Volkan, 1979b, 1981a, 2007a, 2007b; Volkan & Zintl, 1993).
Some thirty years after Erol’s death I once more visited Cyprus. One
summer night some friends took me to a garden restaurant, and one
of them who knew Erol’s story pointed out a bearded man behind the
bar and told me that this man was Erol’s younger brother. I spontane-
ously got up from my chair and approached this man and said to him,
“My name is Vamık. Does this name mean anything to you?” He began
to cry and I found myself also crying out loud, right in the midst of
people dining, with soothing classical music playing in the background.
This event activated my mourning process, which lasted many, many
months. This time I was very aware of it.
It is clear that my hidden perennial mourning process and my readi-
ness to give sublimated responses to it existed when I met Attis. Now,
decades later, I can state that by devoting my interest to treating a poten-
tial murderer I unconsciously wished to understand why people kill
other people. With this understanding, most likely, I wanted to change
potential murderers’ internal worlds and stop them from killing peo-
ple. In my case, by treating Attis, I wanted to keep Erol Mulla alive!
I used to think that my supervisor’s attitude towards me was due to
his fascination with having a patient on his inpatient unit who was a
potential wife killer. As I write this book now another thought has come
to my mind about my supervisor. The chairman of the Department of
Psychiatry had also lost a finger. When there was interest about my
presenting Attis’ case during one of the department’s weekly case con-
ferences that was open to all faculty members, psychiatry residents, and
nursing staff, my supervisor prevented the presentation. He indicated
that talking about a patient’s cut finger in front of the chairperson might
make the “boss” uncomfortable. I had no history of how the chairman
had lost his finger; it was a mystery to me. Did my supervisor’s invest-
ment in Attis’ case have something to do with his wondering about the
chairman’s response to losing his finger? What was my supervisor’s
relationship with the chairman?
It is clear that some of my personal issues were connected with my
early work with Attis, although I was then not aware of them. If such
connections become available to a therapist he must think about how
such connections may influence the therapeutic process. The topic of
countertransference should not remain simply as a theoretical concept.
Sometimes, aspects of the therapist’s or analyst’s countertransference

remain hidden, and this was the situation while I was working with
Attis, at least during the initial years of our relationship. In presenting
total stories of therapeutic processes it is important, however, to report
therapist’s or analyst’s personal issues that influence their investment
in treatment processes in good or bad ways. I believe that in the long
run my issues were helpful in my staying with Attis for decades and
this was, in turn as we will see, very helpful to him.
After staying at North Carolina Memorial Hospital for three months
Attis was discharged. Obviously, he was not well, but sufficiently organ-
ised to return to his daily life while clinging on to Gloria. He resumed
his work as the Methodist minister of his community. He began to
come to Chapel Hill once a week to have sessions with me. Before I
give details of my therapeutic work with him after his first three-month
hospitalisation at the North Carolina Memorial Hospital I will examine
the following issues in the next three chapters:
• The impact of a childhood injury to a body part that symbolises a

penis and its role in the evolution of an “actualised unconscious
fantasy”
• The personality organisation of a person like Attis
• Typical psychological factors in the development of a psychotic
core.
CHAPTER FOUR
A childhood injury to a body part

that stands for a penis and actualised
unconscious fantasy
H
ow fear of physical injury develops throughout childhood
and adolescence, in both boys and girls, has been reviewed
by Jerome Blackman. He tells us: “When we speak of fear of
physical injury, we are dealing both with reality and fantasy. Sometimes
it is difficult to distinguish between the two” (Blackman, 2014, p. 123).
He reminds us that some causes of fear of physical injury are identi-
cal in girls and boys. When children begin walking they become aware
that when they fall, they get hurt. They also become aware that they
can be physically hurt by someone else, such as a sibling who pushes
them down. Blackman adds that while going through the separation–
individuation phase (Mahler, 1968; Mahler, Pine & Bergman, 1975) chil-
dren, both girls and boys, also share a similar fear of physical injury.
When they experience aggression in the service of psychic separation
from their mothers and other mothering persons they develop the
capacity to fear that other persons who are targets for their aggressive
feelings, in turn, can harm them. Blackman then illustrates how fear
of physical injury in girls and boys is also dissimilar when the fear is
linked to fantasies involving sexual organs. When little girls finger their
vaginas, realise an “inner canal” and learn that babies come through
this canal, they develop the fear that they can be hurt. Of course each
33
girl’s handling of this fear and the fantasy associated with it will be
different owing to many factors. As Blackman states, many girls deny
such “vulnerability”. Boys begin to finger their genitals for pleasure just
before the age of two. Blackman states: “By age three, their competi-
tive feelings toward either parent will likely be projected, so that either
parent is feared, even if the parents are gentle. For boys, the witness-
ing of the female genitalia (mother undressing, or girls being diapered
during play groups) creates a thought of being without their pendu-
lous penis. This thought adds to what is dramatically referred to as
‘castration anxiety’” (Blackman, 2014, pp. 123–124).
Castration anxiety is fear of loss of, or injury to, a penis. In 1905
Sigmund Freud thought that castration anxiety was due to external
traumatic threats. Later, he noticed that even in cases in which there
is no such threat, the male child will still have a fantasy of castration
(Freud, 1916–1917). As he imagines that girls are castrated, the little
boy fears that he can be castrated too. He fears that his father will
punish him for his oedipal wishes for his mother by castrating him.
The boy suppresses or represses his oedipal longing for his mother and
internalises his father’s image as his superego. Freud also suggested
that little girls develop penis envy and a feeling of inferiority due to not
having a penis.
Today, Freud’s ideas about castration fantasies in girls is questioned
or rejected (see, for example, Bernstein, 1990). In our clinical practice
however, we often notice that our adult male patients with neurotic
personality organisation—even without a history of traumatic threats
or injuries to their penises or body parts that represent a penis—
express castration fantasies. Usually, such fantasies are unconscious,
and only through therapeutic work do patients become aware of them.
I presented the total psychoanalytic process of a patient I call Gable to
illustrate in great detail the appearance of castration anxiety (Volkan,
2010). When Gable was three and a half years old his father was sent to
a faraway island in the Pacific Ocean on military duty where he stayed
for a little over a year. When his father was away, Gable slept with his
mother in the parental bed. When his father returned he shared the bed
with Gable’s mother and the boy was “forced” to sleep alone in another
room. The mother used to smoke cigarettes without telling her husband.
She would come to her son’s room in early evening to put little Gable
to sleep. She would close her son’s bedroom door, open a window, and
smoke a cigarette sitting on the boy’s bed, rubbing her son’s hair to
A C H I L D H O O D I N J U RY TO A B O DY PA R T T H AT S TA N D S F O R A P E N I S 35
help him get to sleep while whispering, “This [her smoking a cigarette]
is our secret. Do not tell your father.” When Gable told me this story
for the first time he made a slip of the tongue. He was referring to how
his mother’s smoking was like burning “incense” in his bedroom, but
instead he said that the room was filled with “incest.” It appears that
his mother’s sharing a “secret” with him while she was putting him to
bed exaggerated Gable’s castration anxiety. When he was twenty-four
years old and studying English literature at the University of Virginia
he became my analysand. Two years before we started working
together, his father, then a general in the United States Armed Forces,
had moved with Gable’s mother and younger sister to a foreign country
where he had been assigned. During the two years when his family was
away, Gable remained in the United States and secretly married. Then
he received a telegram from his father stating that he, his wife, and
his daughter were getting ready to return to the United States. Gable
became aware that he could no longer keep his marriage a secret and
that his father would know that his son was using his penis for sexual
intercourse. Gable became involved in various self-castration activities.
For example, he quit his studies and became a road worker, getting cuts
and bruises in the course of his workday. When he started his analysis
with me his main preoccupation was to show me bleeding cuts on his
arms and legs: he was already “castrated”; his analyst would have no
need to castrate him!
When a male patient develops an oedipal transference neurosis, he
may experience his analyst as a competitor for the love of a woman,
such as a young female secretary who works at a place near the ana-
lyst’s office. At the same time, the patient may evolve bodily symptoms
and start visiting several physicians to find out what is wrong with his
body, although in reality he suffers from no bodily ailment. He may
dream about his analyst carrying a gun (a symbol of a penis) bigger
than the gun he is carrying. Furthermore, the patient’s own gun does
not function well; it is broken. Going through such periods during an
analytic process eventually makes the patient aware of his childhood
castration fantasy.
Attis’ finger was cut off “accidentally” by one of his brothers when
Attis was four years old. He most likely experienced fear of physical
injury before his finger was cut off, but after experiencing actual bod-
ily harm, in child Attis’ unconscious fantasy the cut finger became a
cut penis. With the help of his mother’s bizarre behaviour—keeping
the severed finger in a bottle—Attis’ castration fantasy became “real”.

Before examining the details of Attis’ “actualised” unconscious fantasy
I will examine theoretical and clinical aspects of unconscious fantasies
in general.
Sigmund Freud described two types of unconscious fantasies:
“Unconscious phantasies have been unconscious all along and have
been formed in the unconscious; or—as is more often the case—they
were once conscious phantasies, day-dreams, and have been purposely
forgotten and have become unconscious through ‘repression’” (Freud,
1908a, p. 161). The first type is usually conceptualised as inherited rep-
resentations of the instinctual drives. Melanie Klein (1946, 1948) and her
followers have given us illustrations of this type, such as a child’s fantasy
about a “bad breast”. Here, my focus is on a type of unconscious fantasy
that resembles Freud’s second type of unconscious fantasy and is simi-
lar to Jacob Arlow’s (1969) and Theodore Shapiro’s (1990) descriptions
of it: a child making an “interpretation” of an external event that reflects
dreads or wishes and defences associated with such dreads and wishes
according to the phase-specific oral, anal, phallic, and genital preoc-
cupations associated with related affects and ego functions available to
him, and also contaminating this “interpretation” with primary process
thinking. A small girl who is traumatised by witnessing an aggressive
primal scene may develop an unconscious fantasy that, when naked
and holding each other, a man eats a woman.
Many psychoanalysts noticed that a repressed or sometimes disso-
ciated “mental content”, the unconscious fantasy, exerts an inter-
minable psychodynamic effect on subsequent perceptions, affects,
behaviour, thinking, responses to reality, and adaptive or maladaptive
compromise formations (Beres, 1962; Sandler & Nagera, 1963; Arlow,
1969; Silverman, 1979; Inderbitzin & Levy, 1990; Shapiro, 1990, 2008).
In psychoanalytic treatment, when the influence of this mental con-
tent on the patient become observable, then the patient and the ana-
lyst develop a “storyline” that transfers the unconscious fantasy into a
formed thought process. Once the storyline of an unconscious fantasy
is found, the unconscious fantasy then resembles an ordinary conscious
fantasy or daydream, but remains illogical due to its absorption of pri-
mary process thinking.
Most unconscious fantasies concern themselves with body
functions—such as eating, defecating, and having an erection—birth,
death, sex, aggression, early object relations, separation–individuation,
oedipal issues, physical injury, castration, family romance, mother’s

pregnancy, father’s penis, and siblings.
Some unconscious fantasies are common. For example, Ast
and I, in our book on siblings (Volkan & Ast, 1997) illustrated the
commonality of various types of sibling-related womb fantasies.
Such fantasies were described by Bertrand Levin as long ago as 1935.
He illustrated how some womb fantasies underlie claustrophobia.
A storyline of a womb fantasy could be: “I want to be my mother’s only
child in her womb. I will enter there and kill my unborn sibling, but
my sibling in turn may kill me.” An adult under the influence of such
an unconscious fantasy, obviously without knowing why, may have
anxiety about entering caves or may do the opposite and visit caves
regularly. Caves symbolically represent a mother’s womb without the
person being aware of the psychological reason for either a hobby as a
cave explorer or anxiety when entering a cave.
Since this book describes the case of a potential murderer, I will now
briefly describe the story of a woman who, as a child, had a death wish
towards a sister and an unconscious fantasy of being a murderer. In
her case, dealing with the influence of an unconscious fantasy in adult-
hood was sublimated primarily by utilisation of reaction formation.
When new events in her external world reactivated circumstances in
her childhood that led to the formation of her unconscious fantasy, her
sublimation broke down. The story of this woman, Amanda, was pre-
sented by Piyale Comert (2006).
Exhibiting preoccupation with her physical health, Amanda started
her analysis at the age of thirty-nine, the age her mother had been when
she died. Piyale Comert tells us how Amanda had a sister four years her
senior. The sister had Noonan’s syndrome and therefore a heart defect
that required frequent hospitalisations until she had successful heart
surgery at the age of thirteen. On many occasions when her sister was
hospitalised, child Amanda would be left alone in the cafeteria of the
hospital and would feel unloved. As she verbalised again and again dur-
ing her analysis, Amanda patiently waited “for my turn” to be noticed
and loved. She recalled how she, at age three, had thrown her sister’s
Barbie doll out the window of the car during a family trip. During her
childhood, she often wished her sister would be kidnapped by gypsies.
Eventually, Amanda and her analyst would openly verbalise Amanda’s
unconscious death wish for her sister and her unconscious fantasy
of being a murderer. Amanda’s parents’ anxiety about the possibility
of losing their oldest daughter during her hospitalisations played a

role in supporting Amanda’s wish and fantasy that her sister would
disappear.
Adult Amanda’s primary way of adapting to her unconscious fantasy
and related guilt was through reaction formation. After her sister, who
was married, gave birth to a son, he was diagnosed with having a more
severe version of Noonan’s than his mother’s. Amanda did everything
to “steal” this boy from her sister and take care of him. Her unconscious
fantasy about getting rid of her sister was replaced by her becoming
the saviour of her nephew. While the boy was growing up she lavished
him with gifts and other generosities. When the boy turned eighteen,
most likely due to his wish to individuate away from his aunt and also
perhaps due to being prompted by his mother, he refused to accept his
aunt’s monthly financial aid. This event broke down Amanda’s adapta-
tion to her childhood unconscious fantasy and she felt depressed.
Piyale Comert (2006) states: “Around this time, she [Amanda]
had a dream: Amanda goes into a cave to investigate what is inside
and a ferocious animal/monster reaches out trying to grab her. We
understood this dream as Amanda trying to reclaim her mother’s
womb and being greeted by her ferocious sister who stakes claim to
the mother by blocking Amanda’s access. The monster is also Amanda
herself inside her mother and spewing terror.” Amanda’s nephew’s
refusal of her financial help and her womb dream occurred one year
after Amanda’ mother’s death and just as her father was starting to
date a young woman. Once more, Amanda’s “turn to be noticed and
loved” did not materialise. All these events placed Amanda at the
mercy of the influence of her unconscious fantasy. As Gabriele Ast and
I wrote: “One cannot stop murderous rage and associated unconscious
fantasies by conscious decisions, nor can one control the effectiveness
and reliability of reaction formations or sublimations” (Volkan & Ast,
1997, p. 73).
There are unconscious fantasies that are highly individualised; they
belong only to the individual that has them. This occurs especially if
the initiation of the unconscious fantasy is due to an unusual specific
trauma or a collection of such traumas. For example, Gabriele Ast and
I (Volkan & Ast, 2001) described the case of Gitta, who was born with a
life-threateningly defective body. Beginning in infancy and lasting until
she was nineteen years old, she endured forty surgical interventions.
When she was born, Gitta was literally leaking from her mouth; her
saliva had to be wiped out often in order to keep her alive, a task that
her mother performed throughout Gitta’s early childhood, as well as
later when Gitta had to remain immobilised, sometimes for months,
after some of her surgeries. As an infant, Gitta had been tube-fed, requir-
ing a “hole” to be made in her body. And, throughout her childhood,
the various surgical procedures and additional periods of tube feeding
required countless additional openings to be made in her young body.
Yet, when she started analysis in her late twenties with Dr. Ast, her
physical appearance was for all practical purposes normal.
Gitta was exposed to the reality that as long as she bled or some
other fluid (urine, faeces) came out of her body, she was not dead. Her
unconscious fantasy was that she had a leaking body and that as long as
her body leaked she was alive. The content of her unconscious fantasy
could be seen rather openly in some of her conscious behaviour and
thinking. For example, as an adult, she wore sanitary napkins every day
since she “believed” that her menstrual flow was constant. She hesi-
tated entering a swimming pool and avoided swimming in a nearby
lake; later in analysis, it became apparent that she was afraid that the
pool or lake water would enter her body through its “holes” and con-
taminate her own fluids. Her unconscious fantasy was actualised.
Actualisation of an unconscious fantasy (Volkan, 2004b, 2010;
Volkan & Ast, 2001) occurs when the actual trauma is severe or a series
of actual traumas are accumulated, and when they interfere with “the
usual restriction of fantasy only or mostly to the psychological realm”
(Volkan & Ast, 2001, p. 569). The individual continues to experience
symbols or objects of displacement representing various aspects of the
actualised fantasies as “protosymbols” (Werner & Kaplan, 1963). That
is to say, to this individual, they are what in actuality they represent. In
Gitta’s case her actualised unconscious fantasy was highly individual-
ised. I do not know of another woman who believes that her menstrual
flow is constant and that her body is constantly leaking.
Sometimes common unconscious fantasies, shared by others, may
also become actualised in an individual case. A girl’s unconscious oedi-
pal fantasy, in a routine developmental process, remains in the psycho-
logical realm and it will psychologically influence the individual as an
adult according to the individual’s capacity for repression and subli-
mation to one degree or another. If the influence of the girl’s uncon-
scious fantasy that is related to her wish to possess her father is very
strong and not well sublimated, she, as an adult, may have a tendency
to marry an older man (a father figure) or several older men one after
another. Nevertheless, her unconscious fantasy still stays within the
psychological realm. But if, while developing an unconscious oedipal
fantasy, the little girl is severely traumatised, such as by being sexually
assaulted by her father or a father substitute like an uncle or a priest,
her unconscious oedipal fantasy may become “actualised”. Because
there is a strong link between the unconscious fantasy and reality, the
little girl’s unconscious fantasy will exist in both the psychological and
experiential realms. During her adult sexual relations, the actualised
unconscious fantasy, as the heir of her severe traumatic childhood
event, can be experienced as “real”, or at least partly real, and exist-
ing in the present time. For example, if a man makes sexual advances
towards her, most of the time or on some occasions, she can experience
this man as the original traumatising and victimising father, uncle, or
priest, even though in reality the man’s advances remain within socially
acceptable patterns. The man is not someone behaving like the origi-
nal assaulting person; in the patient’s mind, he is the assaulting per-
son. If Piyale Comert’s patient Amanda’s sister had died in childhood,
Amanda might have developed an actualised unconscious fantasy that
she was a murderer.
Besides incest or repeated sexual stimulation by parents or others,
malignant sibling rivalry, severe bodily injuries, surgeries, near-death
experiences, drastic object losses, and exposure to massive destructions
caused by events such as earthquakes or wars during childhood make
a child prone to developing actualised unconscious fantasies. Severe
actual trauma or accumulation of such traumas in early childhood may
lead to developmental ego defects in mental structuring. Whenever
there are ego defects, such as not being able to utilise differentiation
among various self- or object images, or integration of them and repres-
sion of certain affects effectively, there are also object-relations conflicts.
In other words, as an adult the individual will experience tension or, as
often is the case, severe anxiety concerning differentiating self-images
from object images as well as integrating or not integrating libidinally
and aggressively loaded self- and object images within, or externalising
them on to others and re-internalising them. I do not separate such indi-
viduals into those having only ego defects or only early object-relations
conflicts. Such individuals’ actualised unconscious fantasies reflect
both ego defects and early object-relations conflicts and link them.
When such a person’s adult life is dominated extensively by actualised
unconscious fantasy, that person will exhibit a clear break with reality.
This situation applies to Attis’ case.
At other times, we meet patients who separate and isolate a trau-
matised self-image with its corresponding object images and affects
from the rest of more developed self-representation and thus dissoci-
ate their typical or actualised unconscious fantasies. What they do is
known as “encapsulation” (D. Rosenfeld, 1992; H. Rosenfeld, 1965; see
also Brenner, 2001, 2004). Encapsulation may break down, especially
when an adult patient becomes involved in an event that closely reflects
the theme of the original trauma. If encapsulation breaks down, the rest
of the individual’s self-system will be assaulted by the previously sepa-
rated and isolated part, which may also include a previously “hidden”
typical or actualised unconscious fantasy. When a previously actualised
unconscious fantasy emerges from its “envelope”, the individual may
experience overwhelming tension and a limited or more generalised
break with reality.
There is one more condition that is related to an unusual outcome
for unconscious fantasies. Under certain circumstances a previously
typical unconscious fantasy may become like an actualised one. For
example, a man who had a murderous unconscious fantasy about his
sibling in his mother’s belly became a cave explorer as an adult. He had
sublimated the influence of his typical unconscious fantasy through
developing a hobby. One day he unexpectedly found a dead body in
a cave. His fantasy was thus actualised in his adulthood (Volkan &
Ast, 1997).
In this chapter I will not dwell further on unconscious fantasies
that become actualised in adulthood since this topic is not related to
Attis’ case. Attis’ actualised unconscious fantasy of being castrated had
evolved when he was a child. Attis is not the only person I studied
whose finger was cut off by an older brother and who had an actual-
ised castration fantasy. After I became a training and supervising psy-
choanalyst, a younger colleague—let us call him Dr. Matlock—began
receiving supervision from me while analysing a man named Smith.
I was fascinated to learn that Smith’s little finger was “accidentally” cut
off just above the distal interphalangeal joint by his older brother on a
camping trip. At that time he was eight and his brother was fourteen.
Like Attis had done, Smith had placed his hand on a log being chopped
by the older boy and the tip of his finger was lopped off. In addition
to Smith and his brother being victims of this kind of physical trauma,
both scenarios involved parents who could be grossly insensitive and

unempathic with their offspring.
Smith, living on the East Coast of the United States, entered anal-
ysis with Dr. Matlock when he was fifty years old for panic and/or
depressive states. Smith had never been married and from adolescence
onwards was highly inhibited around women and men of author-
ity. He suffered from premature ejaculation and erectile dysfunction,
except when he was with a woman named Mary who lived on the West
Coast of the United States. Although they lived over 2,000 miles apart,
the two had been sexually involved for several decades. Smith would
have an urgent impulse to fly and visit Mary again and again in spite of
the fact that it was expensive and interfered with his routine work. He
described his impulse to be with Mary not as a wish, but as a most puz-
zling need. Often Smith idealised her and called her a “perfect woman”,
despite much evidence that she was quite neurotic herself. After pre-
senting aspects of Smith’s life story I will present Smith’s repeated visits
to Mary as they reflect the influence of his actualised unconscious fan-
tasy of being castrated.
Smith was the third of three sons born to his parents. His brothers
were two and six years older respectively. He described his mother,
an elementary school teacher, as a passive, waiflike woman who was
utterly bereft of maternal qualities. She openly told him that she never
loved his father and would have divorced him if it were not for him and
his brothers. His father, a war veteran, worked as a foreman in a ship-
yard until his “conversion” in his late forties prompted him to resign
this job and open a Christian bookstore. Smith described his father as a
self-important man who disdained his sons, especially the two younger
ones. Whenever his knowledge, opinions, or decisions were questioned
he would fly into a rage. Smith thought his father an arrogant fool,
although in his presence he never gave the slightest hint that he nur-
tured such a sentiment, he was so afraid of him.
Smith’s middle brother was a reclusive child who spent much of his
time in his room with his nose buried in books. A teacher once wrote
a note to his mother in which she expressed her opinion that the child
felt “neglected and unloved”. His oldest brother was a sadistic boy who
once tried to kill his middle brother by drowning him in a pool as Smith
looked helplessly on. Had an adult not intervened to save the boy, he
might have succeeded. The oldest brother, besides cutting off the tip of
Smith’s finger with an axe, also tried to sodomise Smith after he emerged
from a shower several months later. When his parents were not around,
this brother would taunt and tease Smith mercilessly. Sometimes these
verbal assaults would turn physical and he would savagely beat his
hapless brother.
Shortly after Smith’s finger was cut off, his father noticed a swollen
area near his son’s groin during a bath. He was seen by a doctor who
diagnosed a inguinal hernia about two inches from his penis. He
received a hernial repair and remained in the hospital for several days
to recuperate. Around this same time, his teacher decided that she
would have her male students come to school dressed in girls’ clothes.
This terrified Smith; he went into “a tailspin of panic” and complained
to the principal who cancelled this ill-conceived stunt. Dr. Matlock and
I assumed that his difficulty going through a “normal” oedipal phase,
having his finger cut off by his sadistic brother, being abused by the
same brother, undergoing surgery, and being asked to dress like a girl
combined to actualise Smith’s castration anxiety.
At the pubertal age Smith was a shy, inhibited youngster, especially
with girls. In high school it would often take him hours to find the
courage to call a girl for a date. Upon graduation from high school,
he attended college where he earned good marks and led a seemingly
active social life, despite his shyness around young women. To manage
his anxieties when in their company, he began to drink heavily and/or
use drugs. He pledged a fraternity but resigned within a year because
of the anxiety he felt around his fraternity brothers.
After college, he taught high school for a while and then decided to
attend graduate school to work towards a master’s degree in vocational
counselling. His first job in his new career was as a vocational counsel-
lor in a state mental hospital. He dreaded staff conferences where he
had to present reports on patients he had evaluated because he would
panic whenever he had to speak. In his analysis it would become clear
that his motivation for working in a mental hospital included a wish
to find solutions for his own psychological issues and/or project his
difficulties onto others. Within a year he grew dissatisfied with this job
and entered the military where he experienced his superiors as strong
and stable parent figures. This helped him and eventually he was com-
missioned as an officer. After twenty years in the military he retired and
started a business that he could manage mostly from his lonely home.
Smith sought psychoanalytic treatment soon after the death of his
father. The father’s death had rekindled aspects of unresolved oedipal
issues which permeated the copious dream material that he brought

to his sessions during the initial phase of his analysis. Typical of these
dreams was one in which two planes (penises) were flying side by side.
He compared the airplanes and then tried to shoot the other one down,
experiencing anxiety while doing so. Both planes landed safely but as
he deplaned the other pilot came after him and tried to kill him.
Now let me return to Smith’s need to visit Mary, which had contin-
ued after he entered psychoanalysis. These visits sometimes interfered
with his hold on his psychoanalytic appointments. Smith declared that
he had no intention of marrying Marry, but he had to be with her, espe-
cially following an event that made him feel humiliated, such as when
he faced a problem in his business or was treated badly by an older
male waiter at a restaurant. He was well into the first year of his anal-
ysis when Dr. Matlock was informed, almost as an aside, about how
Smith’s trips to be with Mary were directly related to the actualisation
of his castration fantasy. Upon his return from a weekend trip to the
West Coast, Smith opened his session by saying, “We [meaning him and
Mary] feed off each other. But what we really have most in common is
our deformed little finger.” It was then that Dr. Matlock and I learned
that Mary too had lost part of a finger. Smith continued, “We are a cou-
ple of neurotics in love.”
He described how, before having sex, he and Mary would place
together their cut fingers as if one partial finger was an extension of
the other partial finger. Then Smith would not have erectile dysfunc-
tion or premature ejaculation. Dr. Matlock silently formulated that two
half fingers make a whole finger (whole penis) and that Smith, through
a mental fusion of the two fingers, was undoing his actualised castra-
tion. This was why he needed to fly to the West Coast again and again.
Later in Smith’s analysis we were able to adduce more data supporting
Dr. Matlock’s formulation about the meaning of these trips.
For Smith, two cut fingers touching one another did not simply
create a symbol of an uncastrated penis; they created a protosymbol
(Werner & Kaplan, 1963), and Smith experienced possessing a com-
plete penis. Even his repeated experiences in “finding” his uncastrated
penis and not simply its symbol included distortion of reality. Smith,
unlike Attis, did not have formed delusions and hallucinations. He was
able to test the reality in his daily life. Even though he had a history
of fearing being killed by his sadistic brother and, in his dreams, by
figures symbolising this brother and/or his father, he did not have an
impulse to murder someone. Smith had a higher personality organisa-
tion than Attis.
Before returning to Attis’ case let me mention my circumcision when
I was eight years old. In the culture of the Muslim environment where
I grew up, circumcision of boys was carried out without anaesthesia,
usually between the ages of four and eight. Because of many compensa-
tory and counterphobic factors, such as verbal preparation, ceremonies,
and gifts, this procedure would become something strongly needed
by the ego, so much so that the lack of it might be severely traumatic
(Öztürk & Volkan, 1971). My circumcision took place in a room of our
rented house in Nicosia. I was surrounded by my father and his adult
male friends and relatives. I sat on my paternal uncle’s lap. He held my
legs apart as a barber circumcised me and as someone put a Turkish
delight in my mouth. Everyone in the room clapped their hands and
congratulated me for becoming a “man”. I went through this religious/
cultural developmental passage without any complications.
Attis’ loss of one of his fingers when he was four years old and his
mother’s peculiar way of dealing with this loss during his childhood,
in fact, for decades, were central events that shaped Attis’ personal psy-
chological structure, especially his difficulty with reality testing. In his
own way he, in action, informed me about this at the beginning of his
initial three-month stay at the North Carolina Memorial Hospital. As
I have already stated, he broke his three-week silence while meeting
with me as an inpatient only after showing his fingers from under the
blanket behind which he was hiding and then drawing them back. He
then described his hallucination of snakes and his fear that they would
be cut by a guillotine. For me, snakes were symbols for his penis, but
for Attis they were more than symbols. When a guillotine cut a snake
into two parts the snake was his penis; he was terrified. After the time
he wiggled his fingers from behind the blanket, Attis always concealed
the stump of his finger beneath his other hand, and it would be years
before he could show it to me without anxiety.
A mother’s role in distorting reality for a child can play a
significant part in the child’s holding on to psychotic behaviour, espe-
cially when this distortion prevents a child from taming typical uncon-
scious fantasies, such as those linked with separation–individuation
and oedipal issues. The main storyline of Attis’ actualised unconscious
fantasy could be read in the following way: “I am castrated by my

brother, my mother’s extension, but my castrated penis is alive. I cannot
psychologically separate from my mother as long as she possesses my
penis.” Later, in his mind, his actualised castration by his mother was
condensed with his fantasy of being castrated and sodomised by his
father. Then, in another bizarre action, Attis’ mother saved her hus-
band’s removed appendix, which forced her son to have further strange
fantasies, one of which was the most obvious one: his idea of eating his
father’s appendix in the service of “reaching up” for an oedipal escape.
For Attis, his finger and his father’s appendix in bottles were not simply
symbols; they were penises. After his mother’s death when he took the
bottled finger to his home and put it into a dresser drawer in the bed-
room he was sharing with Gloria he still could not believe that he repos-
sessed his cut penis. After his mother’s death Gloria represented his
mother even more, and his “mother” lived on. By killing Gloria Attis
hoped to separate psychologically from his mother. It was this thought
that made him a potential wife killer.
Unlike Smith, Attis did not have erectile dysfunction or premature
ejaculation. But, as I gathered more information about him, I learned
that his love making was rather mechanical in the service of discharg-
ing his sexual excitement. He did not share with Gloria that he some-
times turned into a frog and perceived her vagina as a walrus (vagina
dentata). Just as he divided his penises into three and vaginas into two,
his self-representation was also split, in fact, fragmented. In the next
chapter I will examine such a self-representation before I describe my
further work with the Methodist minister.
CHAPTER FIVE
Thoughts on personality organisations
A
ccording to the classical psychoanalytic view, only neurotic
patients are analysable, but even some individuals whom
Freud attempted to treat had more psychological problems
than individuals with typical neurotic conditions. Since the early
days of psychoanalysis, patients with many types of psychopathology
have visited psychoanalysts’ offices. Nevertheless, when I started my
training in psychiatry, patients accepted for psychoanalytic treatment
were selected very carefully. There would be a serious evaluation of a
patient’s suitability for undergoing psychoanalysis, especially with a
beginner in the field. If the therapist was still in psychoanalytic training
this evaluation had to be approved by the supervisor. Individuals with
enough ego strength, those considered to have only neurotic problems,
were selected to undergo psychoanalysis.
In 1953, a few years before I came to the United States, some well-
known psychoanalysts began to notice that it was an illusion that psy-
choanalysts only treated neurotic individuals. Under the umbrella,
which they named the “widening scope of psychoanalysis”, they began
47
to have a discussion on this topic (A. Freud, 1954; Jacobson, 1954; Stone,
1954, Weigert, 1954). Anna Freud said:
If all the skill, knowledge and pioneering effort which was spent
on widening the scope of application of psychoanalysis had been
employed instead on intensifying and improving our technique in
the original field, I cannot help but feel that, by now, we would
find the treatment of the common neuroses child’s play, instead of
struggling with their technical problems as we have continued to
do. How do analysts decide if they are given the choice between
returning to health half a dozen young people with good prospects
in life but disturbed in their enjoyment and efficiency by compara-
tively mild neuroses, or to devote the same time, trouble and effort
to one single borderline case, who may or may not be saved from
spending the rest of his life in an institution? Personally, I can feel the
pull in both directions, perhaps with a bias toward the former task;
as a body, the [American] Psychoanalytic Association has inclined
in recent years toward the latter. (A. Freud, 1954, pp. 610–611)
Anna Freud’s preference was not followed. As years passed, along with
the decrease in old-type “suitable cases” rushing to undergo psycho-
analysis, many individuals with conditions above and beyond neurotic
problems began filling the psychoanalysts’ and psychoanalytic thera-
pists’ offices. This meant that aspects of classical psychoanalytic tech-
nique, which were designed to treat neurotic patients, would not be
applicable in the treatment of individuals who have other types of men-
tal problems. As I gained more and more experience in working with
patients, I gave up focusing on surface diagnostic terms that referred
to this or that type of neurosis or psychosis and preoccupation with
symptoms and signs of mental problems. Of course, such diagnostic
terms and definitions of signs and symptoms usually provide initial
significant information about an individual. Also, diagnoses accord-
ing to The Diagnostic and Statistical Manual of Mental Disorders (DSM),
published by the American Psychiatric Association, is required in situa-
tions such as when a clinician needs to meet requirements for insurance
coverage. When evaluating an individual’s mental condition and/or
soon after starting to work with this individual, I began to ask myself,
“What am I treating?” This question can be answered by going beyond
putting the patient under a diagnostic category and referring to signs
T H O U G H T S O N P E R S O N A L I T Y O R G A N I S AT I O N S 49
and symptoms. Making an “internal map” of the individual’s psychic

structure is necessary in order to better understand intrapsychic con-
flicts. For me, treatment meant modification in the patient’s internal
map. This modification should be observed clinically when the patient
starts performing psychological tasks that she could not perform
effectively earlier.
In 1963, as well as in 1969, Donald Winnicott, a paediatrician who
became a psychoanalyst and introduced us to his version of object rela-
tions theory, “played” with diagrams and wrote papers about what
he considered a “circle” representing a person. He wrote: “Inside the
circle is collected all the interplay of forces and objects that constitute
the inner reality of the individual at this moment of time” (Winnicott,
1963, p. 75). By 1969 he was telling us that “the individual” was a rela-
tively modern concept. Until a few hundred years ago, he informed
us, outside of a few exceptional “total individuals” (Winnicott, 1969,
p. 222) everyone was unintegrated. Even in 1969, when he wrote again
about a circle representing a person, he believed that the world was
mainly composed of individuals who could not achieve integration
and be a total unit. He noted that it is necessary to divide this circle by
putting a line down its centre and stated that “there must always be
war or potential war along the line in the centre, on either side of the
line there become organized groupings of benign and persecutory ele-
ments” (pp. 222–223). He continued: “Idealists often speak as if there
were such a thing as an individual with no line down the middle in
the diagram of the person, where there is nothing but benign forces for
use for good purposes” (p. 223). If we find a person who appears to be
free of “bad” forces and objects, this simply means that the individual
“is getting relief from a real or imagined or a provoked or delusional
persecution” (pp. 223–224).
Many years after I read Winnicott’s papers I too began to “play” with
a circle that stands for a person in order to define three main types of
internal maps, personality organisations. The first one is the high-level
(neurotic) personality organisation. It is represented by Winnicott’s cir-
cle with a line down its centre. The individual who possesses this type
of internal map has a capacity to tolerate ambivalence, since opposite
halves of the circle touch one another even though they are divided by
a line. I consider this line not as a straight line but a segmented one in
order to illustrate that persons who possess a high-level (neurotic) per-
sonality organisation have an integrated self-representation in spite of
their experiencing ambivalence. The degree of tolerance for ambivalent

feelings, thoughts and perceptions will be different from person to per-
son. Such individuals perceive object images or representations realisti-
cally while experiencing varying degrees of ambivalence about them.
Their reality testing is good and they own both sides of their mental
conflicts. These individuals’ primary defence mechanism is repression
and their anxiety has a signalling function, heralding internal danger
stemming from mental conflicts. The psychoanalytic structural theory
that divides mind into id, ego, and superego is applicable in formu-
lating such individuals’ mental conflicts and describing the role of the
superego in relation to ego functions and pressure from the id. Classical
psychoanalytic technique was designed and evolved to be utilised for
such individuals. Pre-oedipal problems that appear during the psycho-
analytic treatment of persons with high-level personality organisation
are mostly due to defensive regressions and fixations, and not due to ego
deficiencies. Such patients work through them, become more directly
pre-occupied with oedipal issues, develop oedipal transference neuro-
sis and then resolve it. At the end of their successful analytic process
they make some parts of the line in the middle of the circle more flexible
or more pronounced according to their improved reality testing.
We also treat individuals who cannot be represented by a circle with
a segmented line down its centre. These are individuals whose pri-
mary defence mechanism is splitting. The circle’s opposite sides do not
touch each other, or touch each other only in limited areas. Therefore,
we need to draw a new circle that is composed of two parts with a gap
between them. A circle with a gap between its opposite sides stands for
my second internal map, the low-level personality organisation. Indi-
viduals with low-level personality organisation do not possess a fully
integrated self-representation. Persons with narcissistic or borderline
pathology fit into this category.
A person with narcissistic personality organisation defensively
separates what became known in the psychoanalytic literature as the
“grandiose self” (being number one) from a devalued “hungry self”.
To illustrate this we can draw the grandiose self bigger than the hungry
self within the circle and put space between them. Or, we can imagine
a pecan pie on a plate with a slice removed fully, or mostly, from the
rest of the pie. Persons with borderline personality organisation split
their libidinally invested half of the circle from the representation of
their aggressively invested half of the circle. Or, we can imagine another
pecan pie on a plate cut in the middle and separated fully or mostly into
two halves. Object representations of individuals with narcissistic or
borderline personality organisation are also unintegrated. They do not
own both sides of their mental conflicts to one degree or another, except
in limited areas where the opposite parts still touch one another. We
cannot effectively explain their mental conflicts with structural theory
mainly because they do not have fully developed superegos. Theoreti-
cally speaking, a fully developed superego is one in which identifi-
cations with both punitive and loving aspects of paternal (and other
caregivers’) representations are integrated as compromise-formation
takes place. Again, theoretically speaking, a fully developed superego
only exists in people with high-level (neurotic) personality organisa-
tion, and anyone whose personality organisation is below the high-level
range does not have a fully developed superego. Therefore, in the old
psychoanalytic literature when psychoanalysts attempted to explain
the psychology of persons with a low-level internal map, they used
terms such as “forerunners of the superego”, “precursors of the super-
ego”, “archaic superego”, “superego lacunae”, “benign superego”, and
“punitive superego”.
Patients with a low-level internal map possess object relations con-
flicts linked with ego deficiencies, such as deficiency in utilising integra-
tion of self- and/or object images with associated affects and repression
of “unwanted” mental contents, to one degree or another. Object rela-
tions conflict refers to tensions concerning integrating or not integrating
libidinally and aggressively loaded self- and object images within, or
externalising them on to others and re-internalising them. As Theodore
Dorpat (1976) stated, conflicts between being dependent and becoming
independent—or between a desire to be close to an object (and its rep-
resentation) and a desire to be distant—cannot be understood without
applying a theory of object relations. Sometimes persons with low-level
personality organisation present oedipal material. A closer look sug-
gests that by presenting oedipal material, they try to “reach up” (Boyer,
1961, 1983; Volkan, 1976, 1997, 2010) in order to get away from their pre-
oedipal object relation conflicts. The treatment technique for dealing
with individuals with a low-level internal map is to help them to expe-
rience and work through, borrowing a term from Melanie Klein (1946,
1948), “crucial juncture” experiences: a patient’s bringing together her
opposite self- and object images with their associated affects so that she
can begin to mend her internal world. Only after she accomplishes such
mending will the patient be capable of genuinely working through her

oedipal issues with an integrated self-representation.
In order to visualise the third type of internal map, the psychotic per-
sonality organisation, consider hitting on the inside of Winnicott’s circle
with a hammer and smashing it into some big and many small pieces.
The self-representation of persons with psychotic personality organi-
sation is fragmented. Their object representations too are fragmented.
Such individuals utilise fragmentation as their main mental defence sys-
tem. They present primitive object relations conflicts accompanied with
defects in ego functions, such as reality testing function. Fragmented
self- and object images sometimes fuse and then diffuse, or are involved
in an exaggerated and easily observable internalisation–externalisation
cycle. For example, during a therapeutic hour the patient moves his
mouth “eating” the analyst and then he externalises him by spitting.
In chronic psychotic states the patient can hold on to one fragmented
part or a very small number of sections and wipe out others with severe
breaks with reality supported by established delusions and hallucina-
tions. In such situations the internalisation–externalisation cycle cannot
be easily observed.
Individuals who have multiple personality organisation (Brenner, 2001,
2004) exhibit an advanced version of psychotic personality organisation.
Their fragmented self-images and corresponding object images have
evolved to possess distinct characteristics and become stable enough
for the individual to sense them, as if various identities (personalities)
exist within the individual. The person usually gives them names—one
is Madeline, the other one Grace, and still another one Fatima. One of
these personalities, if advanced enough, does not recognise the lower-
level ones since the function of repression is available to it. Meanwhile,
the lower-level personalities, without the benefit of repression, may be
aware of the existence of the highest one and sometimes each other.
The internalisation–externalisation cycle in individuals with a
psychotic personality organisation is accompanied by a projection-
introjections cycle. I use the terms internalisation and externalisation to
describe the in and out movements of self- and object images, and the
terms introjection and projection to refer to sending thoughts, affects,
perceptions, and protosymbols (Werner & Kaplan, 1963) inward or
outward, often resulting in a sense of internal destruction or para-
noid expectation. Persons with the third kind of internal map show no
sophisticated “fit” between what is internalised/introjected, and the

reality of the object or thing before it is taken in, and no sophisticated
“fit” between what is externalised/projected and the target. Further-
more, the internalisation–externalisation cycle in such individuals is
not masked by sophisticated symbols. Patients with psychotic person-
ality organisation do not experience typical anxiety that has a signal-
ling function for sensing a mental conflict. Anxiety can evolve as an
“emotional flooding” (Volkan, 1976) and become overwhelming for the
patient. Such individuals defend themselves from experiencing emo-
tional flooding by further fragmentation and further fusion-diffusion,
externalisation-internalisation, projection-introjection cycles, and/or
wiping out more reality.
Patients with psychotic personality organisation too sometimes uti-
lise “reaching up” (Boyer, 1961, 1983; Volkan, 1976, 1997, 2010): they
bring up oedipal material, typically in an unmasked (unrepressed)
fashion, in order to escape their primitive object relations conflicts.
Approaching such individuals with classical psychoanalytic technique
will go nowhere. The useful technique for them will first aim to help
them develop a new healthy mental core that will support the indi-
vidual to move up to a low-level personality organisation. There are
cases with of people with psychotic personality organisation who, by
going through psychoanalytic treatment, reach a high-level personality
organisation. My description of the treatment of Jane, from its begin-
ning to its end (Volkan, 1995), is such an example. Later in this book I
will present an overview of the treatment process of Ricky, who was also
able to change his psychotic internal map and, through psychoanalytic
therapy, to reach a high-level personality organisation. This book will
also describe how the Methodist minister changed his internal map.
The interplay between age-appropriate experiences and the matura-
tion of the central nervous system, the importance of a “fit” between
the infant and the mother in the development of what psychoanalysts
call “ego functions”, and ability to form mental images of relation-
ships with others (“object relations”) have been scientifically studied,
especially since the 1970s (for example, see: Greenspan, 1997, 1989;
Stern, 1985; Emde, 1991; Brazelton & Greenspan, 2000; Purhonen,
Pääkkönen, Yppärilä, Lehtonen & Karhu, 2001; Lehtonen, 2003; Bloom,
2010). One fact we learned is that an infant’s mind is more active
than we had thought decades ago when we used to speak about an
“autistic phase” (Mahler, 1968). But, no matter how much potential and
ability an infant possesses, in infancy no one has a fully separate self;
the infant’s mind can be conceptualised as being in a creative state of
confusion. From René Spitz’s work (1946, 1965) decades ago on smiling
response, separation anxiety, and stranger anxiety, to John Bowlby’s
(1953, 1969) examination of attachment, to Henri Parens’ (2007) more
recent studies, we have learned how the child slowly develops the abil-
ity to differentiate herself from others and also to differentiate between
various internalised or external object images. The child also develops
an integrating ego function that allows her to put together, mend, pre-
viously separated opposite self- and or object images. As Daniel Stern
(1985) noted, an infant is fed four to six times a day and each feeding
experience produces different degrees of pleasure. Stern illustrates that
as the child grows up, different experiences become categorised in the
child’s mind as “good” and “bad” (see also Lehtonen’s 2003 studies).
We hear echoes of Harry Stack Sullivan’s (1962) description of “good
me”, “bad me”, “good mother”, “bad mother”, and “not me”, and writ-
ings of others on the type of object relation theory that concerns the
internalisation of interpersonal experiences that remain inside the indi-
vidual’s mental structure (Jacobson, 1964; Kernberg, 1966, 1975, 1976,
1980, 1988; Volkan, 1976, 1995; Dorpat, 1976; Gedo, 1979). This type of
object relations theory stresses the formation of self- and object images
and representations contaminated with affects that reflect the original
infant–mother relationship as well as the subsequent development of
more mature dyadic, triadic, and multiple internal and external rela-
tions with more differentiated affects in general. Only after the develop-
ment of integrative ego function in the service of integrating opposites
does a child evolve the concept and sense of being “average” and toler-
ance of ambivalence.
I emphasised the differentiation and integration of ego functions
when defining the three types of internal maps. When a person has a
high-level (neurotic) personality organisation he is capable of utilising
both differentiation and integration functions. When an adult has low-
level personality organisation he is capable of differentiation, but not
capable of integration to one degree or another. In his case the “nor-
mal splitting” that we see during a small child’s mental development
does not disappear for all practical purposes, but turns into “defensive
splitting” and then is utilised as the main mental defence in adult-
hood. When a person has a psychotic personality organisation, both his
differentiation and integration functions are deficient. An adult with a

psychotic internal map turns this deficiency into defensive utilisation
and holds on to fragmentation, fusion/diffusion, and internalisation-
externalisation as primary mental defences.
In practice, it is sometimes difficult to make very clear distinctions
between the three types of personality organisations. Even a person
who has fragmented self- and object images can behave for some
short or long time as a person with a higher level personality organi-
sation. This occurs when this person can hold onto a self-image that
is rather advanced without including it in speedy fusion-diffusion
or internalisation–externalisation cycles. Attis could hold on to his
Methodist minister self-concept and behave, at least on the surface, as
a “normal” individual for short or long periods of time. I suggest that
thinking of three types of internal maps can serve as a guide for the
therapist as to how to begin and continue treating a patient.
CHAPTER SIX
The psychotic core
S
ince Attis is the main subject of this book I will continue to play
with the internal map of a psychotic personality organisation. I will
place a metaphorical doughnut in the middle of the fragmented
circle belonging to such an individual. This metaphorical doughnut rep-
resents the psychotic core, which in my earlier writings I named “infan-
tile psychotic self” (Volkan, 1995) or “the seed of madness” (Volkan &
Akhtar, 1997). My metaphorical doughnut is a filled doughnut, filled
with rotten jelly, distasteful affects as expression of aggression.
Psychoanalytic theories on aggression go all the way back to Freud’s
inconsistent thoughts on this topic prior to his coming up with the
“death instinct” in 1920 (Freud, 1920g), an idea out of favour in today’s
psychoanalytic literature. Today there are considerations that fit Henri
Parens’ (1979 [2008]) “multi-trends theory of aggression”. Parens states
that the way parents rear their child is a direct factor in that child’s
aggression profile, while he also considers the role of a child’s average-
expectable biological conditions in this profile. The quality of attach-
ment and the child’s aggression profile are linked. Parens describes
a wide range of affective expressions, from anger to hostility, to rage,
to hate, to benign or malignant prejudice. Adults with a psychotic
internal map sometimes present such affective expressions. However,
57
the affective expressions in the middle of my metaphorical doughnut,

which develop in childhood, are unnameable, or they can only be
described as “excessive unpleasure” (Kernberg, 1966).
When I was working intensively with numerous individuals with
psychotic personality organisation, some of them spontaneously
described the existence of a “doughnut” in their internal worlds. Attis
never used this analogy. Those who actually used the word “dough-
nut” seemed to be referring to a ring doughnut with the dough missing
in the middle. For them, the missing middle stood for an “emptiness”
they felt in the core of their mental existence. They, in fact, did not
have ring doughnuts, but filled doughnuts. However, by utilising
extensive denial, they managed to perceive the rotten jelly as “noth-
ing”, and hold on to an illusion that unbearable unpleasantness/
aggression was erased. I agree with Peter Fonagy and Mary Target
(Fonagy & Target, 2002) that a patient’s feeling “empty” and denying
her existence by generalising this feeling can also be in the service of
protecting herself from being attacked and “killed” by another person
perceived as a dangerous bad object. People do not kill you if you do
not exist. The patient, as Fonagy and Target stated, may also empty
the other person in order that that person is not a target of her mur-
derous aggression.
Let us re-visualise the filled doughnut in the middle of the smashed
circle. Its inside looks like a sponge soaked with rotten jelly. The sponge
is surrounded by fragmented self- and internalised object images. The
rotten jelly oozes into gaps between fragmented images. It is the rotten
jelly that prevents the pieces of the self- and internalised object images
from getting together and mending. Such patients, in fact, are preoc-
cupied with attempts to change the “bad” jelly to “good” jelly. They
are “object addicts“ (Fenichel, 1945, p. 436); they need to find ways for
libidinal objects to be internalised. Donald Burnham (1969) wrote about
the individual with my third-type internal map and stated:
The very excessiveness of his need for objects also makes them
inordinately dangerous and fearsome since they can destroy him
through abandonment … They can make or break him … Thus
threat may be further understood if we consider that his precari-
ously balanced inner structure is extraordinarily vulnerable to
external influences in its most literal sense, “flowing into”. He
lacks adequate insulation from others … Like a ship at sea without
T H E P S Y C H OT I C C O R E 59
adequate navigational equipment, he requires directions from

external sources. (Burnham, 1969, p. 28)
The aim of a psychoanalytically informed treatment of people who

possess such a condition is to replace the rotten jelly with a sweet
(libidinal) one that will function as a glue for mending fragmented
elements.
Today, the dominant tendency for explaining why someone suffers
from schizophrenia or has psychotic signs and symptoms is to present
data from ongoing extensive research on brain functions, micro-injuries,
neurodevelopmental alterations, and genetics. I am not an expert in
examining fully and evaluating findings from such research. I have
studied some of those that have general relevance for psychoanaly-
sis (for example: Reiser, 1990; Tienari, 1991; Leigh & Reiser, 1992; Van
der Kolk, 2000; Beutel, Stern & Silbersweig, 2003; Levin, 2004; Solms &
Turnbull, 2010 & Laufer, 2013). Robert Cancro’s statement years ago
that biological theories are “devoid of psychological content” and
“increasingly suffer from reductionism” (Cancro, 1986, p. 106) remains
true. Cancro also wrote: “Theory can only be useful within a particular
realm of discourse, and psychoanalytic theory must function within its
assumptions it utilizes” (Cancro, 1986, p. 106). He hoped that in the
future our understanding of the biology of mental activities such as
memory and thought would become rich enough to help us shift from
the universe of psychology into that of biology with ease. He imagined
that when this happened it might be possible to include biological con-
cepts in psychoanalytic theories.
During a child’s developmental years, genetic and neurological fac-
tors can become combined with psychological ones in the creation of
a psychotic core saturated with unnameable “bad/aggressive” affects.
Also, let us not forget familial, cultural, religious influences, and the
impact of wars and warlike conditions on a child’s developing internal
world. We also have information that illustrates that when the psychol-
ogy of a person changes, due to psychotherapy for example, biological
changes in the brain also occur. The problem here is this: when an adult
with a third-type internal map, psychotic personality organisation,
comes for psychotherapy, the clinician usually does not know or can-
not evaluate the exact mixture of biological factors with psychological
ones and what the most influential factors are for the patient’s existing
condition. Certainly, some patients who exhibit psychotic symptoms
do have neurological deficits. Can other patients’ psychotic symptoms

be due only to psychological factors? My answer is “yes”. My experi-
ence with Attis, more of which will be described later, is one reason I
give this answer. While certain neurological or genetic alterations can
be measured and examined in typical scientific ways, I cannot imagine
a typical scientific way to study and measure an unconscious fantasy
as I described earlier in this book and its role in shaping someone’s
internal map.
My personal work for decades with individuals like Attis, and my
observations during three months per year for the last ten years at the
Austen Riggs Center in Stockbridge, Massachusetts, have taught me
a great deal about multiple psychological factors that play a key role in
establishing a psychotic core in a developing child. At the Austen Riggs
Center, twice weekly case presentations include extensive reports on
these cases’ family backgrounds, often including their ancestors’ his-
tory. We need to go beyond Frieda Fromm-Reichmann’s (1959) old
“schizophregenic mother” image and be more specific about how the
child’s mother as well as other mothering persons function in relation
to the child. Some mothers and/or family members cannot provide a
reasonable “fit” between their own activities and temperaments and
those of their children. Children being presented with mental functions
that create “unassimilable contradiction” (Burnham, 1969, p. 55) have
been studied (for example, see: Torsti, 1998; Alanen, 1993; Greenspan,
1997; Brazelton & Greenspan, 2000; Tizón, 2007). How a parent’s inabil-
ity to think about the child’s mental experiences deprive the child of
the chance to form a viable sense of himself has also been examined
extensively (Fonagy & Target, 1997). Sometimes, important individuals
in the child’s environment interfere with the child’s transitional object
(Winnicott, 1953). This interferes with the child’s working through
his “experiments” to separate mother-me from external objects. I fre-
quently noted cases when the mother or mothering person interfered
with the child’s reality testing, integrative function, and developing a
body image. Such interferences occurred in Attis’ case.
Now I will focus on mothering persons’ and the child’s specific type
of unconscious fantasies, interactions between them, and their role in
a child’s holding on to a primitive internal map with a doughnut in its
middle filled with rotten jelly. Maurice Apprey (1997) and Gabriele Ast
and I (Volkan & Ast, 1997) describe some mothers’ unconscious fantasy
that their children disappear or die. A child’s own unconscious fantasy
corresponding to her mother’s unconscious fantasy, when it is put into

words, could be read in the following way: “My mother did not wish
me to be born. I should get rid of my (mental) self and have a psy-
chological death in order to please my mother and thus turn her into
the longed-for ‘good’ mother.” Such an unconscious fantasy, especially
when it is actualised, can stop the child’s mental development to one
degree or another and make the child hold on to “bad” affects and thus
develop a psychotic core. Committing oneself to a psychological death
goes along with the maintenance of “excessive unpleasure”.
A patient’s initial family history and initial signs and symptoms can
suggest clues about the existence of a mother’s or mothering person’s
death wish for a child and the child’s corresponding unconscious fan-
tasy. For example, a person with psychotic personality organisation pre-
sented a family story in which the patient was conceived a week prior
to the mother’s planned surgery to have her tubes tied. In another case,
there was a family scenario in which the mother did not know that she
was pregnant until the seventh month of her pregnancy. Both patients
had repeating dreams of disappearing and sometimes reappearing as a
symbolic baby in another environment, and delusions of having other
parents or, in the second case, also being brought to Earth from outer
space. The second patient tried to change her name and carved a new
name on her body.
Besides a mother’s or mothering person’s unconscious fantasy that
her child disappears, and the child’s corresponding actualised uncon-
scious fantasy, there are other unconscious fantasies in the dyadic rela-
tionship that play a role in the child’s establishing and holding on to a
psychotic core. Frances, in her mid-twenties, had a psychotic personal-
ity organisation. Before she became my patient she had communicated
with spirits and allowed a religious cult leader to perform an exorcism
on her to remove the “devil” in her chest, her psychotic core. She was
adopted as a newborn baby primarily to replace her adoptive mother’s
brother, a pilot who had lost his life after an accident just prior to the
adoption. Frances’ adoptive maternal grandmother, who performed
most of the mothering functions for Frances, openly talked about
God taking away her son and then giving Frances to the family. The
grandmother often referred to Frances as a reincarnation of Francis, the
dead pilot (Volkan & Ast, 1997). As a child, Frances was given the dead
pilots’ childhood toys to play with. The mother and the grandmother
had both conscious and unconscious fantasies that the child they
adopted was also the dead pilot. Frances, as a “living linking object”
(Volkan, 1981a), as a “replacement child” (Cain & Cain, 1964; Legg &
Sherick, 1976; Green & Solnit, 1964; Poznanski, 1972; Ainslie & Solyom,
1986; Volkan & Ast, 1997), had an unconscious fantasy of being a rein-
carnated individual. Frances’ developmental push to find herself and
individuate, and the force stemming from her mother’s and grand-
mother’s shared unconscious fantasy to keep her as an extension of
a dead person, along with her corresponding unconscious fantasy
of containing a reincarnated man in her self-representation, created
psychic confusion, unnameable bad affects as a rotten jelly inside her,
and triggered her to form a psychotic core.
Here is still another factor forcing a child to develop and maintain
a seed of madness. The child’s experiencing a drastic actual trauma or
series of actual traumas and suffering from mental torture—ranging
from being a subject for actual torture by a sibling to being sexually
abused by a priest or uncle—can cause the evolution of a psychotic
core. Severe regressions occurring after adolescence and the second
individuation (Blos, 1979) due to severe traumas will not produce a psy-
chotic core (Volkan, 1997). Persons exposed to such post-adolescence
severe traumas may exhibit defensive regressive fixations and aggres-
sive behaviour but they do not develop a filled doughnut that contains
rotten jelly. I agree with Thomas Freeman (1983) that we should not
perceive psychosis as a regressed extension of neurosis. True psychosis
develops after one goes through the adolescence passage and in adult-
hood because of the existence of a childhood psychotic core, even if it
may have been previously hidden.
I have illustrated different fates of the psychotic core in my previous
writings (Volkan, 1997). According to the type of fate, the surface mani-
festations will also appear in different ways. If the bad jelly in child-
hood floods profusely into the rest of the circle that represents the child,
she develops a clinical picture of childhood psychosis. If the flooding
is not profuse, the child may appear “normal” in certain ways, but
since the rotten jelly oozes out of the encapsulating dough she will also
exhibit some bizarre signs and symptoms to one degree or the other,
such as screaming. In adulthood too, when the doughnut functions like
an effective sponge, absorbing most of the rotten jelly so that only parts
of the remaining fragmented self- and internalised object images are
contaminated, the patient exhibits “normal” behaviour to one degree
or another. However, she is also exhibits bizarre behaviours, separated
from her “normal” activities. Bizarre behaviour activities are directly

related to ego defences against sensing the impact of the bad jelly
absorbed by the dough. For example, I supervised for years the psy-
choanalytic psychotherapy of a young woman who was an intelligent
person, a graduate of a well-known law school. She was married and in
many ways she was a good wife. Since her husband was very rich she
did not work. At home she had dozens and dozens of cats. The unusual
thing about this “hobby” was the fact that these cats had leukaemia; she
would take care of only sick cats and spent a great deal of her time with
veterinarians. In her daily life her reality testing was good; for example
when she purchased things at a grocery store she knew that she had to
pay for her purchased items with a smile on her face. During her treat-
ment her therapist and I slowly became keenly aware that her sick cats
represented her psychotic core. It was externalised into the cats and
they had to be under constant care. Her other bizarre symptom told
us more about how these cats actually were part of her core. She had
undergone six reconstructive operations in a conscious attempt to make
her face resemble that of a cat.
If the contamination of the diagram of the person with rotten jelly is
generalised, the adult who has this condition may perceive himself as a
“monster” or use another term descriptive of being filled with unpleas-
ant unnameable aggressive affects. He may also feel “empty”, as I have
already described, when the existence of the monster is completely
denied. In some cases, the patient refers to an internalised object image
that becomes soaked with unnameable aggression and, for example,
calls himself “Jack the Ripper”. The patient does so with a hope that
no other “bad” object can come close to him to provide more rotten
jelly for his psychotic core. In cases when the patient develops a defen-
sive illusion of internalising a “good” libidinal image and maintaining
it within himself he can also become an “angel”. A patient can cling to
one type of existence or non-existence for days or even months. Often,
being Jack the Ripper or an angel can alternate quickly or slowly due to
the patient’s internalisation–externalisation cycle.
Sometimes, usually in the teen years or in early adulthood, a spe-
cific trauma, usually one that unconsciously reminds the individual of
a primary trauma of his childhood or a dysfunctional childhood attach-
ment issue, squeezes the metaphorical doughnut, even though earlier
he was to a great extent able to contain the bad jelly. The rotten jelly
quickly erupts through its container with force and fills up the rest of
the self- and object images in the circle. The patient experiences not
anxiety, but an “emotional flooding” (Volkan, 1974, 1976, 1981b, 1995)
or “organismic panic” (Pao, 1979). He also develops what classical
analysts called “world destruction fantasies” (Fenichel, 1945). Such a
clinical picture describes an acute episode of a schizophrenic condition.
I believe that James Glass’ (1985) study at the Sheppard and Enoch Pratt
Hospital of the psychological breakdown of the inner world of adults
entering acute schizophrenia is a classic. Glass describes, for example,
patients feeling that a star is exploding into millions of pieces within
them. Later world destruction fantasies will alternate with “world con-
struction fantasies” (Fenichel, 1945) also associated in bizarre ways with
disturbances in reality testing, delusion, and hallucinations. Nowadays,
quickly medicating patients is robbing us of the opportunity to notice
these processes.
Attis dealt with his seed of madness from early childhood onwards.
In his adulthood many psychiatrists diagnosed him as suffering from
schizophrenia. He was also given the same diagnosis at the North
Carolina Memorial Hospital. Only later would I, during my clinical
work, be uninterested, or less interested, in making a surface diagnosis
according to a person’s signs and symptoms, instead focusing on the
person’s internal map and the fate of the psychotic core.
Now I will return to my relationship with Attis. Starting in the next
chapter I illustrate how he would slowly make changes to his internal
doughnut with its “bad” jelly.
CHAPTER SEVEN
Beginning outpatient therapy
W
hen I began working with Attis I did not know the concepts
I described in the previous three chapters, although my
inpatient supervisor and, after Attis was discharged from the
hospital, my outpatient supervisor had had psychotherapeutic involve-
ment with patients like him. If I had been an experienced clinician at
that time and if Attis could have driven to Chapel Hill more than once a
week after his discharge from his hospitalisation, the therapeutic proc-
ess that would have evolved between us would have obviously taken
a different course. Notes that I kept after each meeting with my out-
patient supervisor reflect my bewilderment as well as excitement.
When Attis was an inpatient I met him in his hospital room for his
therapy sessions, a secure environment for him and for me. Now and
then I would also greet him briefly when I visited the unit to meet
with my other patients or to speak with the nurses and other person-
nel. Experienced nurses were available to look after him twenty-four
hours a day. Following his discharge from hospital it was only the two
of us, starting a new journey together in one of the rather small rooms
at North Carolina Memorial Hospital’s psychiatric outpatient serv-
ices facility. I would learn much later about how a therapist’s room,
65
its appearance and items within it, become symbolic extensions of a

psychoanalyst, and how any changes in the room become involved in
transference–countertransference issues (Volkan, 2010). For example,
one of my patients once noticed that I had forgotten to water a pot-
ted plant and this induced her recollections of being deprived of her
mother’s love. Gable, to whom I have referred briefly, saw a postcard
on my table during the second year of his analysis that had been sent
to me from Turkey illustrating two half-naked men wrestling at a tradi-
tional wrestling competition. This led to further opening of his oedipal
fears by sexualising our relationship in the transference. When I started
to see Attis as an outpatient, the hospital’s psychiatric services only
offered psychiatric residents their choice of small rooms with only two
chairs and an empty desk. When Attis was present I would see him in
whichever of these rooms was available; we could not even meet in the
same place for each of our sessions, and frequently meeting in different
rooms supported his fragmentation of my image as well as his.
As mentioned earlier, Anna Freud (1968) noted that patients with
high-level (neurotic) personality organisation enter psychoanalysis
(or psychotherapy) with an attitude towards the psychoanalyst that is
largely based on reality, and only later, within the context of a deepen-
ing treatment, develops a full-blown transference that becomes a trans-
ference neurosis. She explains: “To the extent to which a person [with
the first type of internal map] has a healthy part of his personality, his
real relationship to the analyst is never wholly submerged” (A. Freud,
1968, p. 373). A patient with a high-level personality organisation in
ordinary transference activates aspects of an infantile and/or early
childhood self, and aspects of parenting and other childhood object
images. With therapeutic work, activated aspects of the infant’s or
small child’s self-images are linked to and integrated with the patient’s
self-representation. Activated aspects of parenting and other object
images are, in turn, linked to or integrated with the parenting figure
and other representations as experienced in infancy and early child-
hood (Kernberg, 1976). Such linking and integration of what is activated
with the rest of the self- and object representations do not occur in the
transference manifestations of a person with Attis’ internal map. From
the beginning of the therapeutic relationship, a patient with a psychotic
personality organisation will involve the therapist’s and her own vari-
ous corresponding images in her fusion-diffusion and externalisation-
internalisation, accompanied with projection-introjection cycles in an
unrealistic fashion in very open or hidden, and fast or slow, ways.
B E G I N N I N G O U T PAT I E N T T H E R A P Y 67
I still remember Attis’ very first outpatient session with me. He sat in
front of me tightly holding the arms of his chair while managing to hide
his cut finger. He appeared poised to experience a deadly earthquake.
For fifty minutes he insisted that he was a “monster”. Thanks to the
support of my outpatient supervisor, I was well prepared. I tried to stay
calm and spoke now and then, making remarks about our starting a
“new trip” together. I explained that there was no need for us to be in a
hurry. After my first session with Attis as an outpatient my new super-
visor explained to me that Attis internalised aggressively loaded images
and kept them within himself, attempting to become a scary “monster”
during his session in order to protect himself from me because he had
externalised more severely loaded aggressive self- and object images
onto me. I found it very useful that my first and second supervisors
were saying the same thing in relation to their approach to my patient.
Attis continued to remain a “monster” during the following sessions.
Around the time Attis started his weekly outpatient treatment with
me, I accomplished a major milestone in my adjustment to life in the
United States: I bought an old used car and learned how to drive it.
During my first year of residency my monthly salary, as I recall now,
was seventy-five dollars. I also received free meals at the hospital on
working days. I cannot say exactly how seventy-five dollars in the
early 1960s corresponds to that amount today, but I am sure it would
not amount to a reasonable level for a young physician. I learned how
to pay for the old car through instalments. Unlike my experience in
Chicago where I was surrounded by medical interns and residents
who were all foreigners like me, in Chapel Hill all my fellow psychia-
try residents were Americans. I imagined their salaries were identical
with mine. Unlike me, as I understood, some of them were borrowing
money from banks with the knowledge that they would be able to pay
their debts once they finished their residency and started their profes-
sional life. As a foreigner I could not do this. (At that time I had not yet
planned to stay in the United States after my training in psychiatry and
become an American citizen.) When I was living in Cyprus my fam-
ily could not afford a car and I had not learned how to drive. A fellow
psychiatry resident in Chapel Hill, David Fuller, who now resides in
Texas, kindly gave me driving lessons. I bet David never realised how
important his “gift” was for me: I could join other psychiatry residents’
social gatherings and expand my horizons to learn the American way
of life as it existed in a small university town. Looking back, I wonder
now if, as a foreigner, I had identified with Attis. He was “isolated”
because of his psychotic core, and I was “isolated” because I did not
know how to drive a car. If I could do something about my “isolation”,
he could, when the time came, identify with my ability to expand one’s
horizons.
Whenever Attis visited me Gloria accompanied him to Chapel Hill
and met with Rebecca. One day I saw Attis and Gloria in the hospi-
tal’s parking lot when they were getting out of their car. In comparison
to my old car they had a shiny new one. I believe that I did not feel
jealousy. This is because, while growing up in Cyprus a car was not a
symbol for manhood for me. My family could afford to buy me a bicy-
cle and I could compare my bicycle with bicycles of other youngsters
in my neighbourhood. Owning a bicycle was my childhood symbol
of attaining status as a young man. I still recall with great fondness
waking up one morning in my early teen years and noticing a brand
new bicycle next to my bed. My parents had bought it for me and put
it in my bedroom after I fell asleep so I would be surprised the next
morning.
The Methodist Church took good care of Attis. I learned from the
social worker that, not only did the Church make sure that he drove a
shiny new car, they also sent people to gently check on him and protect
Gloria. I also learned that Attis had started to carry out his duties at
the church soon after his discharge from hospital. According to Gloria,
people in general had heard the “rumour” that he had tried to kill his
wife, but those who attended the church services were supportive by
going along with Gloria’s declaration that conducting too many funeral
services was the cause of Attis’ distress. As far as I could learn, Attis
was capable of rendering the routine church services. In his sessions
with me he would not talk about his daily life. My supervisor suggested
that Attis bringing his psychotic transference onto me by presenting
himself as “monster”, while in fact in a hidden way protecting himself
from me—a more vicious “monster”—due to his externalisations and
projections, was helping Attis to remain “normal” in his rural environ-
ment. He encouraged me to continue to tolerate this bizarre behaviour.
A person with a high-level personality organisation brings transference
manifestations to sessions. But the analyst waits—unless such mani-
festations become a source of obstacle for therapeutic work—until the
patient evolves a workable transference neurosis to work on it with the
patient. Similarly, transference psychosis manifestations that a patient
with a psychotic core exhibits at the beginning of his treatment are
not entry points for therapeutic progress until the patient develops a
workable transference psychosis. Later, I will share with the reader the
evolution of Attis’ workable transference psychosis and how, through
our working through it, he made significant progress in changing his
internal world.
As some months passed by I noticed that when Attis and I met in a
therapy room he no longer grabbed the arms of the chair while sitting
in front of me. One day he hallucinated his father’s face on the wall
in the therapy room. At that time Attis himself was not a “monster”.
I suspected that I was also not a “hidden monster”. A terrifying object
image, his father’s face, was externalised on a wall. He began pouring
out references to other terrifying objects “out there,” such as his wife’s
walrus/vagina and a “bitch”, a female parishioner whom he disliked
and who stood for his “bad” mother/the fortune teller in the rural area
where he was born. I noticed that he felt more comfortable with me;
both of us now could “watch” together his externalised “bad” images
separate from both of us, such as on the wall. Even though I could not
actually see his father’s face, I could regress enough in the service of
joining Attis to sense its existence.
When Attis continued to repeat similar scenarios in his following
sessions, this time externalising his terrifying object image more
directly onto Gloria, I wished to help him change his external target,
since I wanted him to be more comfortable at home. Looking back,
perhaps I was afraid that he might become homicidal again. I have
no references about such a consideration in my old notes. In any case,
without using technical words, I would tell him how he might be dis-
placing his dead mother/the “bitch” image onto his wife. Then, as if
he were imitating me, he would repeat my exact statement. It was as
if he would “eat” my statement, but without assimilating it, he would
then spit it out. My remarks would not make him curious, or defensive,
or grateful as a person with the first kind of internal map might. But,
I also felt that his sensing that I “knew” what was bothering him was
supportive to him.
Within a few months I had a drastic experience with Attis “reaching
up” (Boyer, 1971, 1983). During his therapy sessions, Attis talked
openly about incestuous wishes and other aspects of oedipal striv-
ing. His abundant production of bizarre fantasies of having sex with
his mother and identifying with his sadistic father (as when his father
would put a stick up a donkey’s anus) seemed like a kind of primitive
obsessional defence. However, he was far from being considered a

person suffering from an obsessional neurosis. He was simply “reach-
ing up”. His obsession with oedipal issues, which was not accompanied
by the benefit of repression, was in the service of his attempts to control
object relations conflicts and eruptions of rather raw emotions.
My supervisor suggested that I only listen to this material without
blaming Attis. This, I did. Later in my career I would read and learn
more about how it is a mistake for the therapist faced with a patient
like Attis to regard oedipal material as something to deal with, as if the
patient were functioning at the oedipal level. I concur with Rosenfeld
(1965) and Boyer (1971, 1983) in their belief that interpretation of such
oedipal material on a libidinal level, when it is offered to this kind of
patient, can promote psychotic excitement; the patient can all too read-
ily see in such interpretation a seductive invitation on the part of the
therapist. Boyer (1971) states:
If I refer to such material, I do so from the standpoint of its aggres-

sive and manipulative aspects or interpret upwards … Thus, as an
example, if the patient relates that he has open fantasies of inter-
course with his mother, I respond that he must love her very much.
I believe that the patient who suffers from a severe characterologi-
cal or schizophrenic disorder has massive fears of the vicissitudes
of his aggressive impulses and that analysis proceeds smoothest
when attention is directed gently but consistently towards the anal-
ysis of the protective manoeuvres he employs to defend against his
fear that his hostility will result in the analyst’s death or his own.
(p. 70)
Attis confessed that during this time he was sexually dysfunctional

with Gloria because of incestuous implications, and fear of retaliation
from his father’s representation and what I might do to him. I told him
openly that I would not hurt him and that I was more interested in being
curious about what had made him busy with sexualised images of his
parents. I did not tell him that he “loved” his mother, but suggested
that his sexualised fantasies about his mother might be a search for a
loving mother. I also shared with him my observation that he reached
towards sexualised material after he had been preoccupied with scary
objects such as his father’s face on the wall, the “bitch”, and his wife’s
vagina. I added that when he started to tell me about sexual wishes
he ended up once more facing danger, as if there was no way to feel

secure. I wanted him to know that his dangerous perceptions might
have something to do with his childhood experiences, such as his find-
ing himself in a burning house or hearing a neighbour harming his own
body. I did not give more details, but stated that we would go at his
pace to understand his fears. He calmed down.
About six months after he started his outpatient therapy with me,
I learned that Gloria would attend a teachers’ conference in a neigh-
bouring state that was important for her career. As her departure
approached, Attis’ terror increased once more. I noticed that he also
increased his fusion of his wife’s mental representation with that of his
rejecting mother image while his thoughts of murdering her in order
to find his “freedom” also reappeared. I understood that he could no
longer function at church.
I told Attis how an external event—Gloria’s expected departure—
was creating severe difficulties in his internal world and because of
this I wanted to re-hospitalise him. Referring to the reappearance of
his murderous thoughts about Gloria, I explained to him that if he did
something aggressive and was put in a prison I would not know how to
maintain our therapeutic relationship since he would not then be able
come to see me regularly. By then I had learned the English phrase, “It
takes two to tango” and I used it to emphasise that our work needed
two persons—he and I—since my dancing alone while he was in prison
would take neither of us anywhere. Therefore, I was asking him to stay
in the hospital before Gloria’s departure and for a while after her return
until the impact of this event settled down. I remember how he smiled
and agreed to come back to the hospital. He felt comfortable there,
appeared “normal”, and on several occasions told nurses that he was
back because he was, at this time in his life, sensitive about “losing”
Gloria, since he had not yet fully mourned his mother’s death.
In addition to the time just before Gloria’s departure and while she
was away for a week or so, Attis remained in the hospital one more
month. One reason for this was the church authorities’ decision not
to return Attis to his church. Apparently, Baptist Pastor Johns was
spreading more and more vicious rumours about Attis because of his
re-hospitalisation. The church authorities gave Attis a leave of absence.
He and his wife moved to a new rural area over 100 miles away from
the previous location and now 150 miles away from Chapel Hill. He
became the Methodist minister of a smaller church. I learned that this
area was a beautiful place and near a resort area with golf courses and
swimming pools.
As Attis was settling into this new place, he attended all his weekly
sessions with me. Now, I was observing in a more concrete fashion
another version of transference psychosis. Instead of remaining as a
“monster”, he “fused” with my protective image. In a metaphorical
sense, I was located in his internal doughnut absorbing the rotten jelly,
and keeping it from flooding the rest of his self-representation. He there-
fore became concerned about my health and welfare. I would tell him
that I was alright, and able to keep my mental capacities. In those days
at work we always wore ties while seeing patients. One day I noticed
that Attis had purchased a tie exactly like mine and he was wearing it.
Two men wearing the same tie were meeting in a small therapy room.
Soon this situation became even more interesting. Attis began to dress
like me, becoming like me, and telling me, using my own words, that he
was alright and that he could keep his mental functions and work as a
minister. He would tell me about his sermons at the church and I would
notice his repetition of some sentence that I had uttered a week before
during our sessions, such as, “We do not need to hurry,” or, “I tell you,
curiosity will not kill us or damage us.”
I began learning a great deal about the childhood stories already
reported earlier in this book. Sometimes he could even “intellectually”
connect these stories with events in his adult life. I did not “interpret”
his identification with me. My supervisor and I wondered if his keeping
my “good” image in his psychotic core would continue. Would he be
able to assimilate my image effectively? We doubted that this “identifi-
cation” with me would settle in him. However, it was good to see such a
process; when the time came, he could repeat it with a more permanent
outcome.
In general, after moving to his new location and bein physically
away from Pastor Johns, Attis’ terror seemed much tamer, and he
would even laugh during some of his sessions. One day he tried to tell
me a joke. Slowly I began to notice that along with my stubbornness to
stay with him, rain or shine, there was another person in his life who
was helping him to make a better adjustment to his psychotic personal-
ity organisation. This man, let us call him Mr. Wiley, was the previous
Methodist minister whom Attis replaced. He was older than Attis and
had remained in the area after his retirement and after Attis took over
his job. Obviously, he was much older than I. But slowly I noticed how
Attis had fused my “good” image with the image of Mr. Wiley. On a few
occasions he called me Dr. Wiley instead of Dr. Volkan. One day when
he came to his session he kept looking at my face in silence for a long
time. Then he declared that Wiley and I looked alike. I did not interfere
with his fusing me with Wiley.
In the second year as an outpatient Attis could not wait to come to
his sessions in order to report how Wiley had been nice to him, how
they did this or that together. I learned that the older man loved to play
golf and invited Attis to join him and become a golfer. Attis’ sessions
were filled with his descriptions of how he would try different golf
clubs, how he would hit the ball in different ways. I still did not tell him
that Wiley also represented my image. My supervisor told me not to
interfere with Attis’ having experience in real life with a “good” object
image. In reality I did not know anything about playing golf. During
my developmental years and my teen years in Cyprus no one in my
environment was interested in this sport; it would not have come up
for discussion at all. I remember that in my mid-teens a high-school
classmate of mine whose family was rich and had some social connec-
tion with the ruling British authorities took me to the British governor’s
place in Nicosia where there was a tennis court. My friend had permis-
sion to use this court. That day he had tennis rackets and a tennis ball
for us to try playing there. Soon after I stepped onto the court, how-
ever, a Cypriot Greek guard working at the governor’s place appeared,
screaming at us to get off the court because we did not have proper ten-
nis shoes. I still recall this event as a very humiliating one. Around this
time, I think, I also visited my first golf course, and it may have been
next to the tennis court. Tennis and golf belonged to the British elite and
some very rich Greek and Turkish people, not to a Cypriot Turk like me
whom the British called a “native”. When Attis was talking with excite-
ment about his golf practices and his developing love for golf, I was
not emotionally with him. Sometimes I would feel bored. Obviously,
I told my supervisor what Attis was talking about, but he did not seem
to have curiosity about the meaning of Attis’ preoccupation with golf
clubs and golf balls either. He continued to inform me that Attis was
having experiences with a “good” object image. To this day I do not
know if my supervisor played golf himself or was interested in going to
golf tournaments or watching them on television.
I wondered if the golf clubs represented Attis’ detached penis, but
did not share this idea with him. Only much later did I make a deeper
formulation about Attis’ preoccupation with golf at this time in his life.
Wiley, his image also fused with mine, was helping Attis to develop a
symbol and also learn about sublimation. Golf clubs stood for an axe
that castrates and also for an axe that Attis could use to cut someone’s
throat. By learning how to play golf, Attis was not only taking the
danger out of the axe, but also was learning to express his incredible
childhood rage by sublimation. You do not kill anyone by playing golf;
you only hit an actual ball without hurting your father’s balls! I will
return to this formulation later in the book.
CHAPTER EIGHT
Linking interpretations, a flesh-coloured

car, and emotional flooding
A
s months passed, Attis’ hallucinations and delusions seemed
to lessen, but they did not disappear. After experiencing a con-
frontation with a member of his church, an especially awful
“bitch”, he still sensed the presence of his dead mother or father at a
new cemetery, this one located closer to his new home, and Gloria’s
vagina again became a walrus with teeth. Perhaps he noticed my bore-
dom with his endless golf stories. He continued to make some refer-
ences to them, but now in his sessions he began a routine. He would
simply tell me that he was having a bodily experience, such as neck
pain. Then he would stop, give no associations, stay silent and look at
me as if I knew why his neck was hurting. My inquiries as to what had
triggered his bodily sensations went nowhere. Then he would tell me
about a sermon he had given the previous Sunday or something about
his duties at his church.
After his second year of coming to see me, Attis was coming to his
sessions alone most of the time, without Gloria. One day he came to
his session and described how he was in a cold sweat. He was actually
sweating. Only towards the end of his session did I learn that, as he was
approaching Chapel Hill, he had seen a “mean-looking” policeman in
a police cruiser parked by the side of the highway. He had a thought
75
that he might be stopped by the policeman because earlier he had been

driving over the speed limit. When I heard his story about the police-
man I automatically linked his cold sweat as he entered the therapy
room and his noticing the “mean-looking” policeman. Soon, reporting
a bodily symptom at the beginning of his session and then, during the
latter part of the session referring to an event that most likely caused
him to have that bodily experience became his habit. I would verbalise
the connection between his reported bodily sensation and the actual
event without connecting his experience with possible related genetic
material such as the “mean-looking” policeman representing his sadis-
tic father. Such exercises seemed to lead Attis towards developing bet-
ter reality testing. I now know that my patient had introduced me to a
technique that refers to “linking interpretations”.
It was Peter Giovacchini (1969, 1972) who first described linking
interpretations, and I expanded this concept further (Volkan, 1976,
1987). Giovacchini based his description of linking interpretation
on Freud’s (1900a) concept of day residue in dreams. As day residue,
insignificant impressions derived from the real world—seeing a police
cruiser parked at the side of a highway like Attis described, or pass-
ing a billboard depicting a smiling woman holding a milk bottle—join
infantile aggressive or libidinal wishes to initiate the content of dreams.
Giovacchini applied Freud’s understanding of day residue to the clini-
cal setting, stating, “An interpretation may make a casual connection by
referring to the day residue which may be the stimulus for the flow of
the patient’s associations or for some otherwise unexplainable behav-
iour” (Giovacchini, 1969, p. 180). I had first noted the usefulness of link-
ing interpretations when working with Attis, an individual with poor
reality testing. Such “interpretations” link events in external reality to
intrapsychic phenomena and promote contact with reality.
Here is another example of a linking interpretation I offered to
another patient, Jane, who also had poor reality testing. While on my
couch, she looked at the ceiling and said that blood was dripping from
holes in the ceiling tiles. I connected this bizarre perception with the
patient’s earlier statement that she had just begun menstruating, thus
linking her perception of her bleeding body with a “bleeding” environ-
ment (Volkan, 1995). At that time I did not connect her sharing about her
menstruation during the session with the fact that she had been abused
by her father as a child until one day he saw her menstruating and
stopped abusing her. Jane was not yet ready to deal with this genetic
L I N K I N G I N T E R P R E TAT I O N S 77
material. Much later in her analysis she could handle her memories of
abuse and work through her terrible trauma.
My playing “linking games” with Attis lasted many months until
he began making such links himself, illustrating his own ability to note
how external events induce bodily sensations with associated feelings
and thoughts. This development was important for him in develop-
ing integrative function and psychological mindedness. I noticed how
proud he was to have accomplished this. Meanwhile, some external
events continued to initiate his old fears and his old ways of handling
them, such as acutely and openly becoming involved in internalisation-
externalisation and introjective-projective cycles. During those times,
he or I, or both of us, would be “monsters”, or someone else “out there”
would be a “monster”. Some sessions were filled with his grievances
and lists of people whom he saw as agents of annihilation or castra-
tion. These experiences would make him hungry for libidinal objects
to be “eaten up”, and then Wiley or I would emerge as “good” object
images.
After three years at Chapel Hill I finished my psychiatry residency
training and moved to Goldsboro, North Carolina where I began to
work as a staff psychiatrist at Cherry Hospital, which was only for
African-Americans. Other physicians at Cherry Hospital were all immi-
grants from different countries (Volkan, 2009). Once I moved to Cherry
Hospital I no longer had a supervisor in Chapel Hill. However, I contin-
ued to go to North Carolina Memorial Hospital once a week to attend
some educational sessions and continued to see Attis as an outpatient.
I began reading volumes of the International Journal of Psychoanalysis
starting with Volume I; my reading replaced my sessions with a super-
visor. Attis—I do not recall how—knew that I no longer lived in Chapel
Hill. He seemed to express appreciation that I was still his therapist; at
the same time I sensed that he perceived me as a different individual.
In his sessions he appeared rather paranoid and cautious. I told him
that I was the same person even though Chapel Hill was no longer my
home.
Then one day when he came to see me I realised how happy he
was. Before the session was over I learned that he had bought a
“flesh-coloured car”. I thought that this car symbolised the finger in the
bottle, his detached penis, and it patched up his sense of self. This time
I did not make a “linking interpretation” since he had started an event
that seemed to have direct connection with his internal conflicts and
since he seemed to create a symbol for his penis. I wanted to wait and
see how his “flesh-coloured car” would appear in his sessions. Dur-
ing the following sessions I noted that the car was not yet a symbol
for him; it was a protosymbol. For example, while going to a service
station to have the car serviced, he would have tactile sensations on
his penis whenever a serviceman raised the car’s hood. Once, when
the car’s exhaust pipe was damaged, he actually developed haemor-
rhoids. I do not know how a psychological phenomenon initiates a
physical bodily change but, in Attis’ case, this actually occurred. Soon,
he returned to a paranoid state when he felt that the car was not run-
ning well and accused the man who sold him the car of giving him an
inferior vehicle.
Towards the end of the fourth year of our first meeting there was
much snow in North Carolina. Attis called to cancel a number of his
hours with me on the grounds that the bad weather made the trip dan-
gerous. He offered, as an additional justification, the need to officiate
at an unusual number of funerals among his parishioners. I wondered
if he wanted to keep his “flesh coloured car”/penis away from me
and under his control. I should not be the mother who would “steel”
it and keep it in a bottle. In a general sense I imagined that the cancel-
lations represented his wish to separate from the “early bad mother”/
therapist, and the winter weather helped him to defend this wish. I con-
cluded that he was experiencing the following fear: if he came to me,
I might not only steel his car/penis, but engulf him. He seemed to fear
that he might kill me, and thus himself, or part of himself which was
fused with me.
When he called to cancel another session he was questioned by a
new secretary about his reason for cancelling the appointment and felt
great resentment over what he regarded as her aggressive curiosity. He
saw her as an extension of me, the “bad mother” image, and during
his next hour with me he opened the session with a complaint, albeit a
calm complaint, about the secretary’s pointed questions. He then began
to relate a quarrel that had taken place in his hometown. The owner of
a funeral home there had discontinued his ambulance service because
it was unprofitable, and the townspeople were sharply critical of this
curtailment of service. As he reviewed this, Attis became very angry;
he spoke of what had occurred as unjust persecution. He felt involved in
it himself inasmuch as he had been called by a community leader who
suggested that the financial affairs of the mortuary needed investigation.
Attis wanted to give a sermon in support of the owner of the funeral

home although this would endanger his own image in the community.
In following his opening complaint about inquisitive interference over
the telephone by telling of another episode involving telephone pres-
sure, Attis did not seem to see the parallel between them: how in each a
persecuting “bad” object tried to intrude on a victimised one. I did not
interrupt him and continued to listen. Attis went on to say that he had
recently been upset. He had returned to the habit of looking into clos-
ets for his dead father. Although he had, in the past, hallucinated his
father’s presence, his search now referred to a certain temper tantrum
his father had had accompanied by his punitive and taunting grin. Attis
was experiencing fear not only due to his “bad” mother’s intentions but
also his “bad” father’s sadistic attitude.
Attis reported that, on his way to my office that day, he thought of
turning his car around and going back home. I considered that he was
afraid of losing control of his anger. He wished to protect me from his
fury by thinking of not being with me. Nevertheless, he came to his
appointment. But he was angered further by something that had hap-
pened as he parked his flesh-coloured car outside my office. He had
located an empty spot in the crowded parking lot but had been “tricked
out of it” by a “big guy” even though he had found it first. This inci-
dent triggered the anger that supported the emotions that had attended
other episodes he talked about during the hour. He recalled the brother
who had cut off his finger; he was angry because his brother had been
his mother’s favourite and she had pushed Attis into a lower place. He
had been reminded at a basketball game the previous week of his boy-
hood prowess in athletics, which he had given up because of his moth-
er’s disapproval. There had been two brothers in the game he saw; the
younger, the better player, had refrained, “for psychological reasons”,
from shooting the ball into the basket.
Although on the surface these incidents contained aspects of the
oedipal struggle as it involved a sibling in a triangle, Attis emphasised
the dyad of himself and his mother within the triangle. As Kurt Eissler
(1954) long ago observed in individuals who, like Attis, have a psy-
chotic core, an emotion can accumulate new energy by activating other
memories that feed it (also see Peto, 1968).
Attis grew angrier and angrier as he poured out these memories. He
was not, at this point, conscious that they were all serving to support
his anger and he could not separate one event, with its accompanying
feeling, from another. Suddenly he went into “emotional flooding”

(Volkan, 1976, 1995), also known in the literature as “organismic panic”
(Pao, 1979). Motor activity accompanied this and he moved towards
me to attack. He did not hit me, and after my initial fearful surprise I
found myself uttering his name. Looking back, my calling him by name
was my way of giving him an identity. Apparently, not losing my thera-
peutic position spontaneously made me a “good object” that acknowl-
edged him as a human being! Attis felt “paralysed” as his motor activity
lapsed. I remembered how he had become catatonic when he attempted
to cut Gloria’s neck with an axe.
When we tried later to understand this feeling of “paralysis”, he
recalled the events of the night during which he had left the house in
search of an axe with which to kill his wife. Although, on one level,
his “paralysis” might seem a highly sophisticated defence mechanism
directed by a developed superego, the patient’s associations pointed to
a global defence, like a primitive state of shock, a manoeuvre of “play-
ing possum”.
Patients with psychotic personality organisations resist getting well,
getting rid of their psychotic core, since true wellness means visiting
their internalised metaphorical doughnut filled with most unpleasant
affects, experiencing and tolerating them, and then getting rid of the
doughnut. Having an emotional flooding represents such a visitation.
Patients do so after they have internalised the therapist’s protective
image and are able to keep it within themselves in a steady fashion. In
other words, an emotional flooding after the patient can maintain a sta-
ble libidinal image of the therapist is a sign of major improvement.
After his emotional flooding and his paralysis were over, Attis
described his emotional flooding experience as a swollen balloon satu-
rated with unpleasant affects bursting and destroying everything within
him and around him. He used the word “balloon”, instead of a dough-
nut filled with rotten jelly! He told me that when he heard me calling his
name his perception of himself as a monster gave way to a perception
of himself as a groundhog. He adhered to this throughout what was left
of the hour. The groundhog image is tamer than that of the monster. In
layman’s terms I explained to him that since he was often reminded
when he was a child that he had been born on Groundhog Day, the
groundhog image symbolised the core primary affective relationship
between the mother and child upon which the first, but undifferen-
tiated, self- and object images accumulated. In the following hours, he
was able to feel and understand his rage against his primary love object
from whom he could not obtain the needed libidinal input. This had
made his separation–individuation impossible.
During his emotional flooding none of us died. I verbalised this.
After this event Attis never again mentioned his wish and fear of mur-
dering Gloria.
When I was treating Attis I was inexperienced, and also saw him
only once a week. It took four years in treatment for Attis to revisit
the evening he attempted to kill Gloria, and he described undergoing a
“metamorphosis” during the experience. Since experiencing and toler-
ating an emotional flooding by a patient like Attis is the most important
event in the treatment, I will briefly describe an emotional flooding by
another patient. I had had more experience with individuals with psy-
chotic personality organisation when Jane, a twenty-one-year-old col-
lege student whose case I briefly reported earlier, became my patient.
I saw Jane intensively, four times a week on my couch. During her first
eleven months with me Jane primarily experienced my images as “bad”,
and my “bad” image was involved in her internalisation–externalisation
and introjective-projective cycles. Both of us tolerated this. Then I
noticed her regarding me steadily as a new “good” object. Sitting on the
couch briefly at the end of her sessions she would ask me to turn this
or that way and move into or away from the light. I did not move and
said nothing. She explained that she was taking my picture by blinking
her eyes. I could clearly observe her becoming a camera and her blink-
ing eyes like the shutter of a camera. When she left my presence, she
went to a dark room and mentally developed my picture, externalising
it onto the external world but keeping it near her. This behaviour went
on for some months. Meanwhile, we were able to define my function
for her as a “good” libidinal object. As a child she could not depend on
her mother who was depressed due to the loss of Jane’s sister, who died
at the age of three when Jane was one and a half. Neither could Jane
depend on her father’s image. In “losing” his wife to depression he had
turned to Jane and made her his target for incest.
One day on my couch Jane reported losing the boundaries of her
back while lying there (representing her fusing her body image with my
image). She experienced high anxiety, but not a true emotional flood-
ing. Jane said that the couch had turned into a swimming pool and that
she was floating above the water. She began moving her arms in order
not to sink into the couch. She was also uncertain where her back ended
and where my couch began. Sitting behind her I stayed silent and let
her experience this fusing, waiting to see what would develop. The next
day she lost the boundaries of her back once more while lying on the
couch. But this time she had come prepared. She opened her purse and
pulled out a sharp pencil and stuck it into her hand. With high anxiety
she reported that she felt pain. “But”, she said, “I now know that my
hand and my body belong to me.” She was in control of disconnecting
her self-image from my image (the couch). Soon after this, Jane experi-
enced an emotional flooding and was overwhelmed with indescribable
“bad” feelings on the couch. Interestingly, this horrifying experience
was accompanied by a “hallucination” of a big mouth with scary
laughter coming from it. The laughter “echoed” in Jane’s mind, driv-
ing her “crazy”. She named her emotional flooding “Cosmic Laughter”.
Later we understood the nature of her specific type of emotional flood-
ing: Her mother, who had lost Jane’s sister when Jane was one and a
half years old, was depressed. Even while she was pregnant with Jane
she knew that her older daughter would not live because of a congeni-
tal anomaly. Furthermore, the depressed mother had a breast infection
(confirmed by her mother during Jane’s treatment) while nursing Jane.
Because of the pain, she would abruptly remove her breast from infant
Jane’s mouth and then after a while, give her breast to the infant once
more, and then remove it again. This interaction between the depressed
mother and her baby was a faulty ingredient that was the key to the
initiation of Jane’s psychotic core, a doughnut filled with indescriba-
ble unpleasant affects. In the treatment, this poisonous mother/infant
interaction was repeated while she was on my couch, accompanied
by flooding of “bad” emotions, and was then mastered (Volkan, 1974,
1995).
In the next chapter I will describe how Attis developed a most
workable transference psychosis. He became involved in a new
internalisation–externalisation cycle which led to his stabilising a libidi-
nal infantile core through stable identification with me as a new thera-
peutic libidinal object, replacing his psychotic core, and thus no longer
possessing a doughnut or balloon full of most unpleasant affects.
CHAPTER NINE
Turkey dinners and identification with

a therapeutic libidinal object
T
he week following his emotional flooding Attis entered my office
looking very pale. He told me that the suit he was wearing was
very much like one of mine; in fact, the one I wore on this occa-
sion. In those days, since I did not have much money, I purchased my
clothing off the rack. Attis could easily find the same clothing. He had
had the impulse the day before to visit a clothing store and while there
had purchased the suit in question, along with a shirt and tie very like
my own. He also told me that he had eaten a turkey dinner the night
before and had been anxious ever since. He knew that I had come to the
United States from Turkey. Although his awareness that his imitative
behaviour, his buying the new suit, had been spontaneous, he remained
unaware of the meaning of his symbolic internalisation of me by eating
the turkey dinner. As the hour progressed, he spoke of his fantasies of
destruction directed towards me that he had entertained en route to
my office. I told him that a turkey stood for my image; it was a symbol
since I was a Turk and had come to the USA from Turkey. I added that
he had a wish to resemble me by “eating me up” and his subsequent
fear was that he had destroyed me by this act. I chose not to tell him
that he might also want to destroy me because he was afraid that every
libidinal object in his mind could turn into a destructive one. In a sense,
83
I “humanised” his bizarre wish to eat me. Following this exchange, he

relaxed and asked what I thought about the recent Supreme Court deci-
sion about prayer in schools; he speculated about my religion. The tenor
of my reply was: “Look, if you want to be like me, you need not make
the resemblance an all-or-nothing business. You can get useful things
from me, and you may reject other aspects of me. You can choose. You
are a different person than I and, in the long run, we will continue being
two different persons and continue to work together.”
He wore the same lookalike clothing to our next session, saying that
he had been impelled to do so. Just before we began the hour, he broke
the usual routine by a trip to the bathroom where he had a hard stool.
When he informed me about this he kept looking at me as if he was
inquiring about something and waiting for an explanation. I explained
that during the previous hour I had told him how he could choose what
he wanted to keep about my image and what he wanted to get rid of.
I asked him if he had a turkey dinner the night before this visit too. The
answer was “yes”. I told him that by defecating he tested me in order to
be sure that I really meant what I had told him and added: “Once more,
I tell you that it is alright to get rid of my stinking parts.” He laughed.
Attis continued to eat turkey dinners and go to the bathroom just
before or just after his sessions. His turkey dishes were still, to a great
extent, my protosymbols (Werner & Kaplan, 1963) for him. I verbalised
the difference between a protosymbol and a symbol. Upon this, Attis
recalled having a fantasy some time ago after having a hard stool that
he was getting rid of his father’s appendix/penis from his belly. He had
a similar fantasy in a bathroom after defecating just before his session
with me. He told me this with a big smile on his face, and added that
his father’s appendix/penis was now gone forever, and he would no
longer think of having it in his stomach. Around this time, Attis thought
about his own death. I reminded him of his wish and attempts to “kill”
unwanted things in himself, from his father’s appendix, to his moth-
er’s/father’s and my unwanted aspects. When he stopped completely
fusing with them he would stop thinking of his own death.
I noted that Attis was developing a genuine understanding of what
a symbol was; it was not identical with the thing it represented. He
brought a dream to his next session. He would, as the reader knows,
talk about his visual hallucinations, but this was the first time that
he reported a dream. In the dream he was holding a golf club. Then
he noticed that the club turned into an axe. This confused him. Then the
TURKEY DINNERS AND A LIBIDINAL OBJECT 85
axe became a golf club again and he felt comfortable. There was a day
residue for his dream. Wiley was moving to California to a retirement
place not far away from his married daughter. The day before Attis had
his dream parishioners of his church had gathered there with food and
drink to say goodbye to their former minister. Attis gave a speech count-
ing the good things Wiley had done for his community and when he
finished his speech he hugged the older man. Now I clearly understood
how Attis, by spending time with golf clubs, was also learning how to
make an axe not dangerous. He and I could now see that the golf club
that Wiley had introduced to him stood as a symbol that he had tamed.
When we talked about this Attis murmured, “A golf club is a golf club!”
Wiley moved away and Attis continued to play golf.
After the events I described above, one day, with great pleasure,
Attis told me of a sensation of getting out of his shell, developing a
new personality. He wanted to take a long vacation trip and explore
wider and wider areas. In my mind I visualised a groundhog that was
going to explore its surroundings, sunshine or rain. Attis talked about
his imagining my immigration to the United States from Turkey as a
highly adventurous undertaking. Unlike me, he added, all of his life,
he had been confined within a limited geographical area. He had never
travelled outside the state of North Carolina in which he was born.
I thought that this was not an accident but a reflection of his patho-
logical makeup. It reflected his difficulty in separation–individuation.
He could not leave his state/mother. Developing new personality, how-
ever, should now allow Attis to try to individuate away from the repre-
sentation of his mother. He continued to express a desire to travel out
of his state and have “adventures”. He could do so through keeping
the “good” aspects of turkeys he had eaten. He also said that I was not
really a turkey, I was a person, and he smiled.
In one of his next sessions, Attis set Pennsylvania as his travel objec-
tive; this did, in fact, involve a considerable journey for him. His associa-
tions centred on the Liberty Bell in Philadelphia. Here I will not dwell on
the history of how this bell, which weighs 2000 pounds and which was
cast in London in the mid-seventeenth century, became the main icon of
American independence. I felt that for Attis the Liberty Bell indicated a
need for symbolic celebration of his “rebirth”. As we discussed the pro-
posed trip to Philadelphia, I mentioned having once made the trip there
myself, implying that it was not a journey that involved any danger.
In retrospect, I suspect that I sensed in him anxiety about finding his
liberty and that my remark was in response to this. I needed to protect

him—and, perhaps, myself within him—through such reassurance. My
response was determined by my countertransference, but I think it was
a proper one. At this time I did not know that Attis’ brother who had
amputated his finger was living not far from Philadelphia with his fam-
ily. Attis had not mentioned this fact to me.
Before long, Attis did take a six-week vacation to Philadelphia and
Gloria accompanied him. When he returned to see me he seemed
excited. Right away he focused on the Liberty Bell and seeing the
crack on it. As far as I could find out there is disagreement about when
the crack first appeared on the Liberty Bell. There is a strong opinion
that it originally cracked when first rung after the bell was brought to
Philadelphia. In fact, the last names of two workmen who re-cast the bell
appear on it. With a big smile Attis declared: “I know what a symbol is!
When I noticed the crack on the bell first I thought that the bell stood for
my cut finger/penis. Then, it stood for my freedom. Even though there
is a crack on the bell people come to see it. It is so important.”
Then there was a silence, during which I think both of us celebrated
Attis owning his penis. After this Attis never had a delusion or a
thought about Gloria’s vagina turning into a walrus. He also stopped
thinking and believing that his parents would come out of their graves
and hunt him.
Attis informed me that his elder brother who had amputated his
finger lived with his family near Philadelphia. The two brothers had
not been in close contact for decades. On his return journey Attis and
Gloria visited Attis’ brother and his family. “I wanted to show him
my ‘new personality’,” Attis said. I realised that his choosing to visit
Philadelphia was what Samuel Novey (1968) called a “second look”.
Novey described how after working through some internal problems,
some patients go to their childhood locations and/or talk with adults
who were around during their childhood to collect information to ver-
ify their newly gained insights and internal changes. Attis did not go to
his childhood location, but to Philadelphia where there is a bell with a
crack in it, and where the brother who had amputated one of his fingers
lived nearby. Philadelphia was a place where he would have a “second
look” experience.
Before telling the story of Attis after his trip to Philadelphia,
let us return to his eating turkey dinners and visits to bathrooms.
From the time I had met him there had been many examples of his
TURKEY DINNERS AND A LIBIDINAL OBJECT 87
internalisation–externalisation cycles. In Chapter Five I wrote about

how individuals with psychotic personality organisation defend
themselves from experiencing overwhelming anxiety or emotional
flooding by externalisation-internalisation and also by further fragmen-
tation, further fusion-diffusion, further projection-introjection, and/
or wiping out more reality. But it is also true that, after “testing” the
therapist’s image long enough, the patient utilises the internalisation-
externalisation cycles as the point where he catches a chance to begin
to change his internal world and get rid of his psychotic core. After
experiencing and tolerating an emotional flooding, Attis could more
easily choose and keep libidinal object images within and identify with
them, and externalise only aggressively tinged object images. His eat-
ing of turkey dinners and getting rid of my unwanted aspects through
his rectum stabilised selected libidinal aspect of my image in him. This
furthered the turning point in his treatment.
In the next chapter I will examine internalisation–externalisation
and accompanying introjection-projection cycles in a treatment process,
by giving examples from two other cases in order to further illustrate
various functions of such cycles, including a patient’s collecting libidinal
images within and identifying with them, thus modifying his psychotic
core and saying goodbye to the psychotic personality organisation.
CHAPTER TEN
Internalisation–externalisation cycles
and the alteration of the psychotic core
I
n ‘Three essays on the theory of sexuality’ Sigmund Freud (1905d)
referred to the experience of sucking as an essential gratification
tied to the oral zone and linked with nutrition. Although Freud
(1887–1902) mentioned “identification” in his letters to Wilhelm Fliess,
it was in Three Essays that he wrote about the sexual aim of the oral
phase (oral incorporation of the object) which became a prototype of
identification. Adapting the terms “introject” and “introjections” from
Sándor Ferenczi (1909), Freud applied them to the analysis of mourn-
ing and melancholia (Freud, 1917e), which signalled the beginnings of
the concept of internalised object images. Mourning refers to an obliga-
tory preoccupation with the internalised images of a dead person or
lost thing. The Kleinian school should receive the credit for carrying
the study of object relatedness and the internalisation of objects—at
the outset, part of objects—back to the beginnings of life experi-
ences. As Otto Kernberg’s (1969) review of the Kleinian formulations
also shows, this school influenced what was then the mainstream of
psychoanalysis to focus further on the earliest level of relatedness.
Internalisation–externalisation of self- and object images (accompanied
by introjection and projections of affects and thoughts as the infant and
child grow up), the earliest type of relatedness for everyone, inevitably
89
reappears prominently in the process of treating persons like Attis. This

was noticed long ago by many analysts (for example see: Searles, 1951;
Hoedemaker, 1955; Limentani, 1956; Szasz, 1957; Abse & Ewing, 1960;
Cameron, 1961; Boyer, 1967).
For some time the experiences a patient like Attis has with external
objects may provide him with little new material, since the appearance
of his primitive relatedness causes him to perceive whatever he internal-
ises as representatives of archaic objects. Initially, the therapist’s image
does not provide the patient with an analytical attitude that he may
use as a characterological modality of his own. It is up to the therapist
to differentiate herself at the outset from the archaic object images, in
piecemeal fashion, in order to help her patient alter his internal world.
Since the reactivation of primitive relatedness to objects naturally
leads the patient to internalise his therapist, any manoeuvre of the
therapist to offer himself openly to his patient with a psychotic core
as a model is usually a seductive intrusion that may lead to extreme
anxiety. Some early analysts, noticing the patient’s internalisation–
externalisation cycles and their libidinal object hunger, seemed to
have had a wish to offer themselves to their patients as “good” objects
and were involved in actions that were desperate efforts to respond
to patients’ needs. For example, I recall reading how Marguerite
Sechehaye (1951) put two green apples on her breasts and offered the
apples as a symbol of herself to her patient, Renée. We should remem-
ber Harold Searles (1951) stating that the “incorporative processes”
within the transference–countertransference relationship with an indi-
vidual with psychotic personality organisation, when used as a defence
against overwhelming anxiety, can be the basis of many stalemates in
psychoanalytic therapy.
During their analytic treatment we notice that individuals with
higher level personality organisations also use the internalisation-
externalisation process, but usually such cycles are hidden behind more
complex interactions between the patient and the analyst, unless the
patient regresses a great deal, whether it is in the service of progression
or not. Sometimes internalisation–externalisation relatedness appears
in neurotic patients’ dreams. In fact, internalisation–externalisation
cycles are at the foundation of each psychoanalytic process. Therefore,
when we think of a description of any psychoanalytic process we need
to make a reference to internalisation–externalisation cycles and their
resulting in new healthy identifications.
I N T E R N A L I S AT I O N – E X T E R N A L I S AT I O N C Y C L E S 91
James Strachey was one of the first psychoanalysts who, in 1934,

offered a metapsychology of psychoanalytic technique. Of course, at that
time he was not dividing the analysands’ personality organisations into
different categories, as I have illustrated in this book. Later, Strachey’s
ideas were modified and expanded by many analysts who came after
him. Briefly, the focus of Strachey’s metapsychology is internalisation-
externalisation and accompanying introjection-projection processes
that take place during analytic work. The analyst does not return the
analysand’s externalisations and projections right away, and thus
through her analytic stance modifies them before giving them back to
the patient. The analyst becomes, according to Strachey, an auxiliary
superego. Such a process, through identifications, changes the patient’s
severe superego.
Following Strachey, in 1956 Paula Heimann described how the ana-
lyst becomes an auxiliary ego. Heimann tells us to imagine an infant who
first shrinks from a new object, a cat, and takes flight into his mother’s
arms. After the mother gently strokes the cat’s back and shows the infant
that the creature is not dangerous, the infant, encouraged by his mother,
does the same thing. The old terms “auxiliary superego” and “auxiliary
ego” refer to the analyst as a new object, analytic introject, or developmen-
tal object—terms used by analysts of later years (Szasz, 1957; Loewald,
1960; Cameron, 1961; Giovacchini, 1972; Kernberg, 1975; Volkan, 1976;
Tähkä, 1993; Volkan & Ast, 1994). The analyst’s newness does not refer
to his or her social existence in the real world, but depends on the ana-
lyst being an object (and its representation) not hitherto encountered.
The patient’s interaction with a “new object” is akin to a nurturing
child–mother relationship (Rapaport, 1951; Ekstein, 1966).
Attis’ internalisation–externalisation cycles became “therapeutic”
when he started to eat turkey prior to his visits with me and when
he felt uncomfortable “defecating” selected aspects of my image. In
this chapter I will give examples of internalisation–externalisation
processes, accompanied by introjections and projections of affects and
thoughts of two other patients with psychotic personality organisation.
I do this in order to provide the reader with a better understanding
and appreciation of Attis’ way of being stuck in such relatedness for a
long time before utilising the same relatedness to change his internal
world. The following cases are from a time in my life when I had
become a more experienced therapist and when I could see my patients
more intensively during their treatments.
Sharon, in her late twenties, was a beautiful woman who had a

psychotic core. She was the daughter of an extremely narcissistic
woman and an ineffectual man who had inherited a huge amount of
money. The family had no financial concerns and lived in an enormous
home. Sharon had two older sisters and was born eight years after her
second sister. Her mother was very upset when she realised that she
was once more pregnant. Before Sharon was born—as Sharon heard her
mother tell it again and again while she was growing up—her mother
often sat naked in the family room in front of a huge mirror and adored
her body. Her husband, her two children and one of the family maids
were allowed to be in the room with her when she was naked. She told
them that she did not wish her belly be swollen again by pregnancy.
She thought of abortion, but she did not go through with it. Sharon
was definitely an unwanted child. After she was born, her mother again
began to sit naked in front of the mirror. This time she noticed that her
pregnancy with Sharon had caused some wrinkles to appear on her
abdomen. She hated Sharon because of this. She gave up sitting naked
during the daytime a few months after Sharon was born.
It appears that the family members dealt with her hated existence
in a most bizarre fashion by attempting to make Sharon pure and thus
acceptable. From Sharon’s very early childhood onwards, her mother,
her father, and even her two older sisters gave Sharon enemas almost
daily. If Sharon exhibited confusion or anxiety she would receive enemas
more than once a day. This went on and on. By the time I met Sharon I
had heard enough bizarre stories about childrearing that learning the
facts of Sharon’s upbringing did not shock me. Often, individuals with
severe mental problems come to see clinicians under the impression
that only biology, genetics, or neurological issues cause patients’ condi-
tions. This is a big mistake.
When she was age fifteen Sharon wrapped a piece of faecal mate-
rial in a tissue and presented it to a sister in the family room where
the other members of the family were present. After this episode the
enemas were discontinued. On the surface Sharon appeared “normal”.
After high school she attended a college, but left it without graduating.
When I listened to her description of her high school and college days,
in my mind, I perceived her as a “beautiful doll” with limited emotional
expressions and logical mind. At the age of twenty-five, she married
a man who was the son of another rich man and who, with the help
of one of his father’s able assistants, had an administrative job in his
father’s business. I guessed that he wanted to possess a “beautiful doll”

and so he married Sharon.
Soon after her marriage Sharon’s primitive object relationship
became very obvious. She persuaded her husband to give her an
enema before sex and she became addicted to sleeping pills. Her ana-
lytic treatment started a few years after her marriage when her addic-
tion to enemas and pills increased and when she supposedly exhibited
some catatonic spells, such as staying “frozen” in front of a mirror.
I imagined that she was imitating her mother for some psychological
purpose. She did not tell me about this symptom. I started to work with
her four times a week. In spite of her physical beauty she appeared to
me at times to be little more than a gastrointestinal tube as she lay on
my couch. She would try to arouse in me a desire to intrude within
her body; at the same time she feared such intrusion. She perceived
her analysis as an enema experience, feeling that the analyst would go
to work in her entrails. She therefore needed to protect herself from
internalising my image as a “bad”, intrusive object. Her experiences
with enemas were condensed with her primal scene fantasies and on
the couch she illustrated a kind of “reaching up” (Boyer, 1961, 1983;
Volkan, 1976, 1997, 2010), talking endlessly of sexualised desires and
dreads.
In the eighth month of Sharon’s treatment I took a two-week holiday,
during which I more clearly became the non-caring mother. When our
work resumed she would simply lie on the couch and speak almost
exclusively about her typical daily activities: staying home, placing an
enema tube in her rectum, watching television, and sometimes mastur-
bating. I sensed that placing an enema tube in her rectum was reassur-
ance that she was in control of whatever went into or came out of her
body/soul. One day, just before she ended her session, Sharon urinated
on my couch, but only a little. During those days I had a couch covered
with plastic. I did not know what to say or what to do for a few minutes.
Then I asked her to go to the bathroom near my office, get some wet
and dry paper towels, come back to my office, wipe off the urine and
then dry the plastic. Without hesitation she did this. The next day she
urinated on my couch again. This time she had come well-prepared;
she had brought her cleaning supplies. I told her that our work’s magic
was to put her wishes and dreads, and especially her bodily impulses in
words during our sessions. I explained that I could maintain my curios-
ity better when I heard words describing her impulse to urinate on my
couch, than wondering about who would clean my couch. She did not
urinate on my couch again.
Soon, I noticed that she would secretly chew on something while on
my couch. When whatever she had in her mouth was chewed away
she would put a new thing in her mouth while trying to hide her
action from me. After some days I expressed my curiosity of her new
actions on the couch. I learned that what she was popping into her
mouth were ring-shaped mints that were sold as Life Savers. I sensed
that her Life Savers were protosymbols: as long as she had one in her
mouth, my “bad” image could not enter her; her life would be saved.
Sharon’s use of Life Savers continued for a few months, until one day
she declared that she no longer needed them. She now had sweet can-
dies in her mouth. I understood that her fear of internalising my image
was no longer a matter of psychological life and death for her, and
that now I was somewhat different from her archaic destructive object
images, which were most likely linked to her aggressive self-fragments
externalised onto me. I explained her internalisation and did not refer
to her externalisation; in other words, I focused on what was terrify-
ing her—the notion that my “coming in” might destroy her viscera.
I wanted to wait before mentioning how she also had aggressive feel-
ings that she put into me. Her chewing candies continued for some
months despite my explanations. When I sensed that her attitude was
more relaxed, I suggested that we might try to work without anything
in her mouth. If she did not like something I said or did she could feel
free to speak about it. She was somewhat flooded with emotions dur-
ing the next session, but not disorganised. She told me that she did not
have anything in her mouth. We began a new phase, so to speak, of
her treatment.
Soon, however, Sharon’s father-in-law assigned her husband to an
administrative job in London. He also assigned his able assistant to
guide his son’s work there. I was informed that the family had found
a new therapist for Sharon in England. I lost my patient. Four years
later I received a very brief note from Sharon’s husband, with no return
address. It simply stated that Sharon’s therapy with her new therapists,
several of them, had not been successful and that she had committed
suicide. I still recall my shock, sadness, and feelings of helplessness
with an accompanying idea that if I had continued working with her
she would still be alive, even hopefully with self-esteem and without a
psychotic core.
While Sharon’s case illustrates internalisation–externalisation in a

most obvious way, I did not have a chance to see if she would “move
up” and identify with me as a “new object”. Ricky, the next patient I
will describe, also began his treatment with me by illustrating his
internalisation–externalisation cycle with bodily actions. In working
with him over the years I would very clearly see the changing functions
of his cycle and his move to a level in which his aggression-filled psy-
chotic core was replaced by a libidinal one. Another reason why I chose
to write about Ricky is the fact that he had a deformity with his fingers.
Thus, I connect his case with that of Attis. In some ways, as the reader
will see, Ricky and Attis, as children, shared certain psychological posi-
tions, such as the illusion that their mother had the power to correct
their physical deformities but never would.
Ricky was an eighteen-year-old when I first saw him. I worked with
him in my office at the University of Virginia Hospital in Charlottesville,
Virginia where I had seen Sharon. After staying in North Carolina for
five years I had moved to Virginia and become a faculty member of
the Department of Psychiatry at the University of Virginia School of
Medicine. I received the following information from Ricky’s referring
psychiatrist: Ricky was born with a deformed right hand and foot, his
right fingers and toes being much shorter than the left ones. Beginning
on his fourth birthday, his mother started giving him “wedding rings”
for birthday presents. These rings were large and would not fit his
deformed fingers. The mother never talked openly with Ricky about
his congenital deformity. The referring psychiatrist was aware that
the mother was incapable of teaching Ricky what was real and what
was unreal. When Ricky was in high school a girl casually told him
that his voice sounded different. He interpreted this to mean that girls
might think that another part of his body, his penis, might be deformed
too. Soon after this incident he developed overt psychotic symptoms.
He read every book he could find about Nazi Germany. His ideal did
not appear to be Adolf Hitler himself, but Hitler’s “right arm”, Joseph
Goebbels, who in reality had a deformed leg. Thinking of his mother
as Hitler and himself as Goebbels, Ricky thought that he could intimi-
date everybody. The referring psychiatrist told me that this was the way
Ricky was attempting to deal with his castration anxiety. He added that
Ricky was submissive to his tyrannical mother, as Goebbels had been
submissive to Hitler. When Ricky reached the age of sixteen, his mother
gave him the usual gift of a golden wedding ring for his birthday. The
next day his parents committed him to a state hospital. The referring
psychiatrist worked at this state hospital and looked after Ricky who
was placed in a ward with other mentally troubled youngsters. The
psychiatrist told me that Ricky was given medication. Whenever he had
time the psychiatrist would talk with Ricky and tell him that in reality
he was not castrated. At the hospital, Ricky’s psychological condition
improved. He no longer talked about Hitler and Goebbels. His psychia-
trist, however, noticed that Ricky kept walking with an erect stance like
a Nazi soldier would have done. The psychiatrist thought that holding
his body in an erect position while walking was Ricky’s way of deny-
ing his castration—he was making his body an erect penis. Ricky was
discharged and I was asked to treat him as an outpatient.
Listening to the physician, I realised that I was hearing another
bizarre story of how a mother had related to her child, most likely in
order to deny her narcissistic hurt, anger, and guilt for giving birth to a
child with a physical deformity. I sensed that Ricky had more problems
than anxiousness about feeling castrated. I thought that his obsession
with the Nazis, calling his mother Hitler and himself Goebbels, might
be linked to a doughnut with “bad” jelly sitting in the middle of his
soul.
During my first two sessions I noted how Ricky held his body erect
and rigid. Yes, the referring physician was right. He was walking like
the Nazi soldiers parading in front of Hitler! He was interested in inani-
mate objects in my office, such as paintings on my office walls and my
books on the bookshelf. I sensed that he was trying to familiarise him-
self in these new surroundings. During the middle of his third hour
with me Ricky suddenly stopped talking, his eyelids appeared heavy
and he started to make sucking movements with his lips. After a while
I thought that he was also making spitting motions and sounds. I said to
myself: “You are observing the most concrete and drastic internalisation-
externalisation event of your career.”
A sign with my name on it was attached to the side of my door
opening to a corridor outside. There were three more offices of other
physicians also with doors opening to the same corridor, also with
name signs. Ricky told me that he had read my name, Vamık Volkan,
again before coming in for his third session. He concluded that I was
a German and “as strong as Hitler”. Obviously he had noticed my
accent and sensed that I was not originally from America. He informed
me that he was drinking and spitting out German wine. If he were a
patient with a neurotic personality organisation I would most likely

have said nothing and waited to hear more of his remarks about me. It
was important to create a “reality base” for Ricky, so I said: “I am not
German; I am an ethnic Turk.” Without any hesitation he asked me: “Do
Turks make wine too?” I responded: “Yes.” He then asked his second
question: “Do Turks make sweet wine or sour wine?” I said: “Both,”
and added, “You have a choice. You can choose whichever you want.”
Ricky chose the sweet Turkish wine and with a more obvious mouth
motion and deep sound he took in a big sip of it and seemed relaxed.
I was thankful to Attis for being my first teacher and introducing me to
the fact that some patients in obligatory fashion, openly and in bizarre
ways present eating and spitting out object and/or self-images.
I will not give details of Ricky’s case or his treatment. My only pur-
pose is to tell stories to illustrate changing functions and aims of his
internalisation–externalisation cycles associated with changing intro-
jections and projections of affects and thoughts during his treatment
with me.
Sometime after drinking sweet Turkish wine during his third session
Ricky heard an internal voice with a Turkish accent, which would tell
him what to do. But he also had another internal voice with a German
accent telling him not to listen to the first voice. Hearing these two inter-
nal voices continued for many, many months. When my internalised
object image competed with his “Hitler mother” image Ricky would
often became flustered. I told him that there was no rush to choose
between the two voices and that the voice with the Turkish accent was
rather new to him. I added that surely he was not yet sure if this Turkish
voice would be helpful to him. He should take his time to test and get
to know this new voice.
During the second year of his treatment I learned that Ricky had
replaced his preoccupation with books on Nazi Germany with an inter-
est in history books about Turks. However, his learning that Turks had a
reputation as “terrible warmongers” confused him. He could not differ-
entiate a “terrible Turk” from a Nazi German. This situation, I sensed,
put a buffer between us. During his sessions he would whistle so that
my image and voice would not be heard and would not be internalised
or introjected through his ears. He was like Sharon with her Life Saver
or candy in her mouth. I tolerated his whistling sessions long enough
before I asked him to stop whistling so that both of us could experience
what would happen and try to put our understanding of it into words.
I added that he was free to tell me when he perceived me as a scary

person and that I had no intention of killing him as I had no power to
make his fingers and toes longer.
After his whistling stopped I noticed that he was using my image as
a libidinalising object. He began imagining eating “Turkish delights”.
As his “Turkish delight” he began using me as someone who would
teach him reality testing. Did I know the exact distance between
Charlottesville and Washington? At first I replied directly and told him
the exact distance. Then I asked him to find out the answers so that he
could develop his autonomy. When he resisted this, I dealt with the
resistance by telling him, for example, that if he figured out the distance
between Charlottesville and Washington by himself and reported it to
me I would still be around and not leave him. In fact, we could then
experience a relationship between two knowledgeable individuals,
which, I explained, might be exciting and pleasurable.
At times Ricky would sexualise his “eating” of a Turkish delight
and behave as if he was submitting to me sexually. Slowly this behav-
iour reflected his development of a “neurotic” father transference. He
moved up to identify with more mature and sophisticated analyst func-
tions, and gave up his psychotic symptoms and preoccupation with
the Nazis. Meanwhile, he finished his high school studies and became
a university student. Some months later he started dating a young
woman and his analysis came to an end.
CHAPTER ELEVEN
Workable transference
A
fter returning from Philadelphia, Attis behaved as if he were
born again. But an external event would make him anxious that
his newborn “self” would be treated like the original one who
had been under the shadow of his early mother. In the waiting room
before one of his sessions, he overheard several office personnel speak-
ing about my having a new baby girl. I was married during my first
year of psychiatric residency in Chapel Hill and what Attis overheard
was true. I had never mentioned to him that I was married and he had
not known of my wife’s pregnancy. Without meaning to do so, the office
personnel had provided him with a readymade suitable event to trig-
ger memories of his earlier life history. Instead of becoming fragmented
and involved in exaggerated defensive internalisation–externalisation
cycles, Attis’ examination of his early life experiences this time looked
like an examination of similar issues by a person with higher-level per-
sonality organisation.
In the session after Attis found out about my new baby, he repeat-
edly referred to my newborn, calling her “him”, although he was aware
that the child was female. Attis also reminded me of how amused he
had been during his visit to his older brother, only four years his senior,
99
when his brother had several times called him “son”. I sensed that he
was behaving as if he were my newborn child; he was being “born”
again. In the following sessions I noticed that the psychological impact
of his hearing that I had a new baby had changed. This time my baby
represented for Attis his younger siblings, the twins, a boy and a girl,
and his youngest sister with hearing difficulty. As he did in his child-
hood, he now had to compete with a sibling(s) born after him and face
a mother/therapist who would not have time to take care of him and
love him.
While I did not deny that, indeed, I had a newborn baby in my home,
I told Attis that it might be unfortunate that the office personnel had
allowed him to hear something about my life. Back then, without today’s
incredible communication technology, psychoanalytic therapists could
easily manage to keep facts of their private lives away from their patients.
Today when patients become preoccupied with a therapist’s private life
they may learn about it through the internet or Facebook, using such
information as a focus for resistance against examining their own inter-
nal worlds. When this happens, the therapist needs to say something
like this to the patient: “I know that you are very curious about me. This
is expected. We meet in this room four times a week. Allow yourself to
get to know me as we interact in this room. Your inquiring about my life
outside of this room will interfere with our relationship in the service of
understanding your wishes, dreads, and conflicts, your internal world;
it may make our psychological travelling together in this room diffi-
cult.” Such remarks, without accusing or humiliating the patient, help
them to develop a more workable transference relationship.
Now, returning to Attis, I suggested that, due to what we knew of
his childhood, the knowledge of my baby might be burdensome to him.
Then I added that we could turn this development between us into an
opportunity for examining together his early disappointments in life
and render their impact on him harmless. Being aware that he had
transferred his disappointment and rage with his early mother onto
me, I wanted him to know that I was in full control of my faculties and
prepared to continue with his treatment. He felt somewhat relaxed but,
in spite of this, after this session he went to an internist for a thorough
medical check-up. I felt that he sought the examination for psychologi-
cal reasons, wanting reassurance that his “new personality” was indeed
a healthy one and that his murderous rage about my having a daughter
would not return to him and damage him.
WORKABLE TRANSFERENCE 101
My becoming his early mother in the transference continued. Was

he playing second fiddle to my new baby? Would I be able to give him
my attention now that I had a new baby at home to distract me? He
was also exhibiting an “observing ego”, even though it was not yet
firmly established. Both of us recalled again and again how he had had
to play “second fiddle” in competition for his mother’s attention when
the twins and his deaf sister were born. Sometime later he returned
to the feeling that he was a newborn child—an adult with a new per-
sonality. His transference manifestations reflected his anxiety that the
newborn “son” might face castration by his mother or her agent as the
original son.
I was surprised to hear that Attis had recently become president of his
district ministerial association. I realised that as he, without the impact
of a psychotic core, was able to work on the psychological problems
between us, he had become freer from his disturbing symptoms while
performing his duties at his church. His transference expectation that
the mother/therapist might castrate him resulted in his idea of giving
up his new position of honour—a self-castration proposed to control the
castration he felt I might inflict on him. He ceased having sexual rela-
tions with Gloria. His old flesh-coloured car once more became “alive”,
a penis. He wanted to sell it in another gesture of self-castration. When
he began playing golf with Mr. Wiley he would, at times, be petrified to
put his fingers in a hole to retrieve a ball, thinking that a small creature
in the hole might eat them. Wiley’s kindness had helped him to get
rid of this symptom, but now it returned. Putting his fingers in a hole
would induce in him severe anxiety and he would then develop psy-
chosomatic disturbances such as diarrhoea or stomach aches. In fact, he
periodically abandoned golf, and it would take some months before he
found the courage to play again. However, at the same time that Attis
was having these thoughts and experiences concerning self-castration
or castration by others, he was also maintaining his “observing ego” to
some extent, and was aware of the reasons for his thoughts and activi-
ties. What a change! He was aware that he had two visions about me:
I was a new, non-threatening object, standing by him and exploring his
internal world with him, and I was also a representative of his scary
early mother. He brought two dreams to his two consequent sessions.
In the first one his old friend Wiley appeared. Wiley held Attis’ arm in
a friendly way and they walked onto a golf course. Once on the golf
course Attis found himself half-naked with a big erect penis between
his legs. There were happy rabbits freely jumping around. Attis also
started to jump up and down happily. He turned around and saw me,
instead of Wiley, with an approving smile on my face. A week later in
his dream I turned into a “bitch”.
According to Wilfred Abse and John Ewing (1960), “The inevitable
introjection of the therapist [by a person with psychotic personality
organisation] is itself partly corrective insofar as this introject competes
with the archaic introject of the tyrannical mother” (p. 508). Harold
Searles (1986) expressed a similar view when he spoke of experiences
of jealousy involving an internal object. Attis’ old unloving and tyran-
nical mother image actively competed with my new analytic object
image. Sometimes Attis speculated as to which would be victorious. He
could not integrate his two visions of me; my self-representation was
split into a “good” one and a “bad” one, but not fragmented into many
pieces. In those days there was no in-depth investigation of the diagnos-
tic category known today as a “borderline” condition. Especially after
Otto Kernberg’s work (1975, 1988) psychoanalysts and psychodynamic
therapists began studying borderline patients and their split internal
worlds.
Attis decided that his mother had been like Soviet leader Nikita
Khrushchev, regarded at that time in America as an aggressively
invested “bad” object representation, and the brother who had
“castrated” him resembled Fidel Castro. Attis’ talk about Khrushchev
and Castro, I thought, reflected his interest in finding a more widened
external world, and his increased ability to find and maintain symbols.
His therapist was from Turkey, which was on the side of the United
States. I sensed that he had been reading news about Turkey. I did not
ask him a question about this because I did not wish to interfere with
his developing ego function related to expanding his knowledge about
the external world. He reported that, although his mother had warned
him not to trust strangers (foreigners), he felt that he could trust me.
In a later session, when I was a “good” object for him, Attis was able
to express gratitude to me for saving him from “fire”, his metaphorical
doughnut filled with aggression. He recalled that, when his mother had
saved him from the burning house and, later, when she had “preserved”
his penis (the finger in the bottle), obligation to her had necessitated his
being in her shadow, unindividuated, and remaining ill.
For some months Attis alternated between trusting me and think-
ing that I might still be like his archaic object images. He wondered if I
would demand total submission of his new self to me. His mother had
stolen his penis, although at the same time she had preserved it. He
was afraid of freedom from her lest she destroy it. In a new transfer-
ence situation, he saw me as a homosexual and began to refer to me
as such during several sessions. Rather than focusing on his externali-
sation and projection of aspects of his old hermaphrodite image onto
me, I interpreted the early mother transference. If I were a homosexual,
I would emulate his mother in keeping his penis. Once more, I helped
him to differentiate between his mother representation and the new
analytic object. I also explained to him why he was having difficulty
in integrating my mental images and then perceiving me as someone
who is basically the same person all the time. I referred to his anxiety
that if he put together “good” and “bad” therapist, the latter one may
destroy the first one. I told him that I was the same person all the time.
However, I was not in hurry for him to see me in the same way. This
would happen slowly. I asked him to continue to observe this process
with me.
I was hopeful that when the new analytic object was rendered less
dangerous by my explanations and interpretations, Attis could identify
with its enriching functions selectively. Slowly but steadily, within a
year he began to maintain his new and rather integrated sense of self
most of the time; I sensed that he relinquished his psychotic core more
effectively. But, still, he kept split images of me. Our work was by no
means complete. Then I moved away, to a new state, to Virginia.
In early 1963, when I had completed my two-year obligation to work
at state hospitals in North Carolina, I came to Charlottesville as a new
faculty member at the University of Virginia. I was in the Department
of Neuropsychiatry, since at that time the departments of psychiatry
and neurology were combined. One of my supervisors at Chapel Hill
was Wilfred Abse who had been accepted as a professor of psychiatry
in Charlottesville, and with his help I also obtained a position there.
Just before I told Attis about my upcoming relocation he was attempt-
ing to relate to me as a strong father figure who could help him, through
the mechanism of identification with the aggressor (A. Freud, 1936) to
intrapsychically separate further from his early mother’s representa-
tion. I discussed my new position at the University of Virginia with
him, explaining that my own realities had convinced me to move to
another state. I explained where we were in his treatment and gave him
the name of a therapist I knew from my psychiatric residency days who
then had an office in a town not far from where Attis and Gloria lived.
I moved to Charlottesville with an increased self-esteem due to the fact
that my years-long dream of being a teacher had finally come true.
The chairperson of the psychiatry department in Charlottesville
would not become a figure for identification for me as a scholar. He was
a nice man whose main interest was reincarnation. He travelled around
the globe interviewing people whom he considered to be reincarnated
individuals. A few years after I became a faculty member at the Uni-
versity of Virginia I was invited to a psychiatric meeting in Adana,
Turkey. While in Adana, I learned that my chairperson had already
been in this Turkish city on several occasions. Local people had chosen
a boy and “educated” him to be a reincarnated figure of a man who
had died some time before. As “proof” of the boy’s reincarnation, they
focused on a birthmark on his face that was apparently similar to one
the dead man also had. I learned that the department chairperson had
an “agent” in Istanbul searching for reincarnated individuals in Turkey.
The people in Adana, through this agent, had invited the chairperson to
come to Adana and, for a fee that represented a huge sum for local peo-
ple, to study the “reincarnated” boy. After I learned this story I further
distanced myself from the chairperson. Soon he left his position but
remained a faculty member in the department. With a huge grant and
with the help of a few assistants, he would continue to investigate rein-
carnation. The new chairperson, who also came to Charlottesville from
University of North Carolina, was a psychoanalyst. I received United
States citizenship on 4 July 1968 at Monticello, Thomas Jefferson’s home
in Charlottesville. Soon I also received a modest grant and began my
psychoanalytic training at the Washington Psychoanalytic Institute.
A few months after I had settled in Charlottesville I received a
telephone call from Attis. He told me that he had decided not to
continue with the psychiatrist to whom I had referred him. Working
with this therapist, he added, was not at all like working with me.
He used a psychiatric term—I do not know how he learned it—to tell
me that he had “regressed”. He informed me that he wanted to drive
to Charlottesville to meet with me once a month. Doing this, he was
sure, would be better than my referring him to yet another therapist,
and he wanted me to understand his determination. He would not
seek treatment from anyone else, and was sure that coming to see me
would prevent his “regression”, I accepted and we began to meet in
Charlottesville. We did this for decades, with less and less frequency
as time passed. However, under certain conditions, such as when he
was diagnosed with heart problems in his seventies, I was always will-
ing to see him more frequently. Attis would never return to a psychotic
disorganisation. Indeed, his visits with me and sometimes his telephone
calls to me prevented his regression. During the first dozen years after
my move to Charlottesville he made an adaptation to life at a borderline
personality level; he became my “satellite”.
CHAPTER TWELVE
Satellite state and therapeutic play
A
ccording to Greek mythology, master craftsman Daedalus,
imprisoned on Crete, found that escape from the island would
be difficult since King Minos was keeping watch by sea and
offering a large reward for his capture. To escape, Daedalus crafted a pair
of wings for himself and another for his son Icarus, made from feathers
held in place with wax. At the moment of escape, Daedalus warned his
son not to soar too high, lest the sun melt the wax, nor swoop too low,
lest the feathers be wetted by the sea (Graves, 1957). Icarus disobeyed
his father’s instructions and began soaring towards the sun. The heat
melted the wax holding the wings together, and Icarus fell into the sea
and drowned.
The dangers of flying higher than the father, indicating problems
at the oedipal level, have received much attention in psychoanalytic
literature. For example, Douglas Danford Bond’s (1952) study of mili-
tary pilots during World War II indicated that Icarian fantasies were
extremely common among fliers who developed phobias about flying.
According to this author, many pilots who had flying phobias regarded
the renunciation of flying as equivalent to a self-executed castration.
In referring to Attis’ case, let us focus on Daedalus’ advice that
Icarus should not swoop too low lest the feathers be wetted and he
107
would plunge into the sea. Icarian fantasies of this latter type mainly
refer to unresolved separation–individuation problems. During the
first years after I moved to Charlottesville, Attis came to see me once
a month and later once every two or three months. He would also
telephone me on some occasions. During the second and third years
after our long-distance relationship had begun, he reported dreams in
which he, or a representative of himself, moved around a central object.
A characteristic of these dreams was the dependent state of the satellite,
which never seemed to leave its orbit. The following is an example of
Attis’ dreams:
I dreamed of a huge steel ball, like the earth, and an eagle. Every
hundred years, the eagle would fly by and brush the ball with its
wing tip.
Earlier in this book I referred to Theodore Dorpat’s (1976) statement,

which describes how a desire to be close to an object and desire to be
distant cannot be understood without applying a theory of object rela-
tions. Attis’ associations to the above dream were associated with his
relations with me and my mental representation. He told me that he
was the eagle and he was doomed to spend an eternity circling around
a steel ball until the steel ball was worn out, when he would be free
from me who represented a combination of his early mother and a new
object. Two representations were sometimes integrated and at other
times unintegrated. He experienced seeing me, every month or less, on
one level as if a century went by after each visit. But still he would not
accept another therapist with an office closer to him. Meanwhile, usu-
ally every three years or so, the Methodist Church continued assigning
him to new locations in North Carolina, even though he was no longer
exhibiting bizarre behaviour. In fact, he told me that the church then
thought of him as a good model for a Methodist minister.
Attis taught me how a person with a borderline personality organi-
sation can make an “adaptation” to life by creating a “satellite state”
and by controlling the maintenance of this state. Obviously, after I
moved to Charlottesville, I was no longer involved in conducting a
typical therapeutic process with Attis. As he had hoped, however, this
new type of relationship between us, his being my satellite, was pre-
venting the possibility of his experiencing major regression and going
back to a psychotic personality organisation. As long as Attis circled
S AT E L L I T E S TAT E A N D T H E R A P E U T I C P L AY 109
around me—as he did around the church, by never totally committing

himself to it and by often desiring to resign from his religious post—he
functioned without clinical psychosis. He was careful to stay in an orbit
around me as he was careful in his dealings with the church authorities.
If he came close to me, he could be engulfed; if he went too far from
me, he could be without regulatory powers. Unlike the times when I
first met him, Attis was not making references to God, Jesus, or the
Bible during his sessions. Once, as the reader will recall, he had tried
to identify with Jesus when he had his first dramatic psychotic epi-
sode, and went through a forest to a mountaintop, surrendered to God
and almost died. Now, he was not a deeply religious person. He was
obviously using religious statements while performing his duty as a
Methodist minister, but he sometimes informed me that he found his
job at the church rather boring. He wished he had training for another
kind of profession. Intrapsychically speaking, during this time in his
life the church had evolved as another steel ball, primarily represent-
ing a mother figure, and he was circling round it just as he was circling
around me.
It was my observation of Attis’ behaviour patterns, as well as those
of two other patients, that led me and Robert Corney to formulate a
peculiar adjustment to life that we referred to as being in a “satellite
state” (Volkan & Corney, 1968). We maintained that, in this circum-
stance, the clinical picture was that of a borderline case. Our formu-
lation on the satellite state was based on Margaret Mahler’s and her
associates’ (Mahler & Furer, 1963, 1966) description of autistic, symbi-
otic, and separation–individuation schema. After our paper was pub-
lished, Margaret Mahler, in a letter to me, supported our formulation.
We now know that an infant’s mind is more active than we had thought
and that “normal autism” as described by Mahler cannot be accepted.
It has been reported that Mahler herself, prior to her death, had ques-
tioned some of her perceptions about the autistic period. However,
her description of the symbiotic phase and the one that follows it, the
separation–individuation phase, has stood up well to closer scrutiny.
After the symbiotic period, the infant begins a series of overlapping
advancements which, if successfully traversed, will permit him to
evolve as a separate and distinct individual. These crucial times have
been called the phase of separation–individuation and, in the normal
child, extend, for all practical purposes, until about thirty-six months
of age.
Margaret Mahler and Manuel Furer (1963, 1966) specifically state

that they do not mean physical separation from mother in behavioural
terms, but an intrapsychic separation which, in a normal situation, takes
place in the physical presence of mother. I adhere to this definition but
feel that in certain adults physical separation experiences can tip the
balance, throwing into bold relief vulnerable individuals’ earlier unre-
solved separation–individuation problems and causing clinical diffi-
culty. In these individuals, the physical separation experience becomes
primitively symbolised and represents the psychic separation experi-
ence. Such was the case when Attis experienced our physical separation
between his infrequent sessions as representing a psychic separation.
His ego development that existed until then now had a major task of
maintaining a satellite relationship with me. I represented a new object
as well as his early mother, a source of instant gratification on one hand
and a source of instant pull to fusion on the other hand, and he felt
obliged to orbit around me. When the centre is perceived as “good”,
the patient feels closeness to it, but does not come too close, fearing that
the centre may turn out to be “bad”. When the centre is perceived as
“bad”, the patient remains distant from it, but not too far distant, in case
the centre may turn out to be “good” again. The need–fear dilemma
(Abse & Ewing, 1960; Burnham, 1969) is handled well by the formation
of a satellite position.
Corney and I came to understand satellite dreams, like those Attis
had, as fulfilling two wishes. First, they permit the expression of an
extreme degree of dependency without the consequent loss of identity
through fusion, which would accompany their conscious recognition
of this desire. Second, they keep aggression under control by permit-
ting wishes for freedom to be expressed without interruption of the sat-
ellite state. Aggression against the representation of the mother, as in
efforts to separate from her influence, is seen as the same as destroying
mother and, as such, is equated with the death of the satellite too. Some
years after Robert Corney and I published our paper on the satellite
state Heinz Kohut reported similar satellite dreams as part of narcissis-
tic transference (Kohut, 1971). He saw the narcissistic patient’s failure
to shoot into space from the orbit as a protection against psychosis. He
also saw the effective pull to the centre as the narcissistic transference.
Kohut’s perceptions supplement what Corney and I described earlier
and, I think, do not nullify our interpretation of these dreams from
the separation–individuation as well as object relation points of view
(Volkan, 1976). Much later another psychoanalyst, Salman Akhtar, who

did his psychiatric residency training at the University of Virginia when
I was a faculty member there, extended our understanding of clinical
manifestations of disturbed optimal distance (Akhtar, 1992a, 1992b).
For a dozen years after his therapy-proper ended, Attis continued
“to brush” me or my office at my new location with his “wing”. Now,
our relationship began to include elements of a father transference. We
returned to the state of his condition as it existed at the end of the five
years of once-a-week treatment when I moved to a new location: his try-
ing to find a “good” father who could pull him out of his troublesome
relationship with his early mother. The following is a description of
some events prior to his development of a steady father transference.
He still had his “finger in a bottle” but now he kept it in the attic rather
than in his bedroom, and it had lost most of its magic. For years now he
showed no preoccupation with it. His vacillation between dependency
upon and hostility towards his wife was no longer so marked, and her
vagina was no longer perceived as the mouth of a walrus. Attis was
not experiencing any hallucinations. During his infrequent visits with
me he only had a single repeating symptom: his relationship with a
“bitch”. Attis was transferred from one church to another in the usual
way, remaining at each for an average of three years. In every congrega-
tion, he located an older “bad” woman, a “bitch”. His appreciation of
what she represented did not keep him from experiencing her as the
early mother. However, there were no fusions of these “bitches” with
the images or representation of his mother or with the images or rep-
resentation of himself. He knew they stood for his early mother; they
were symbols of his early mother.
Whenever he came to Charlottesville I saw him for only fifty minutes
and handled his sessions in the same way I had conducted his therapy
hours when we were working once a week. I continued to charge him
for his visits. By the way, throughout his work with me he never paid
me directly. When I was in North Carolina he sent his checks to the
University of North Carolina’s Memorial Hospital. When he saw me in
Charlottesville he wrote checks for the University of Virginia Hospital.
Physicians who worked at these two university hospitals would only
receive salaries; patients’ payments would go the hospitals.
Attis began filling his sessions with talk about the “bitches”. He was
afraid of them, but I noticed that he was also fighting bravely against
them. His “fights” with them would range from Attis not answering
the “bitches’” questions during church gatherings, to raising his voice

when speaking to them, or even, at one time, becoming involved in
a “plot” with others who did not like a particular “bitch” in order to
remove her from church membership. If he developed extreme anxi-
ety, he would either tolerate it, or make an appointment to come to see
me. On one or two occasions during the year, if his fear was too much
and he could not wait to drive to Charlottesville, he would call and tell
me about his fear of a “bitch”. His telephone calls were short, lasting
only five or ten minutes. After describing an encounter with a “bitch”,
he would usually himself declare how she stood for his early “bad”
mother. In spite of knowing this, he had anxiety. Calling me briefly
and telling his story would help him to relax. Even though we were
not in a routine therapy process, I continued to refrain from giving
him any advice, but joined him in looking at intrapsychic processes.
His “fights” with these older women were his basic psychic exercises
in his attempts to complete his separation–individuation phase. In his
involvement in these exercises, more and more he saw me as the strong
father with whose functions he wished to have more identification.
In his sessions I would hear no remarks about my being a “weak” or
sadistic father, a “Terrible Turk”. He told me that he was reading about
Turkey in newspapers and magazines. He hinted that I was a benign
Turk.
For the first two years after I became an instructor at the University
of Virginia’s medical school I had a very small office without windows.
Perhaps it was the worst office in the whole university hospital sys-
tem. Later, as I moved up the professional ladder, I had better offices.
I became a stronger father figure for Attis after I moved to an office
with windows and after he noticed, while he was waiting in the wait-
ing room, how a secretary talked to me with “respect” when she called
to notify me that Attis had come for his session. As I became a stronger
father figure in Attis’ mind, he became more successful in his fights
against “bitches”. At that time I was not aware that Attis was teaching
me another therapeutic concept, which later I would name “therapeu-
tic play” (Volkan, 1987, 2004b, 2010; Volkan & Ast, 2001; Volkan, Ast &
Greer, 2002). Finding “bitches” and “fighting” with them was Attis’
therapeutic play.
Therapeutic play refers to patients’ certain actions inside and/or
outside the analyst’s office; these actions express an intrapsychic story.
They last for some time—weeks, months, even, as Attis’ case illustrates,
years. Such actions can be considered as two interrelated types. One is
the repetition through activities of a childhood trauma in order to create

the disturbing event in a symbolic fashion in the eternal world while
including the mental image of the analyst in the repeated story as a new
and helpful object, and then slowly reaching to a new and more adap-
tive ending of what had been repeated in action. This shows how the
individual masters the trauma. And the other type of action is the rep-
etition of a childhood actualised unconscious fantasy, which is related
to the trauma, in activities, making the actualised unconscious fantasy
conscious in action and changing its disturbing influence on the patient.
We can consider adult patients involved in a therapeutic play as chil-
dren playing with toys in an analytic session where their repeating play
can be brought under therapeutic scrutiny. Here is an example of an
adult’s therapeutic play:
In Chapter Four I referred to Gitta who was traumatised by forty surgi-

cal interventions beginning in infancy and lasting until she was nineteen
years old, and who had an actualised unconscious fantasy of having a
leaking body. Unlike Attis who was seeing me very infrequently, Gitta
was in analysis with Dr. Gabriele Ast. Renovating her apartment dur-
ing the second year of her analysis, a process that took a little over
nine months, became a crucial part of Gitta’s analysis. The apartment
represented her leaking body: as she modified its internal structures,
repaired its leaking windows, and made it beautiful, she also restruc-
tured her mental image of her body and separated what belonged to her
“memory” and past feeling states from what was real now. Significantly,
her actions incorporated her analyst’s image as well. Rather than buy-
ing the necessary equipment or material for her work all at once or in
substantial instalments, Gitta habitually brought to her sessions a small
brush, or a small amount of paint, or some other small item for the
renovation that she had purchased on the way to the analyst’s office.
Dr. Gabriele Ast—who herself enjoys woodworking—would then talk
with Gitta about what the patient planned to do to her apartment next,
instead of interpreting away the meaning of the patient’s action. After
the function of repairing her apartment/body image took its course,
then the interpretation of the function could be made explicit. In fact,
though, doing so was rather unnecessary; by the time Gitta finished
renovating, she herself already knew the meaning of her activities. It
was the function of her activities that had to be protected until it could
serve its purpose. After months of work on the apartment, Gitta could
differentiate internally between what belonged to her own mental
image of her body and what belonged to the physical existence of the
apartment. (Volkan & Ast, 2001)
Attis’ therapeutic play lasted for many years. I think that if I had seen
him every week or more often, his play would have come to an end
much sooner. By then, I had had experiences with other patients who
performed therapeutic play, and their involvement in such activities all
took place at a faster pace. I will now recount how Attis’ therapeutic
play ended, first by talking about changes that were happening in my
life and then how my patient had noticed these changes. His noticing
“improvements” in my life provided a good model for improvements
in his.
In 1963 when I moved to Charlottesville and was using an office
without windows, horrible things were happening to my family and
friends in Cyprus. The British rule ended on the island in 1960 and the
Republic of Cyprus was established. But soon ethnic troubles between
Cypriot Greeks and Cypriot Turks became inflamed and the Turkish
population on the island was forced to live in enclaves surrounded
by Cypriot Greek troops. In 1964, United Nations soldiers came to the
island and their presence still continues. Cypriot Turks were “impris-
oned” from 1963 to 1974 under subhuman conditions in areas that com-
prised only three per cent of the island. Perhaps my not challenging
my assignment of a small windowless office and feeling like I was in a
prison had something to do with my identification with my imprisoned
family members and friends in Cyprus. In 1968, over eleven years after
I had arrived in the United States, I was able to go to the island and
visit my family and friends. I noticed that Cypriot Turks in the Nicosia
enclave where my parents and sisters were located were raising thou-
sands of parakeets, birds not native to the island, in cages in their run-
down homes, in grocery stores, everywhere. Interviewing many people
in the Nicosia enclave, I realised that birds in cages represented their
imprisoned selves. As long as the birds had babies, survived, and sang,
the Cypriot Turks were able, unconsciously, to maintain hope that they
would not disappear and one day they would be saved (Volkan, 1979b).
After I returned to the United States I could no longer hide my guilt feel-
ings for living in safety while my people were suffering so much and
while no one in my surroundings in Charlottesville—and, it seemed,
the world—knew about their incredibly tragic situation. My mental
condition, I think defensively, made me devote more time to studying
psychoanalysis, developing a stronger psychoanalytic identity, and
being a better teacher. After moving to Charlottesville I had begun my

psychoanalytic training at the Washington Psychoanalytic Institute in
Washington, DC. By 1974 I was an instructor at this institute and later I
functioned there as a training and supervising analyst.
The Turkish Army went to Cyprus in 1974 and divided the island
into Northern Turkish and Southern Greek sections. Greek Cypriots
who had homes in the northern part of the island had to flee to the
south, leaving their properties behind. This time they suffered more
than the Cypriot Turks did. During the war, Cypriot Turks living in
the south of the island escaped to the north and were settled in the
emptied Greek homes. In 1971 I had become a professor of psychiatry
at the University of Virginia, and about the time that the war on Cyprus
ended, I took a sabbatical and spent more than a year in Ankara at my
old medical school as a visiting professor. I told Attis that I would not
be in the United States for thirteen months.
After arriving in Ankara I took the first civilian plane that went to
North Cyprus. This time my family members were free to move around
in North Cyprus. Those who were still children had not seen the sea
because they had been “imprisoned” all their lives in the Nicosia
enclave, even though the nearest seashore was only about fifteen miles
away. One of my most vivid memories of this visit is noticing the excite-
ment of my sisters’ children when we took them to see what the sea
looks like. During my sabbatical the ethnic excitement in Turkey for
saving the Cypriot Turks from living in enclaves was palpable. I do
not remember thinking about Attis much nor communicating with him
during the thirteen months when I was enjoying my sabbatical teaching
at my old medical school.
On my first visit to my office when I returned to the United States,
I noticed a small piece of pink paper on my otherwise empty desk. It said
I had just been appointed as the acting chairperson of the Department of
Psychiatry. One year later I moved up and became the medical director
of the university’s newly acquired 600-bed Blue Ridge Hospital, located
very near Thomas Jefferson’s Monticello. The university’s Department
of Psychiatry, Department of Orthopedics, some divisions of Inter-
nal Medicine and Neurology, some inpatient and outpatient facilities,
and laboratories were now located at the Blue Ridge Hospital, which
at earlier times had been a hospital for patients with tuberculosis and
belonged to the state of Virginia. I would remain as the medical direc-
tor of the Blue Ridge Hospital for eighteen years and take part in the
administration of Virginia University Hospitals in general. Many of the
people at Blue Ridge called me “boss”, and as the “boss” I had a huge
office with a balcony overlooking a beautiful wooded area filled with
birds. Starting in 1980 I also became involved in international relations,
first taking part in bringing together influential Israelis and Egyptians
for unofficial dialogues, which were conducted for six years under the
sponsorship of the American Psychiatric Association. Then, in 1989 I cre-
ated and led the Center for the Study of Mind and Human Interaction at
a building on the Blue Ridge Hospital grounds. The Center’s multidisci-
plinary faculty and I would travel to many areas of the world and bring
enemy representatives together to tame different international conflicts
(Volkan, 2013, 2014b). I also had an office at this Center, but continued
to meet with Attis only at my Medical Director’s office. Attis was not
informed about my involvement in international relations.
Attis came to see me when I was the acting chairperson of the Depart-
ment of Psychiatry at the main university hospital. He did not complain
about the thirteen months I had been unavailable to him. I noted that he
had done a great deal of psychological work by himself. I would never
learn the details, but I sensed that the months of physical separation
between us had caused him to stop being my satellite. A year later he
would come to my huge office at Blue Ridge Hospital. While I did not
talk with him about changes in my professional life, he could see that I
was “moving up”. I recall how impressed he was when he first walked
into my huge office at Blue Ridge Hospital.
After I returned to Charlottesville from Ankara, Attis told me that he
could now say “no” to bitches. He would describe in detail and with
glee how he had conquered his fear of “bitches” and how he could put
them in their place. But, he continued to talk about them as if it was our
routine and habit to discuss this topic. One day while I was in my Blue
Ridge Hospital office my telephone rang. Attis was calling. He said,
“Oh! There is a new bitch in my church.” I guess I spontaneously sensed
that he was not anxious, and he was just calling me for a brief contact.
I found myself responding, “Oh! Not again!” He burst into laughter.
When he stopped laughing, he said, “Thank you,” and hung up. The
next month he visited me. As soon as he entered my office, with a big
smile on his face, he said, “Not again!” From that moment on there were
no more “bitches”. Attis, no longer my satellite, truly completed his
separation–individuation phase. He would continue to visit me several
times a year to deal with other psychological issues while climbing up
his psychological ladder.
CHAPTER THIRTEEN
Crucial juncture experiences
A
s Attis stopped “playing” with bitches, I observed his
involvement in three new areas. First, his relationship with
men, especially when in social settings outside his church,
began to change. In the past, he had been guarded with them. For
example, at times while playing golf he would wonder if the other men
thought of him as a “sissy”. Now he felt equal to the other players,
and sports competition no longer evoked “I am less than a man” fanta-
sies and anxiety or the psychosomatic symptoms, such as the diarrhoea
or stomach-ache, that they once entailed. In fact, Attis began to enjoy
men’s company. Second, he began to indulge in lively flirtations with
various women and even thought of having affairs with them. The third
area reflected an intrapsychic change: he could now maintain an inte-
grated self-representation of himself and others. I noticed that he could
tolerate ambivalence without returning to utilisation of defensive split-
ting. I realised that he had gone through crucial juncture experiences.
As far as I know, the term “crucial juncture” was first used by
Melanie Klein. She wrote: “The synthesis between the loved and hated
aspects of the complete object gives rise to the feelings of mourning
and guilt which imply vital advances in the infant’s emotional and
117
intellectual life. This is also a crucial juncture for the choice of neurosis
or psychosis” (Klein, 1946, p. 100). Later, Otto Kernberg and I used this
term in describing how patients whose primary defence mechanism
is splitting, give up, during their analysis, their dependence on this
defence mechanism, and learn how to integrate their self- and object
images and representations. Kernberg stated that the pathological nar-
cissistic self-structure (the grandiose self) is resolved in analysis when
the patient becomes aware that his ideal concept is basically a fantasy
structure. He wrote that “the deep admiration and love for the ideal
mother” and “the hatred for the distorted dangerous mother” meet in
the transference and, at this crucial point, the patient may experience
depression and suicidal thoughts “because he has mistreated the ana-
lyst and all the significant persons in his life, and he may feel that he has
actually destroyed those whom he could have loved and who might
have loved him” (Kernberg, 1970, p. 81). I have described in detail the
clinical manifestations of crucial juncture experiences of patients with
borderline as well as narcissistic personality organisation in analysis
(Volkan, 1974, 1976, 1987, 1993, 1995, 2010, 2014a). During such experi-
ences, none of them became suicidal. I believe this is because these indi-
viduals experienced therapeutic regressions before attempting crucial
juncture experiences and then had developed stable observing egos.
Patients who do not experience such therapeutic regressions and do
not develop stable observing egos due to a different technique may be
prone to depressions when attempting a crucial juncture experience.
I have noticed that some patients, in fact, were delighted to feel for the
first time what it is to be “average” in certain life experiences and I also
noted their tolerance for ambivalence. One patient spoke about see-
ing a movie in which a mafia boss first kisses one of his men (he loves
him) and the next second he shoots this man (he hates him). The patient
said: “When I saw this scene I suddenly understood what it is to put
opposite elements together. There were only seconds between the mafia
boss showing affection and committing murder. Love and hate touched
one another. I realised that I could never do something like that before.
I now know why I have been afraid of making grey by mixing black and
white. I was afraid of committing murder—getting rid of goodness in
me or in others forever. I will try again mixing black and white and this
time I hope to make grey.”
I cannot report an event in Attis’ life illustrating dramatically his
sensing and feeling an integrated self-representation and integrated
CRUCIAL JUNCTURE EXPERIENCES 119
object representations. If he were in regular treatment I suspect that I

would have noticed such an event, most likely several of them. What
I was noticing was how Attis—then in his mid-fifties, about seventeen
years after I first saw him and after he had given up his adaptation to
life as a satellite of a central figure or thing—had become a person with
a routine high-level personality organisation. He would not refer to
events that had dominated his life when he had a psychotic personality
organisation. He could remember such events, but since he had deve-
loped an ability to repress he would not experience horrible affects that
were linked to the events. When a person develops a high-level person-
ality organisation in adulthood he can also, for the first time, experience
certain feelings that he had not truly known earlier. He can feel sorrow,
remorse, gratitude, and the ability to mourn.
As his identity as an adult male became better established Attis expe-
rienced sorrow for not having children and remorse for not having tried
to have children. He and Gloria discussed the possibility of adopting
children but abandoned it because of his history and their age. Our
meetings then were very poignant; he grieved over his childless state
and tried to be philosophical about life and the years lost to his psy-
chotic personality organisation and psychotic symptoms. Later, Attis
would do his best to be helpful to children and teenagers wherever he
lived. He was particularly good with teenagers, understanding them
and advising their parents in how to deal with them. He saw in them
the sons and daughters he never had.
Mourning in an adult fashion is itself a new experience for patients
like Attis and its appearance illustrates a very positive outcome (Searles,
1986). Mourning allows further refinement of reality (Volkan, 1981a);
an adult mourner comes to realise that some things or some persons
are gone and makes an effort to integrate the experience of loss with
reality so life can go on (Pollock, 1989). When the news of Mr. Wiley’s
death reached him, I noticed that Attis went through genuine grief and
mourning. I stood by him while he mourned. Attis could not mourn
when he lost his father and then his mother, but his ability to mourn in
an adult fashion after losing Mr. Wiley provided further evidence that
his psychotic core was gone.
Attis also began looking at oedipal issues for the first time with an
integrated self-representation. However, dealing with the oedipal issues
at this phase of his life was not like the struggles experienced by per-
sons who in adulthood always had neurotic personality organisation.
When an adult with a neurotic personality organisation comes to

analysis, the analytic work deals with the patient’s conflicts related to
his oedipal issues. On the other hand, Attis, to a great extent, was like
a child going through the oedipal phase for the first time with an inte-
grated self-representation, a youngster who was passing through his
adolescence passage, expanding his world, and finding new libidinal
objects. The technique then needs to be different; the therapist should
aim to help the individual like Attis to move up on the developmental
ladder.
When he told me about flirting with several women, and sometimes
hugging and even kissing them he wondered what I must think of him.
In his references to me at this time of his life I was never a representative
of his sadistic biological father of his childhood, but a “routine” father
figure with whom his son was discussing and exploring an adult male’s
sexual life. In any case, since I was seeing him infrequently, we were
not able to do any serious work on his developmental wishes, activi-
ties, and anxieties during his sessions. In his daily life he continued to
explore owning his penis. I did not encourage him in his new activities
with women, nor did I discourage him. However, when I felt that it was
appropriate, I told him that he was like a teenager trying to date for
the first time. He was, in his actions, expressing and experiencing his
developmental push. He was concerned about what Gloria would say
or do if she knew about his flirting with other women. When I listened
to him I also noticed that Gloria was no longer a representative of his
early mother. She was his wife who had turned into a very close female
friend. But, Attis was not having the intense sexual excitement when
he was with Gloria that he was experiencing when he was with some
other women. Attis genuinely did not wish to hurt Gloria’s feelings
or to embarrass her. Usually Gloria would accompany him when he
drove directly from their home to Charlottesville. Now this routine had
changed. They would take a few days of vacation and spend a night at
a tourist destination on their way to Charlottesville and another night
before returning to their home. After his sessions with me I sometimes
noticed how Attis would grasp Gloria’s hand in the waiting room and
both of them would walk out holding hands as best friends. While relat-
ing to some women with whom he had flirted, he was also getting to
know more about what ambivalence means. When he noticed a woman
with whom he had flirted behaving seductively towards another man,
Attis would feel ambivalence; the woman would remain the same
person whom he liked sometimes and who also disappointed him.
Attis developed a more solid confidence in me. He began to experi-
ence, first with some shyness and anxiety, something that he was not
capable of experiencing before. He tried to be humorous. He tried some
jokes on me, which spontaneously amused me. At times, I could see
oedipal themes in his jokes. I refrained from interpreting them since I
felt that the dominant meaning of telling me jokes was his attempt to
have a man-to-man relationship with me and move up on his psycho-
logical developmental steps.
During one visit Attis informed me that he had become the lover
of a married woman, after a courtship. Both were very careful to be
discreet. Linda was a few years younger than him. She was unhappily
married to a man who drank a great deal and they had no children. In
his sixties, Attis reported happiness he had never before experienced
and sexual freedom he had never before known. I made no distinction
between Attis’ reports of extramarital and other activities. I was as curi-
ous about the meaning of his affair as I was about the meaning of his
other activities. When I felt it was appropriate, I told Attis that he had
made a new adjustment to life in accordance with the new growth in
his psychic system; his wife, in the past, symbolised his mother, but
he had internally separated from the mother/wife representation and
found his own woman, but one who was married to another man. Thus,
he still had to work through issues about the reality that he and Linda
were married to other individuals, and about triangular or multi-person
relationships. I suggested that he would look out for new possibilities,
for newer adjustments.
Attis decided to continue with his affair since he felt he had missed a
loving and sexually very exciting relationship with a woman all his life.
He added: “A man is entitled to fall in love and experience wonderful
sexual activity. Now, at last, I have become a man. I will die knowing
that, after all, I have received what I was entitled to.” He also explained
to me that he was also a friend of his lover, who was apparently an
intelligent person and who had had a horrible marriage. Furthermore,
he informed me that, in spite of his love affair, the friendship between
him and Gloria had deepened too.
Attis retired and he and Gloria moved to a new town and bought
a house in a nice neighbourhood. About a week after moving there
Attis called me and asked for an appointment. I recalled how the last
time he had seen me he had told me that he was not planning to come
to Charlottesville until he and Gloria were settled in their new loca-
tion. He stated that they would be too busy. When he called me for
an appointment I wondered what the urgency was. When he came to
see me I heard about it right away. Attis told me that he had taken the
finger in the bottle to their house, but once there, he had had difficulty
knowing where to put it. “I put it in the attic, then in the basement, then
in a trunk,” he said and added, “I had not thought about it for a long
time before our move to a new house. Now, not finding a place for this
thing bothers me.” He looked at me and waited for me to respond. I still
recall repeating his words, “this thing” and not saying anything else.
He also stayed silent, then smiled and talked about the beauty of their
new location, the golf course, and their new neighbours. He came to see
me again after three months or so. As soon as he sat in front of me he
informed me, casually, as if it was not a big event, that after returning to
their new home from our previous session he had thrown the finger in
the bottle into a trash can, then the garbage man had taken it away. He
did not dwell on his getting rid of “the thing” and changed the topic.
He would never again mention the finger in a bottle.
Attis and Gloria became active members in their new social environ-
ment. They were involved in raising funds to help especially troubled
children and teenagers. Attis, as far as I could learn, was perceived as a
leader for community activities that aimed to help children and teenag-
ers. As well as this, many individuals would come to seek Attis’ advice
for a variety of personal problems. He also enjoyed playing golf, telling
jokes, and appreciated the friendship of many men.
Linda had remained in the town where she and Attis had first met.
Attis would find excuses to visit her, but infrequently. Once, Linda’s
husband became ill and almost died. Another time she was in a near-
fatal accident and it took a long time for her to recover. Attis handled
these realities of life in a mature way. Meanwhile, he and Gloria were
also still “best friends”. All indications were that Gloria was enjoying a
more relaxed Attis.
Attis was not close to his siblings, but when his parents’ farm was
sold the brother who was responsible for the amputation of Attis’ fin-
ger claimed more than his share of the proceeds of its sale. Attis led
the rest of the family in taking the case to court, where they prevailed.
After his parents’ estate was settled, Attis was able to extend a friendly
hand to the brother who had cut off his finger and who had pressed his
claim, and in time they resumed a relatively friendly relationship. His
brother invited him to come to Philadelphia again and visit him and
his family. What was most heartwarming for me was that Attis did all
these things realistically and without much anxiety. He informed me
that during his work with me his journey had taken him through many
stations. Perhaps there were more stations ahead if he and I continued
to travel together. But he was getting older and he wanted to settle in
the place where he was. He was content. Soon, however, the cruelties of
life would strike and upset his contentment.
CHAPTER FOURTEEN
Physical illnesses and psychic freedom
W
hilst still in his sixties, Attis experienced dizzy spells while
playing golf on one occasion, and these occurred again when
he was in the kitchen at his home. His decades of experience
in investigating his internal world led him to seek a possible psycho-
logical cause. He could not come up with a reasonable event initiating
his dizzy spells. Then he called me. Attis’ searching for a psychological
explanation of his dizzy spells made me recall a mental image from
many years before of myself on my analyst’s couch, analysing away a
symptom I was having—regurgitation during sleep that would wake
me up. My analyst suggested that this might be caused by a hiatal her-
nia, which proved to be the case. Remembering this, I suggested to Attis
that he have a physical examination. He went to see a neurologist who
referred him to a cardiologist. Apparently, Attis told this cardiologist
that I was his psychiatrist who had urged him to seek a medical cause
for his dizzy spells. Later, the cardiologist called me and told me Attis
needed a permanent transvenous pacemaker. He had sick sinus syn-
drome, which causes a spectrum of bradyarrhythmias and, occasion-
ally, bradyarrhythmias following tachycardia. The cardiologist noted
that Attis did not want metal in contact with his skin and wondered
if there could be a psychological reason for this aversion. When Attis
125
consulted with me, we noticed that his fear over his physical condition
had stimulated a fear from his childhood. He refused the cardiologist’s
advice because the idea of metal contact with his skin represented the
axe that had removed his finger. Attis ended up agreeing to a pace-
maker if necessary, but when the cardiologist told him that his heart
problem would progress slowly and its advance was unpredictable, he
decided not to get one and continued a normal physical existence, play-
ing golf, helping teenagers, and occasionally visiting his lover.
Nine years after first seeing the cardiologist Attis played golf three
days in a row during Gloria’s absence from home and experienced
some chest pains. He went to a hospital, where he had a heart attack
and fainted. This necessitated triple bypass surgery to save his life, but
he knew nothing of what had happened until it was all over. In his post-
surgery mental state, he felt confused and uncertain about whether he
was dreaming or hallucinating. He had seen his mother, who opened
her arms to him, calling, “Come to me!” This frightened him.
After his triple bypass surgery Gloria had called and informed me
about this unexpected development. She had also asked the surgeon to
call me, which he did. This is how I learned about Attis’ post-surgical
mental state and confusion. Three weeks after surgery and after he was
discharged from the hospital Attis also called me. This time I deliber-
ately kept him on the phone long enough not only to understand how
surgery had evoked memories of the past, but also to stand by him dur-
ing his frightening experience. He was able to tell me his idea that the
assault on his body seemed like a punishment and he remembered see-
ing “fire” in the recovery room. He said, “I knew it was psychologically
motivated. I wouldn’t tell anyone,” and added, “Everything disturbing
from my childhood came back to me.” He dreamed of donkeys and of
how his father had thrust a stick into the anus of one. He thought that
he was punished for his marital infidelity and also recalled playing sex
with a cousin as a child for which he might now be punished. While he
was in his hospital bed he had a feeling that his mother knew all about
his sins. “I sensed my old fusion feelings,” he said. “But I did not really
merge with her, although I sensed her presence.”
Attis was unable to urinate after his operation, and when a nurse,
a large woman, laughed at him and called him “the bladder boy”, he
felt that he was being harassed as he had been as a child, in an intru-
sive, frustrating environment. When he complained of a full bladder
the same nurse screamed at him, “If you say another word, I’ll tie you
P H Y S I CA L I L L N E S S E S A N D P S Y C H I C F R E E D O M 127
to your bed!” In the past he would have turned such a woman into a
“bitch”. This time, feeling humiliated, he planned to report the incident
to his doctor, telling him that such a woman should not be allowed to
practise. But the physician and other nurses were very nice to him, so
he decided not to criticise.
I was impressed that Attis was involved in a kind of self-analysis
during his post-surgery period. One night, after the shock of surgical
trauma and the effects of medication had lessened, Attis re-evaluated
what had happened to him in reality, felt depressed, and was able to
cry. He felt better on the following day. He received a postcard from
Linda, who thought it indiscreet to visit him, and he spoke to her on the
telephone after being discharged from the hospital.
Attis called me every few days during the next three weeks as though
making progress notes. He steadily improved. “The wound on my chest
healed beautifully,” he reported, adding, “I guess the surgery was also a
psychological wound, and it is healing too.” He had many visitors and
was delighted to realise how many friends he had. Bad dreams, such
as the one of his mother inviting him to join her, disappeared. He did
dream that someone was asking him to do construction work for which
he was not yet ready. He associated with its manifest content by saying
that his recovery was like doing construction work and that he was not
physically and psychologically ready to complete it.
He did more and more physical exercise some months after his oper-
ation and got out of the house more often, resuming his golf. He called
to make an appointment with me. “I have something funny to tell you,”
he said. He did not tell me what it was until he arrived at my office:
he had purchased a light-brown car after his recovery from his triple
bypass surgery. When he drove it for the first time, he had a sensation
in his cut finger. Then, while driving he began to laugh when he real-
ised that the trauma of his surgery had made him repeat, symbolically,
the purchase of the flesh-coloured car. Recalling what I had said about
his original flesh-coloured car representing his finger/penis, he told
himself, “A car is a car!” He reported greatly enjoying his new car and
spoke of having driven to see his lover and talking with her.
It was obvious to both of us that this man—once “Jesus Christ”,
a would-be murderer, a hermaphrodite monster—had a great capacity
for self-observation and for reorganising after the regression that had
been forced on him by his surgery, medications, and helplessness in a
hospital bed. Once more, Attis was my teacher. He was my first patient
to describe to me an individual’s psychological response to a major

surgical trauma. He taught me how such a trauma can induce regres-
sion and make traumas of the past reappear. He now stated that he was
just fine. But, I could not help noticing that during this first session with
me after his triple bypass surgery he looked much thinner than before.
He was now seventy years old.
In a later session with me Attis told me that he had decided to go
to the next station after all, which meant saying goodbye to his lover.
He was grateful to Linda because she had joined him while he allowed
himself, at an advanced age, to experience intense sexual pleasures
accompanied by loving feelings. Throughout his stay in the hospital
and recovery at home Attis had felt highly appreciative of Gloria’s
genuine concern for him and felt very close to her. Although she had for
some time been willing to be his wife in name only, after his recovery
from surgery they had resumed sexual relations. Now Attis was finding
sexual union with Gloria comforting. Meanwhile, Linda’s husband’s
health was failing, and she was responsible for and busy with his care.
Attis discussed with Linda the termination of their affair. She under-
stood this; they decided to remain friends. Attis reported these develop-
ments to me, and I listened but offered no opinion.
Attis continued to see Linda but with less and less frequency over
the following years. He felt satisfied that he had obtained intense sexual
pleasures to which, as a man, he felt he was entitled. Memories of such
experiences gave him self-esteem. He and Linda would talk and share
their innermost thoughts and feelings. Attis told me that he understood
what intimacy meant. Meanwhile, he had become fonder of observing
rituals of companionship with Gloria, reading and walking with her. He
would never feel the sexual excitement with Gloria that he had experi-
enced with Linda. He was enjoying a different happiness with Gloria,
a woman who, rain or shine, stood by him. Then new events occurred
to influence his adjustment to his last station in life.
Attis faced new physical problems. He had skin cancer and cysts,
one on his neck and another one on the hand that was missing a fin-
ger. These were treated surgically, as he reported rather ironically. The
brother who had amputated Attis’ finger had surgery as well, for a
malignant prostate tumour. Attis drove alone to the Philadelphia area
and visited his brother in the hospital on two consecutive days. On the
way back he had an impulse to go through Linda’s town. He stopped
there, they met and this time they had sex. While driving home after
P H Y S I CA L I L L N E S S E S A N D P S Y C H I C F R E E D O M 129
being with Linda Attis once more was involved in thinking about the
psychological factors of his actions. When he later met with me he
described his psychological reason for having sex with Linda.
Attis told me that he dreamed the night after visiting his brother of
seeing a man plough a field and cut a sewer line. Awakening, he under-
stood that he was the man who was damaging the sewer lines (his broth-
er’s prostate). He uncovered his repressed desire for revenge on the
dying brother who had taken his finger. Later, while driving back home
from Philadelphia, he had realised that his brother’s operation fell on
the anniversary of President John F. Kennedy’s assassination. Thinking
about a father figure’s assassination, Attis further realised that he had
had an unconscious death wish concerning his brother and father. Then
he ended up having sex with Linda. In a sense, I understood that after
symbolically “killing” an oedipal rival he could have a woman for him-
self! But, when Attis continued to talk more about his brother, another
meaning of his making love to Linda emerged: he was a man in his own
right, and therefore he could have his own woman. Attis told me that
when he was visiting his brother he found many members of his family
there. They had had time to speak about their childhood. Attis noted
that his siblings had largely repressed their childhood memories and
traumas, and seemed a rather stereotypical, conventional family. Attis
thought that he recalled more than the rest of them about their family.
He did not tell this to his siblings. However, internally he felt special;
he was someone who possessed a more realistic view of their family’s
background. Psychologically speaking, he was more grown up. This
reinforced his sense of self. But, what made a significant impact on him
was receiving a beautiful coat from his brother who had had surgery.
This brother who had cut off his finger had never given him anything
before. This time Attis felt that his brother, by giving him a beautiful
coat, was appreciating Attis as someone who was loved and who was a
grown-up man, the true leader of their family. Visiting his brother and
being with other siblings had evoked wishes of revenge and guilt, but
also feelings of psychic freedom, and of being a man in his own right.
Four months later Attis too faced prostate surgery. He came to see
me four days before his operation. In a half serious and half joking
way he told me that his feelings of revenge towards his brother might
have backfired. His brother was dying because his tumour was malig-
nant and could not be removed completely. He wished to talk with his
brother and “tie up loose ends”. But, he knew that his brother might not
understand human psychology and might be disturbed if his younger

brother attempted such a discussion. Attis’ tumour was not malignant.
He felt luckier than his brother and just before he left my office he joked
about paying doctor bills all his life. I knew that he was anxious in spite
of his joking.
His prostate surgery was successful. Later I would learn from him
that his experience with prostate surgery reminded him of some inci-
dents that had followed his triple bypass surgery. When he woke up
in bed, he found that a nurse had tied a blue ribbon on his penis, and
he felt humiliated. This time the nurse was not the large woman, but a
petite one. Attis did not turn her into a “bitch” either. Instead, when he
met with me he connected the petite nurse’s action with his childhood
mother’s lack of empathy for him. Then, with excitement, he went on to
tell me his understanding of the unconscious psychological aspects of
a wish he had had prior to the prostate surgery. At such times I sensed
Attis loved to be a “psychoanalyst”, analysing himself. I would simply
watch him, listen to him, and appreciate his enjoyment. He had a fan-
tasy of taking a trip with Gloria to the Grand Canyon. He concluded
that, “The Grand Canyon is a big vagina.” He then added that this wish
was connected with his conquering his childhood fear of vaginas. He
knew that his fear of this surgery too was stimulating his recollection
of his childhood fears. He joked: “At my age, I’m not going walking
around the Grand Canyon! It’s good to know where this unusual wish
comes from.”
Going back to his childhood this time gave Attis a new and very sig-
nificant insight. He recalled a childhood memory of wishing to touch
his mother’s breast. His mother would not allow it, saying that her aunt
had big breasts and he should fondle hers. He remembered awaiting a
visit from this aunt, but she too forbade his fondling her breast. Attis
now realised that Linda had large breasts, and he wondered if his lover
might also represent this aunt in other ways. He wondered if he was
creating an aunt/mother who would not reject him but would take him
to her bosom and give him pleasure and affirmation instead of a fragile
self-representation. He realised that Linda satisfied him not only as a
lover, but also as a “good” transference object. He added, “I am glad
and proud of myself that I had the opportunity to change the bad things
from my childhood into better ones!”
CHAPTER FIFTEEN
Sunset
A
fter his prostate surgery Attis experienced more heart
problems. He was still in his early seventies. One morning he
woke up with severe chest pains and was taken to a hospital
where he underwent further heart surgery, which was minor in com-
parison to his triple bypass operation. While he was recovering in the
hospital, Linda’s husband, who had been ailing for some time, died. It
was a while before Attis could visit Linda after this, and when he did he
found her grieving. He encouraged her to grieve further.
Soon, Attis would give an anguished response to the death of his
brother who had cut his finger. He came to tell me that old childhood
issues had been appearing in his dreams. After seeing me he drove to
the place his brother had lived, accompanied by Gloria. He wanted
to visit his brother’s widow, but Gloria thought that would not be a
good idea since, while Attis and his brother had become friendly after
their parents’ estate issue was settled, his brother’s wife had not been
welcoming. Attis and Gloria went to the cemetery where his brother
was buried. He walked to his brother’s grave alone and prayed for his
brother’s soul. The next day he called me and told me the dream he
had had that night. In the dream Attis was standing in a room with a
woman Attis knew was his mother. She opened the door of the room
131
and just walked away. Attis was not only saying goodbye to his brother,
his mother’s agent, but also to his mother.
During his next visits with me I found his personality organisation
better integrated than ever before. At his last visit I told him that I had
never seen him so well mentally and upon hearing this he became tear-
ful, as did I. I was worried about his physical wellbeing because he
looked pale and tired. He told me how he was taking heart medications
and getting old. He and Gloria had driven hundreds of miles to see me
and checked in at the same motel where they usually stayed during
their visits to Charlottesville. He needed more sleep and told Gloria
how difficult it was going to be in the future for him to make the trip
to see me. He was still having occasional chest pains. His cardiologist
was not sure if these pains were caused by a possible hiatal hernia or
whether they were the beginnings of another heart problem. Attis told
me that he might not come to see me again, but he would call me. When
they left I found myself wondering if I would ever see Attis again.
I would not.
Through his infrequent telephone calls I learned that Attis and Gloria
sold their house and bought a nice apartment in a resort area on the
North Carolina shore. I noted that one reason for their doing so was
that his cardiologist had moved there to accept a good position at a new
hospital. Attis and Gloria felt safer relocating to where they would have
access to the cardiologist whom they trusted. Attis continued to have
occasional chest pains throughout the next few years, but whenever he
called me he sounded content and relaxed. I still vividly remember his
last telephone call to me. He said:
I am sitting on my balcony and watching the sea. It is so beau-

tiful here. I am with Gloria and we are very happy. By the way
(laughter), here too, neighbours, especially teenagers, have been
treating me as if I am a psychotherapist. I guess they also know
that once upon a time I was a Methodist minister. I do not go out
much, but they visit me often and share their problems. Oh, don’t
worry, I also know how to protect myself. I enjoy helping people,
but if I am tired I protect myself. Oh, the sunset last evening was
incredible. I love to watch the sun disappearing into the sea. I guess
I am thinking of my disappearance. I will disappear like the sun,
while feeling shiny and happy. But, you know, unlike the sun I will
not reappear the next day.
SUNSET 133
I never heard from Attis again. He died in his early eighties. My hunch
is that Gloria tried to get in touch with me after he died. By then I had
retired and she would not have been able to reach me at the university.
If she was able to find my home telephone number she still would not
have found me as I was out of the country at that time. After not hearing
from Attis for a long time I knew that he had died. But, I guess, I wanted
to deny it and never checked to learn the circumstances of his death.
Only when I decided to write the book, with the aid of the internet,
I easily found the date of his death and information about his funeral.
One man who spoke at this funeral referred to Attis as a great man who
had dedicated himself to his neighbours, teenagers in general, never
hesitated to be helpful, and who loved to watch sunsets.
Last words
This book presents the whole life story of an unusual man, Attis, who
had learned to examine his inner world. I met him when he was thirty-
nine years old. During the first five years of our work together his psy-
chotic core was modified. No medication was ever used. Unfortunately,
we could not continue his treatment in order for his psyche to have
further drastic structural modifications within the usual pace of treat-
ment. It seems that the first five years of treatment had put him on the
right track. Over the next twelve years or so, he adjusted to life accord-
ing to his modified internal structure. Then, until his death in his early
eighties, without any intensive therapeutic work, but by using me and
some others as transference figures, he began moving up further on his
developmental ladder.
I hope that the case of Attis will stimulate the reader to think about
questions regarding the nature of his illness and psychotic personality
organisation in general, the role of identification with the therapist,
the tolerance of emotional flooding, the influence of real-life events,
countertransference, and other related issues. I also hope that several
therapeutic concepts described in this book and their clinical illustra-
tions may influence those who are psychoanalytically trained and other
mental health professionals, and encourage them not to lose sight of the
importance of the psychodynamic approach to individuals like Attis
who was not only my patient, but also one of my best teachers. In this
book I share with the reader what he taught me.
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INDEX
Abse, D. W. 90, 102–103, 110 Blackman, J. 33–34

acting out 26 Bloom, P. 53
Agdistis 21 Blos, P. 15, 62
Ainslie, R. C. 28, 62 Blue Ridge Hospital 115–116
Akhtar, S. 57, 111 Bond, D. D. 107
Alanen, Y. O. 60 Bowlby, J. 54
American Psychiatric Association Boyer, L. B. 15, 51, 53, 69–70, 90, 93
48, 116 brain drain 1
ancestor’s syndrome 29 Brazelton, T. B. 53, 60
Apprey, M. 60 Brenner, I. 41, 52
Arlow, J. A. 36 Burnham, D. L. 58–60, 110
Ast, G. xi, 28–29, 37, 41, 60, 62, 91,
112–114 Cain, A. C. 28, 62
Atatürk, K. 7 Cain, B. S. 28, 62
Austen Riggs Center 60 Cameron, N. 90–91
Cancro, R. 59
Baatan Death March x Candlemas Day 12, 17
Beres, D. 36 Castro, F. 102
Bergman, A. 33 Cherry Hospital 3, 77
Bernstein, D. 34 circumcision 45
Beutel, M. E. 59 Comert, P. 37–38, 40
147
148 INDEX
Corney, R. 109–110 Green, N. 28, 62

Cortés, L. 20 Greenspan, S. I. 53, 60
crucial juncture xii, 51, 117–118 Greer, W. 29, 112
Cyprus 1–2, 7, 28, 30–31, 67–68, 73, Groundhog Day 12, 25, 80
114–115
Cypriot Greeks 30, 73, 114–115 Heimann, P. 91
Cypriot Turks 7, 30, 73, 114–115 Hitler, A. x, 95–97
Hoedemaker, E. D. 90
Daedalus 107 hungry self 50
depositing 29
Dionysos 21 Icarus 107
Dorothea Dix Hospital 3 identification xii, 17, 29, 51, 72, 82,
Dorpat, T. L. x, 51, 54, 108 89, 90–91, 103–104, 112, 114,
Duncan, C. x 133
Inderbitzin, L. B. 36
Eissler, K. R. 79 interpretation 3, 27, 70, 103, 110, 113
Ekstein, R. N. 91 linking interpretation xii, 76–77
Emde, R. N. 53
emotional flooding xii, 53, 80, 87, 133 Jack the Ripper 63
empathic description 27 Jacobson, E. 48, 54
encapsulation 41 Jefferson, T. 104, 115
Ewing, J. A. 90, 102–103, 110 Jesus Christ 7–8, 12, 17, 109, 127
Faimberg, H. 29 Kaplan, B. 39, 44, 52, 84

Fenichel, O. 58, 64 Karhu, J. 53
Ferenczi, S. 89 Kayatekin, M. S. 8
Fliess, W. 89 Kennedy, J. F. 129
Fonagy, P. x, 13, 58, 60 Kerényi, C. 21
Freeman, T. 62 Kernberg, O. F. 54, 58, 66, 89, 91,
Freud, A. 26, 48, 66, 103 102, 118
Freud, S. 20, 34, 36, 47, 57, 76, 89 Kestenberg, J. 29
Fromm-Reichmann, F. 60 Khrushchev, N. 102
Fuller, D. 67 Klein, M. 29, 36, 51, 89, 117–118
Furer, M. 109–110 Kohut, H. 110
Gedo, J. E. 54 Langer, W. C. x
Giovacchini, P. 76, 91 Lanza, A. x
Glass, J. 64 Laufer, E. 59
glass bubble 24 Legg, C. 28, 62
Goebbels, J. 95–96 Lehtonen, J. 53–54
grandiose self 50, 118 Leigh, H. 59
Graves, R. 107 Leowald, H. W. 91
INDEX 149
Levin, B. D. 37 neurotic 39, 49–50, 54, 66, 97,

Levin, F. M. 59 119–120
Levy, S. T. 36 psychotic xi–xii, 24, 52–54, 57–59,
Liberty Bell 85–86 61, 66, 72, 80–81, 87, 90–91,
Limentani, D. 90 102, 108, 119, 133
Lutheran Deaconess Hospital 1–2 Peto, A. 79
Pine, F. 33
Mahler, M. S. 13, 33, 54, 109–110 Pollock, G. 20, 119
Midas 21 Poznanski, E. O. 28, 62
Minos, King 107 protosymbol 39, 44, 52, 84
Modell, A. H. 24 psychotic core xii, 32, 57, 59–64, 68,
Monticello 104, 115 72, 79–80, 82, 87, 90, 92,
mourning 20, 30, 89, 117, 119 94–95, 101, 103, 119, 133
perennial mourning 31 Purhanen, M. 53
Mulla, E. 30–31
Rapaport, D. 91
Nagera, H. 36 reaching up 15, 46, 53, 69–70, 93
Nana 21 Reiser, M. F. 59
need–fear dilemma 110 replacement child 28–29, 62
Niederland, W. 30 Rosenfeld, D. 41, 70
North Carolina Memorial Hospital Rosenfeld, H. A. 41
2, 4–5, 8, 20, 23, 25, 32, 45, Rudden, M. G. 24
64–65, 77, 111
Novey, S. 86 Sandler, J. 36
Sandy Hook Elementary School x
Obama, B. 3 Sangarius 21
object addict 58 satellite dream 110
observing ego 101, 118 satellite state xiii, 105, 108–110, 116,
Olinick, S. 24 119
Olsson, P. x schizophrenia 5, 9, 18, 59, 64
Öztürk, O. 45 Schützenberger, A. A. 29
Searles, H. F. 90, 102, 119
Pääkkönen, A. 53 Sechehaye, M. 90
Pao, P. -N 64, 80 Shapiro, T. 36
Parens, H. 54, 57 Shengold, L. 21
personality organisation xii, 49 Sheppard and Enoch Pratt Hospital
borderline 51–51, 105 64
high-level 49–51, 53–54, 66, 99, Sherick, I. 28, 62
119 Silberweig, D. A. 59
low-level 50–51, 53 Silverman, L. H. 36
multiple 52 Solms, M. 59
narcissistic xi, 24, 50–51, 118 Solnit, A. J. 28, 62
150 INDEX
Solyom, A. E. 28, 62 womb 37

Spitz, R. A. 54 University of Virginia Hospital 4, 95,
Stern, D. N. 53–54 111, 115–116
Stern, E. 59
Stone, L. 48 vagina dentata 19–20, 46
Stone, M. H. x Van der Kolk, B. 59
Strachey, J. 91 Virgin Mary 17
Sullivan, H. S. 54 Volkan, V. D. x–xi, 4, 8–9, 15, 20–21,
survivor syndrome 30 24, 26, 28–29, 31, 34, 37, 41,
Szasz, T. S. 90–91 45, 51, 53–54, 57, 60, 62, 64,
66, 76–77, 80, 91, 110–112,
Tähkä, V. 20, 27, 91 114, 116, 118–119
Target, M. x, 13, 58, 60
telescoping of generations 29 Washington Psychoanalytic Institute
terrorist x, 30 4, 21, 103
therapeutic identity 24 Weigert, E. 21, 48
therapeutic instrument 24 Werner, H. 39, 44, 52, 84
therapeutic play xii, 112–114 Winnicott, D. W. 49, 52, 60
Tienari, P. 59
Tizón, L. J. 60 Yoder, D. 12
Torsti, M. 60 Yppärilä, H. 53
transgenerational transposition 29
Turnbull, O. 59 Zeus 21
Zintl, E. 20, 31
unconscious fantasy xii, 35–39, 41,
60–62
actualised xi, 32, 36, 39–42, 113

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WOULD-BE WIFE KILLER

WOULD-BE WIFE KILLER

Copyright © 2015 by Vamık D. Volkan

All rights reserved. No part of this publication may be reproduced, stored

British Library Cataloguing in Publication Data

A C.I.P. for this book is available from the British Library

Typeset by V Publishing Solutions Pvt Ltd., Chennai, India

Printed in Great Britain

ABOUT THE AUTHOR vii

ABOUT THIS BOOK ix

Vamık D. Volkan, M.D., is an emeritus professor of psychiatry at the

and Bahcesehir University, Istanbul, Turkey; and a Visiting Professor

the mind of this Methodist Minister, I will illustrate the appearance of

faced a humiliating event, such as perceived rejection by his wife or

• Description of the psychology of severe physical injury in childhood

adapting to life and developing a variety of symptoms, including

A beginning therapist meets a would-be

from foreign lands, for an orientation. He began by pointing to a

to interview a patient, make sense of psychodynamic formulations,

After spending five years in North Carolina, in 1963 I moved to

it before he was taken to Chapel Hill. He sat on a chair in his hospital

difficult to administer psychological tests to the patient because of

A man with three penises and

The following story further illustrates Attis’ mother’s role in his

Attis was good at athletic activities when they required no

His continuing fear of going to hell and being consumed by fire

dentata, a vagina that contains teeth. Putting a penis in a vagina that

Some years after I first met Attis, when I was a psychoanalytic

My first three months with Attis

The psychiatrist in charge of the inpatient unit would meet with

understanding her husband’s illness and to learn to “manage” him

condition has no difficulty in separating what is real from what is not

behaviour patterns, and symptoms awaken some psychological issues

my motivation, early in my career as a psychiatrist and psychoanalyst

Sometimes, aspects of the therapist’s or analyst’s countertransference

• The impact of a childhood injury to a body part that symbolises a

A childhood injury to a body part

the severed finger in a bottle—Attis’ castration fantasy became “real”.

oedipal issues, physical injury, castration, family romance, mother’s

of losing their oldest daughter during her hospitalisations played a

both scenarios involved parents who could be grossly insensitive and

issues which permeated the copious dream material that he brought

fantasy could be read in the following way: “I am castrated by my

Thoughts on personality organisations

and symptoms. Making an “internal map” of the individual’s psychic

their experiencing ambivalence. The degree of tolerance for ambivalent

mending will the patient be capable of genuinely working through her

sophisticated “fit” between what is internalised/introjected, and the

differentiation and integration functions are deficient. An adult with a

The psychotic core

the affective expressions in the middle of my metaphorical doughnut,

adequate navigational equipment, he requires directions from

The aim of a psychoanalytically informed treatment of people who

do have neurological deficits. Can other patients’ psychotic symptoms

corresponding to her mother’s unconscious fantasy, when it is put into

from her “normal” activities. Bizarre behaviour activities are directly

Beginning outpatient therapy

its appearance and items within it, become symbolic extensions of a

obsessional defence. However, he was far from being considered a