The Psychoanalytic Therapy of Severe Disturbance Paul Williams Psychoanalytic Ideas, 2010

THE PSYCHOANALYTIC THERAPY
OF SEVERE DISTURBANCE
The Psychoanalytic Therapy of Severe Disturbance is one of a series
of books under the title PSYCHOANALYTIC ideas which brings together
the best of Public Lectures and other writings given by analysts of
the British Psycho-Analytical Society on important psychoanalytic
subjects.
Other titles in the Psychoanalytic ideas Series:

Adolescence
Inge Wise (editor)
Autism in Childhood and Autistic Features in Adults:

A Psychoanalytic Perspective
Kate Barrows (editor)
Child Analysis Today

Luis Rodriguez De la Sierra (editor)
Psychoanalytic Ideas and Shakespeare

Inge Wise and Maggie Mills (editors)
Psychosis (Madness)
Paul Williams (editor)
Shame and Jealousy: The Hidden Turmoils

Phil Mollon
Spilt Milk: Perinatal Loss and Breakdown

Joan Raphael-Leff (editor)
Symbolization: Representation and Communication

James Rose (editor)
The Organic and the Inner World

Ronald Doctor and Richard Lucas (editors)
Time and Memory

Rosine J. Perelberg
Unconscious Phantasy
Riccardo Steiner (editor)
“You Ought To!”—A Psychoanalytic Study of the Superego

and Conscience
Bernard Barnett
THE PSYCHOANALYTIC
THERAPY OF SEVERE
DISTURBANCE
Edited by Paul Williams

Series Editors
Inge Wise and Paul Williams
First published in 2010 by
Karnac Books Ltd
118 Finchley Road
London NW3 5HT
Copyright © 2010 by Paul Williams
The right of Paul Williams 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: 978-1-85575-640-3
Typeset by Vikatan Publishing Solutions (P) Ltd., Chennai, India
Printed in Great Britain
www.karnacbooks.com
CONTENTS
FOREWORD vii
ACKNOWLEDGEMENTS ix
WELCOME xi
CHAPTER ONE
The therapeutic action in psychoanalytic
psychotherapy of borderline personality disorder 1
Glen O. Gabbard
CHAPTER TWO
Transference Focused Psychotherapy (TFP) 21
Otto F. Kernberg
CHAPTER THREE
The mentalization based approach to psychotherapy
for borderline personality disorder 35
Peter Fonagy, Mary Target and Anthony Bateman
v
vi CONTENTS
CHAPTER FOUR
Psychoanalytic group therapy with
severely disturbed patients: Benefits and challenges 81
Caroline Garland
CHAPTER FIVE
The fiend that sleeps but does not die:
Toward a psychoanalytic treatment of the addictions 103
Stephen M. Sonnenberg
CHAPTER SIX
Some considerations about the psychoanalytic
conceptualisation and treatment of psychotic disorders 137
Franco de Masi
CHAPTER SEVEN
“First you were an eyebrow” and “How do I
know that my thoughts are my thoughts?” 151
Bent Rosenbaum
CHAPTER EIGHT
Pre-suicide states of mind 171
Donald Campbell
CHAPTER NINE
Individual and large-group identities: Does working
with borderline patients teach us anything about
international negotiations? 185
Vamık D. Volkan
PLENARY DISCUSSION 223
INDEX 243
FOREWORD
In early 2007 colleagues at the Belfast Centre for Psychotherapy,

Professor Paul Williams and Lord Alderdice conveyed their vision
to me of running an international conference on the application of
Psychoanalysis in Psychiatric Practice and Mental Health Services.
This was at a time in Northern Ireland when the Royal College of
Psychiatrists (RCPsych) were actively engaged in developing strat-
egy for specialist services and training in Psychotherapy. We were
also engaged in an initiative to reach out to other organisations and
professionals in Mental Health care. Indeed, the then President of
the RCPsych, Professor Sheila Hollins, had designated one of her
special initiatives as “Increasing the Influence of Psychoanalysis
on Psychiatry”. For all these reasons their vision coincided closely
with College strategy. The College enthusiastically committed to
the opportunity to make this conference idea a reality. The subject
matter of “The Psychoanalytic Therapy of Severe Disturbance” i.e.,
Psychosis and Personality Disorder was settled on as most pertinent
to Psychiatric Services.
Under the very able leadership of Paul and John, a programme
was drawn up and the most eminent international speakers on the
vii
viii FOREWORD
subject engaged to speak. When we announced the Conference

internationally there was an overwhelming response, such that the
Conference venue had to limit numbers to 440 delegates. This was
not entirely a surprise as throughout 25 years of Psychiatric practice
in General Psychiatry and Addiction Services, I have found the
application of Psychoanalytic understanding at it’s most useful when
clinical decisions are at their most challenging and demanding. I have
also regularly observed that Mental Health staff and Psychiatrist
trainees are at their most receptive and hungry for psychoanalytic
concepts after they have acquired the basic phenomenological
training and clinical experience. The meaning and understanding
that Psychoanalytic concepts bring to the management of severe
psychosis and personality disorder is particularly beneficial in this
demanding work.
The success of the Conference I think is most concisely illustrated
by a comment made to me on day 2 of the Conference by one of the
American delegates; “I’ve never been at a Conference where all the
seats are occupied for all of the sessions”.
Much thanks is due to all the Psychoanalysts who gave so gener-
ously of their time for the Conference. Thanks also to the other col-
laborating organisations, the British Psychoanalytical Society, The
Northern Ireland Institute of Human Relations (NIIHR), the North-
ern Ireland Institute for the Study of Psychoanalysis (NIASP) and
the Department of Health, Social Services and Public Safety NI for
their contributions and support. Finally, we are greatly indebted to
Mrs Nora McNairney, Division Manager of the RCPsych NI Office
whose organisational skills made this Conference such a success.
Cathal e Cassidy M.B. FRCPsych.

Chairman of the Royal College of
Psychiatrists (NI Division),
Chairman of the All Ireland
Institute of Psychiatry AIIP (2008)
ACKNOWL EDGEMENTS
A great deal of work went into mounting the conference on the

‘Psychoanalytic Therapy of Severe Disturbance’ in Belfast in June
2008. In addition to the speakers, without whom the conference
would not have been possible, it is important to acknowledge
the contributions of the individuals and groups involved in its
preparation. The first of these is the organising committee: Maria
O’Kane, Cathal Cassidy, John Alderdice, Brian Martindale and
Richard Ingram. The support of other organizations was valuable.
Thanks are due to Graham Johnston of the Northern Ireland Institute
of Human Relations, and to Roselene Hayes, Sharon Elliott and Mary
Simpson for the preparation of this manuscript. Finally, thanks go to
the hundreds of people who came from all over the world to attend
the conference and who contributed in such an enthusiastic way.
Paul Williams
Belfast 2009
ix
WELCOME
Lord Alderdice
My name is John Alderdice. I’m a Psychiatrist and Psychotherapist

here in Belfast and it is my very great pleasure to bid you a warm
welcome to our home City here. It is great to see so many of you and
some of you have come from a very long distance and we appreci-
ate that enormously. Of course, I know that part of the reason you
have come is because of the veritable galaxy of psychoanalytic stars
who are also here. We appreciate them coming. It has been a tre-
mendously encouraging and supportive thing to us and we appre-
ciate that very much. Can I say that, as you have looked through
the programme you will have noticed some tremendous speakers
and extremely interesting topics but one of the things that we have
really learned a lot of in this part of the World is that dialogue is
critically important to progress and so although we are very pleased
to be able to listen at the feet of some of these tremendous speak-
ers, we also want to encourage you to get into dialogue with them
after their presentations and indeed with each other because I think
we are going to learn much more if we don’t just listen and take in,
but if we also engage with each other in conversation and in dia-
logue at the end of the presentations and in the coffee breaks and
xi
xii WELCOME
lunch and the evening social events as well. I think that will add
very considerably to things. Of course you will appreciate that we
have not just learned in this part of the World that dialogue is a good
thing but also that co-operation is very important and we’ve had
the encouragement and luxury of a lot of co-operation from various
people. The Royal College of Psychiatrists has been tremendously
supportive to us and we are going to hear a little bit later on from
the President of the Royal College of Psychiatrists, Profession Sheila
Hollins. I would like to thank her very much indeed for coming and
also thank the representatives of the College; Dr Cathal Cassidy who
runs the College here in Northern Ireland; Brian Martindale, who
of course, has been extremely helpful to us on the organising com-
mittee and particularly Nora McNairney and Liz Main and our col-
leagues in the College office here in Belfast. They have been absolute
gems. We appreciate very much the fact that we have got a Northern
Ireland office of the College now and it has been doing such excel-
lent work and I’d like you to just say thank you very much to them,
even at this very early stage, for all the work and preparation that
they have done. (Applause)
Let me maybe say a little word or two about why we are having
this event. For the last 25 years or so we have been working to try
to build up an understanding of psychoanalytic ideas and how to
apply them, particularly in the clinical area, but not only there and
25 years seems like a long time but it has taken us that length of time
to develop a cohort of people who have some interest and under-
standing and training and experience of working in this kind of way.
We felt that it would be good to try to draw some of these resources
together into a Centre and we have acquired a building, paid for by
the National Health Service, where we have been able to put together,
not just individual offices and spaces for group therapy, but also a
music therapy suite, an art therapy suite, a training and teaching
suite with video conference facilities and this has enabled us to get a
range of analytically informed therapies under way and also a couple
of Masters courses, one in Psychoanalytic Psychotherapy and one in
Art Psychotherapy. We wanted to try to give a bit of momentum to
this work for those who are involved in it. Paul Williams, who was
invited to come over to work with us and give us encouragement
and guidance just a few years ago, came up with the idea that if we
could have a conference that would bring together some of the best
WELCOME xiii
in the World, this would be a tremendous encouragement to those

who were working here and growing and developing in their clini-
cal and professional experience, but it would also send a message to
people in this community, and not least of all, people in the health
care community and in the Ministry or Department of Health and
Social Services—namely, that Psychoanalytic Psychotherapy had an
important contribution to make in some of the very difficult pieces
of work that we have to address. We have a tradition in this part
of the World of applying psychoanalytic understandings to diffi-
cult things. The father of psychoanalysis in this part of the World
was Dr Tom Freeman, and he worked as a General Psychiatrist and
Psychoanalyst all his working life with patients with serious psy-
chotic disorders, particularly schizophrenic illnesses but also manic
depressive psychosis, and so all of us grew up with a sense that
psychoanalysis had something to say to some of the very difficult
problems and so this conference is going to focus on psychosis, on
disturbances of personality and also on the application of our ideas
to socio-cultural problems because that is one of the other things we
have tried to do in this part of the World—to understand why this
community gets so disturbed with violence; violence within itself,
against each other and against people themselves.
In the 1970s we began to observe that as the homicide rate went
up, the suicide rate came down and since the end of the overt terror-
ism, one of the things we have notices has been an increase in the rate
of suicides, particularly amongst young men. So these socio-cultural
developments are not something outside of and divorced from our
clinical work; they impact very much on it. Our psychoanalytic
understandings have really something valuable and important to say
to all of that and so we are grateful that so many people have come
to assist us in understanding these things. I say, “us” because this
has been a collaborative venture; I mentioned the Royal College of
Psychiatrists and the Centre for Psychotherapy but we have also had
support from our Health and Social Services Trust here in Belfast and
Dr Maria O’Kane who is the Director of the Primary Care Services in
Mental Health, has been part of our Planning and Programme Team
and has been very helpful to us. The Northern Ireland Association
for the Study of Psychoanalysis has been intimately involved in the
work of preparation and the Northern Ireland Institute of Human
Relations has also been part of the network of people that have been
xiv WELCOME
working together. Finally, The British Psychoanalytical Society in

London has also been a joint sponsor of this conference. I am really
very grateful to all the colleagues who have co-operated so well in
putting all of this together.
Now I don’t want to scare you that this is Belfast and therefore
I need to give you some emergency precautions. This is a health and
safety issues of which you will all be very much aware so we have got
fire exits on the right hand side and on the left hand side—we gener-
ally don’t use them but just so you know they are there. The second
thing is more a precaution for the speakers and that is to ask that
all of you who have mobile phones, put them off or put them on to
vibrate mode at this point. Those that put them off we will know pay
attention, those that smile from time to time, we know you have got
it on vibrate mode.
Well, I think we are going to have a good time. I think we are going
to have a good time in this Hall and listening to those who make the
presentations. I hope very much that you are going to enjoy Belfast.
It’s a fun City and people in this part of the World do know how to
have a good time, so if you don’t, just ask any of them and they will
show you one. We will have the reception this evening and then if
the weather stays any way good, you will get out and enjoy the City
and I hope a number of you will be coming up to Parliament Build-
ings tomorrow evening and you will enjoy that—that is an interest-
ing place to be.
But I want now to introduce to you and to thank very much
indeed the President of the Royal College of Psychiatrists, Professor
Shelia Hollins. Those of you who are not members of the College
will not quite appreciate what a significant thing it is that she has
given such support to this event going ahead at this time and on
top of all of that, that she is actually here herself. Let me explain to
you why. First of all next week is the Annual General Meeting of
the Royal College of Psychiatrists. This is not a one-hour meeting
to approve minutes. This is a full week of meetings, with a whole
series of parallel sessions, of research papers and presentations. It
is a very big event at the Imperial College, London, and usually,
in fact it is the rule, that the College does not approve or support
any other conference within six weeks of that event. Well, you will
recognise there is no six week gap between Friday and next Tues-
day and Professor Hollins will be more aware of this than some of
WELCOME xv
the rest of us. That is an expression of the support that there has
been for Psychoanalytic Psychotherapy, for our approach and for
those of us in Northern Ireland who have been trying to build it
up. During her time as President she has overseen a number of
very important reports; one on Acute Mental Health Care, one of
Assessment of Risk and one on Psychological Therapies in Primary
Care and in Psychiatry. These are very important pieces of work
and particularly for the third one, I want, on behalf of myself and
behalf of all of you, to thank Professor Hollins for that level of sup-
port from the President of The Royal College of Psychiatrists—it is
very important indeed. On top of all of that she actually finishes up
her three-year tenure as President of the College at the beginning
of next week. So she has cleared a space to come over here, to be
with us, to show her support for this work, for what we are trying
to do and I think for all of us to know that and appreciate that, it
is something we value very greatly indeed Professor Hollins, and
I would like to invite you to come to the podium and open the
conference.
Professor Sheila Hollins

Thank you, Lord Alderdice. It is a real pleasure to be here. Clearing
my office hasn’t quite been as easy as I thought it might be as my PA
went on maternity leave a week ago. So, any of you lucky enough to
have a PA will understand what that means. Part of my mission as
President of the College has been to try to increase and promote the
influence of psychoanalytic thinking on psychological therapies on
the training of psychiatrists but also on psychiatric services. There
isn’t a lot that a President can do, but the Report on Psychological
Therapies, which Lord Alderdice just mentioned, was an attempt to
try to raise our awareness and thinking about psychological thera-
pies, as they are now called in the NHS, across all specialties of psy-
chiatry and when I set up that working group, I set it up with the
intention that it would not be led by our Psychotherapy Faculty, but
it would be a cross-College initiative in order that it would be owned
by the whole College. It ended up as a report published jointly with
the Royal College of General Practitioners.
In England there is a little bit of a worry that the improving
access to psychological therapies initiative might lead to a dumbing
xvi WELCOME
down of psychotherapy. The idea is that a reasonably large injection

of money into developing psychotherapy in Primary Care might
lead to psychotherapy in specialist mental health services dimin-
ishing and there is some evidence in some places that that is hap-
pening and in particular that the psychiatric component to those
services might also be lessened, which again was a good reason for
us to look at it and write a report. Some of the main things that the
report says are that GPs need to become much more psychologi-
cally minded and to know how to refer. But it also states that minor-
ity groups need to be served equally and I just want to say a little
bit more about that.
I am a Psychiatrist working with adults with learning disabili-
ties. For those of you who don’t work in the United Kingdom, the
term “learning disabilities” is equivalent to “intellectual disability”
or “mental retardation” or “mental handicap”. Different words have
been used and the problem about providing psychological therapies
to this client group: the evidence and the guidelines that are pro-
duced for psychological therapies do not mention this group of peo-
ple. Yet they are a group who are probably more traumatised than
other members of our society and if we are talking about severe dis-
turbance, probably more severely disturbed in some instances than
others too. So should we assume that treatment guidelines are trans-
ferable? Does it mean that the added complexity of treating trauma
and relationship difficulties in someone with a learning disability
means that such patients need to be immediately referred to a spe-
cialist service, if it exists?
My clinical work for the last 15 years has been with severely trau-
matised disabled people and I want to just introduce this conference
with a short extract from a piece of work that I’ve been involved
with over those years in a group for men with moderate and severe
learning disabilities, a weekly psychoanalytic group which I run
with Valerie Sinason, a psychoanalyst.
This short extract is from a session three years after treatment
began and three weeks before the last Christmas break. The men
had all suffered sexual abuse. They were all now abusing others.
Two of the men in this extract were living in a locked ward and were
brought weekly to therapy, some 25 miles distance from their hos-
pital. One of the men had been imprisoned for 6 months accused of
abusing children.
WELCOME xvii
Mr A: “I’m upset, very upset. It happened last night. I wet myself.

I couldn’t help it. She rubbed my nose in the urine. She hit
me. She did”.
He became very agitated. Valerie and I were both aware
that this had been a regular occurrence in his past where
that kind of behaviour by nurse but it didn’t take place in
his current environment.
Valerie: “I wonder if because Mr A is so miserable with Christmas
coming, he is remembering something from the past that
used to happen but he feels it is happening now”.
Mr A: sat still listening.
Sheila: “Did you understand that, Mr A? Valerie says that when
you think about what your Mum used to do, it feels as if it
is happening now”
Mr A: “I know. Yes”.
Mr B: “I phoned my Mum at 1 o’clock in the morning. She was
very cross. I rang because I was paranoid.”
Sheila: “What does paranoid mean?”
Mr B: “I thought people knew more about me than they did—
like the police might come and ask about something and
I hadn’t done it.”
Valerie: “You and Mr A have got something in common that helps
the whole group. In the past bad things have happened for
both of you; things other people did to you and things you
did. For example, Mr B, sometimes the police came and
it was fair and sometimes you didn’t think it was fair. But
perhaps, frighteningly, there was evident but you couldn’t
remember doing it.”
Mr B: (After a long pause). “That’s right”.
Valerie: “In those cases, the police did know more than you”.
Mr B: “You mean, I’m not paranoid because sometimes the po-
lice do know more than me.”
Mr A: “I’m going to miss my Mum at Christmas, really miss
her”.
Sheila: “The magic has really gone out of Christmas, hasn’t it?”
Mr D: “Yep, no champagne, or rides in a Rolls Royce to Group
Therapy anymore!”
Mr E: “My Mum won’t have any beer at Christmas because of
fighting”.
xviii WELCOME
Valerie: “And Mr C hasn’t got a Mum to see. He hasn’t seen her

since he was really little and he has no idea where she is.
And Mr A doesn’t see his Mum and Mr B’s Mum doesn’t
want to be woken up at 1.00 am when he is anxious and
Sheila and I are bad mothers not looking after you all at
Christmas and perhaps Mr B you’re worried that if you
move near your Mum, she won’t manage to help you.”
Mr A: “I’m not going to my mother’s. I used to run away to get
to her. I used to run away to find her”.
Sheila: “I think you’re frightened Mr A that when your hospital
closes down, you might have to be with your Mum, who
didn’t look after you. But that won’t happen. You will be
in another safe place”.
A sigh of relief passed round the group.
Mr B: “We don’t have magic about Christmas anymore”.
Valerie: “You’re pleased there will be ward parties but you’re sad
and when you’re sad or sad and angry, all the bad memo-
ries come back”.
I wanted to share this short extract to show you how we find earlier
trauma being expressed through flash backs for example with one
man or through an incomplete memory for another and the impor-
tance of trauma in the lives of people with learning disabilities who
may have been abused or traumatised in such a way.
I’m very pleased to introduce the conference. And I believe that
the complexity of the people whose stories we are going to hear
today and of the work that is being done to help them, is part of
what we need to do as mental health professionals, to understand,
I think, the importance of multi-disciplinary approaches to work-
ing, and of the different contributions that different professions
can bring, including psychiatry, to the Psychoanalytic Treatment of
Severe Disturbance and I wish the conference well.
CHAPTER ONE
The therapeutic action in psychoanalytic

psychotherapy of borderline
personality disorder
Glen O. Gabbard
H
ow does psychoanalytic psychotherapy work? Let me state
at the outset that the answer is clear—we don’t know. Thera-
peutic action has been much discussed in the psychoanalytic
literature, but many of the discussions are inextricably bound to par-
ticular psychoanalytic theories. Times have changed; we no longer
practice in an era in which interpretation is regarded as the exclusive
therapeutic arrow in the analyst’s quiver (Gabbard and Westen, 2003).
Abend (2001) observed that “no analyst today would suggest that the
acquisition of insight is all that transpires in a successful analysis, or
even that it identifies the sole therapeutic influence of the analytic
experience” (p. 5). As Abend implies in his distinction between psy-
choanalysis and “therapeutic influence,” there has been an unfortunate
divide between what is analytically pure and what helps the patient.
In recent contributions (Gabbard, 2007; Gabbard and Westen, 2003),
I have argued that we need to identify what strategies help patients
change, rather than worrying about adherence to a particular analytic
ideal. In any case, Wallerstein (2000) stressed that after reviewing the
data from the monumental 30-year follow-up of the Menninger Foun-
dation Psychotherapy Research Project patients, differentiating thera-
peutic change from analytic change is virtually impossible anyway.
1
2 T H E P S Y C H OA N A LY T I C T H E R A P Y O F S E V E R E D I S T U R BA N C E
There is no single path to therapeutic change. Single mechanism

theories of therapeutic action, no matter how complex, are unlikely to
prove therapeutically useful simply because there are a variety of
targets of change and a variety of strategies for effecting change in
those targets.
While there once was a debate regarding whether insight or the
therapeutic relationship was the key vehicle for change, that either/
or polarization of interpretation vs. the relationship with the thera-
pist has given way to a broad consensus that both aspects of treat-
ment contribute to change in the patient (Cooper, 1989; Jacobs, 1990;
Pulver, 1992; Pine, 1998; Gabbard, 2000; Gabbard and Westen, 2003).
Another shift over time has been away from an archaeological
approach to psychoanalytic treatment. Rather than focusing on the
excavation of buried relics in the patient’s past, most contemporary
analytic therapists, especially those who work with borderline person-
ality disorder, focus more on the here-and-now interaction between
the therapist and the patient. The therapist’s participation in enact-
ments and projective identification allow her to identify a characteristic
“dance” that the patient recreates in a variety of settings based on that
patient’s internal object relations. Hence by studying what transpires
between therapist and patient, one has a sense of what has come before
and what is going on every day outside the treatment relationship.
Attempting to study the therapeutic action of psychotherapy is
complex. If one asks patients what was helpful some time after their
treatment, what one hears is often disappointing to the psychoana-
lytic therapist. One of my patients came back to see me several years
after she had terminated a multi-year analytic process. I asked her
what she had found most helpful, and she replied, “Each day when
I came to your office, you were there.” She evidently failed to recall
any of my carefully formulated interpretations or any of the insights
she’d gathered in the course of her treatment with me. I realized,
however, that my “being present” meant a lot to her because she had
a father who was perennially absent. Hence what was important to
her and what was important to me may have been entirely different.
Patients may not really know what helped them.
If one investigates the issue of how therapy works by interview-
ing therapists, one immediately has to deal with the stark reality
that they are a biased group. They are narcissistically invested in
the outcomes of their patients, and they may view the patient’s
THE THERAPEUTIC ACTION 3
improvement in terms that shed favourable light on how they

conceptualized and formulated the treatment. Moreover, those who
are adherents to a particular theoretical school will emphasize strat-
egies deriving from that school regardless of whether or not they
were helpful to the patient.
Researchers, on the other hand, have the advantage of objectivity
when studying therapeutic action. However, they also are viewing
the process from a disadvantaged point of view in some respects. Psy-
choanalytic psychotherapy is largely about the interior spaces of the
patient and the subtle interactions that occur unconsciously between
two people. The therapist who is immersed in the transference-
countertransference vicissitudes has an immediate sense of who the
patient is and what the patient needs in the way of specific therapeutic
strategies. Moreover, there are moments of meeting (Stern et al, 1998)
that may be extraordinarily meaningful to both patient and thera-
pist but are not part of a therapeutic plan. They occur spontaneously
when the two parties share a joke or a deeply moving experience
where tears come to the eyes of both. A psychotherapy researcher
studying a transcript may entirely miss such moments.
Because all the methodologies to study therapeutic action have
a set of problems associated with them, we must acknowledge that
we may continue to be in the dark for some time in solving this puz-
zle. Greenberg (2005) has suggested that the therapeutic action of
psychoanalytic treatment may ultimately be unknowable for any
specific patient.
Empirical research on transference interpretation

Despite the fact that the therapeutic action of psychoanalytic psy-
chotherapy may be unknowable, we nevertheless will embark on an
overview of what is known about effective treatment for borderline
personality disorder, with the assumption that the research seeking
to find an efficacious treatment will shed some light on therapeutic
action. We know that at least five different types of therapy have
now been empirically validated in randomized controlled trials:
mentalization-based therapy (Bateman and Fonagy, 1999), dialec-
tical behaviour therapy (Linehan et al, 2006), transference-focused
therapy (Clarkin et al, 2007), schema-focused therapy (Giesen-Bloo
et al, 2006), and supportive psychotherapy (Clarkin et al, 2007).
Two of these empirically validated treatments are psychodynamic

forms of therapy: mentalization-based therapy (MBT) and transfer-
ence-focused therapy (TFP). One of the central controversies in the
discussion of these two treatments is the role played by transference
interpretation. While there is no head-to-head comparison in the lit-
erature between MBT and TFP, there is a small body of literature that
has investigated the relative role of psychoanalytic treatments that
focus on transference interpretation vs. those that do not.
In a landmark Norwegian study, Høglend (2006) conducted a
randomized controlled trial of dynamic psychotherapy designed to
determine the impact of a moderate level of transference interpreta-
tions (1–3 per session) in a once-weekly psychotherapy for the dura-
tion of one year. One hundred patients were randomly assigned to a
group using either interpretation of the transference or a group that
did not use such interventions. The authors included brief vignettes
from the therapy so the reader could gain some understanding of the
types of interventions considered to be transference interpretations.
They attempted to avoid the “allegiance effect” so common in psy-
chotherapy research, where researchers pit their favoured treatment
against one that they don’t really think will work. The investigators
cross-trained therapists in each of the therapies used and arranged
for the same therapists to conduct both treatments. The results came
as something of a surprise: there were no overall differences in out-
come between the two treatment cells, but the subgroup of patients
with impaired object relations benefited more from the therapy using
transference interpretation than from the alternative treatment.
The conventional wisdom in predicting psychotherapy outcome
has long been that “the rich get richer” (Gabbard, 2006). In other
words, patients who have greater psychological resources and more
mutually gratifying relationships tend to form a solid therapeutic
alliance with the therapist and gain greater benefit from the therapy.
Such patients would, according to conventional thinking, be more
capable of tolerating transference interpretation than those who are
more disturbed with a shakier therapeutic alliance with the therapist.
Moreover, studies of transference interpretation in brief dynamic
therapy indicate that there is not a positive correlation between that
particular intervention and outcome (Piper et al, 1991).
When the patients who had lower scores on the quality of object
relations in the Høglend study were examined, it was discovered that
61% of those subjects were diagnosable with personality disorders on

the SCID-II (Spitzer et al, 1990). By contrast, only 20% of those meas-
ured as having had high quality object relations had personality dis-
orders. Hence there appeared to be a correlation between personality
disorders and improvement with transference interpretation.
The study design had shortcomings that must be taken into
account. Axis I disorders were not rigorously diagnosed using
standard research interviews. For example, the effects of depression
on outcome could not be evaluated with precision. It is also pos-
sible that some experienced therapists secretly felt that the patients
deprived of transference work were getting less than optimal treat-
ment. Similarly, while investigators attempted to “blind” the raters
who were listening to the audiotapes, the content of these tapes
might well indicate to which group the patient belonged (Gabbard,
2006). Nevertheless, a subsequent report from Høglend et al (2008)
showed that the beneficial effect of transference interpretation for
this subgroup of patients was sustained at three years’ follow-up.
Therapeutic action and borderline personality disorder

While the findings of the Norwegian study are of heuristic value,
they are not specific for any particular personality disorder. When
we focus on borderline personality disorder in particular, we have
at least one randomized controlled trial that emphasizes transfer-
ence interpretation. In a head-to-head comparison of transference-
focused therapy (TFP), dialectical behaviour therapy (DBT), and
supportive therapy (SP) at Cornell-Westchester, 90 patients were
randomly assigned to one of these three treatment groups. Over a
12-month period, six domains of outcome measures were assessed
at 4-month intervals by raters blind to the treatment group. When
results were analyzed using individual growth-curve analysis, all
three treatments appeared to have brought about positive change
in multiple domains to a roughly equivalent extent. However,
in some areas, TFP seemed to do better than the alternative treat-
ments. In fact, TFP was associated with significant improvements
in 10 out of the 12 variables across the six symptom domains, com-
pared with improvement of six variables with SP, and five with
DBT. Only transference-focused psychotherapy brought about sig-
nificant changes in impulsivity, irritability, verbal assault, and direct
assault. Both TFP and DBT—therapies that specifically target sui-

cidal behaviours—did better than supportive therapy in reducing
suicidality.
In a report from the same study on a different dimension of these
findings, Levy et al (2006) demonstrated that TFP produced addi-
tional improvements that were not found with either DBT or SP. The
study subjects who received TFP were more likely to move from
an insecure attachment classification to a secure one. In addition,
they showed significantly greater changes in mentalizing capacity
(measured by reflective functioning) and in narrative coherence,
compared with those in other groups. Problems in mentalization
(a capacity to attribute independent mental states to the self and
others in order to explain and predict behaviour) have been identi-
fied as a specific area of psychopathology in borderline personal-
ity disorder, and another empirically validated treatment, MBT, has
been designed to address it. This randomized controlled trial of the
three studies at Cornell-Westchester provided suggestive evidence
that other therapeutic approaches may also have beneficial effects
on the capacity to mentalize.
While this particular study suggests that TFP is superior to either
treatment, it is also important to note that supportive psychotherapy
did almost as well as TFP but was provided once weekly instead of
twice weekly like the TFP. To be sure, SP in this study was a psy-
choanalytically sophisticated treatment that shared much in com-
mon with TFP, but proscribed transference interpretations. It was
not simply a control condition involving giving praise and advice.
The study also raises a provocative question that goes unanswered
with the data—would reflective functioning and the other symptom
domains have improved to the same degree as TFP if the supportive
therapy had been offered twice weekly?
Giesen-Bloo et al (2006) did a direct comparison between TFP and
schema-focused therapy (SFT) that lasted three years. In this rand-
omized controlled trial, SFT seemed to produce better outcomes than
transference-focused therapy. However, Yeomans (2007), a consult-
ant to the project, clarified that the therapists doing TFP in the study
were actually not well trained in that approach so that the compari-
son was not valid. In his view, they were using a more generic form
of dynamic therapy rather than the specific transference-focused
psychotherapy developed by Kernberg, Clarkin, and the other

members of the research team.
MBT vs. TFP

As noted earlier, two different psychodynamic psychotherapies,
mentalization-based therapy (MBT) and transference-based therapy
(TFP), have both been shown to be efficacious for BPD patients in
randomized controlled trials. Moreover, TFP, a treatment not specifi-
cally designed to improve mentalizing, nevertheless showed greater
gains in that area than either of the control treatments.
When one takes into account the differences between MBT and TFP,
one has difficulty attributing the therapeutic action to the transference
interpretation component. The two modalities approach transference
interpretation quite differently. MBT explicitly de-emphasizes the pro-
vision of insight through transference interpretation. The rationale is
that transference interpretation, especially of anger, is likely to destabi-
lize borderline patients (Gunderson et al, 2007).
Instead, MBT focuses on the current mental state and mental
functioning of the patient. This strategy is designed to help patients
become introspective and develop more of a sense of self-agency. In
other words, the patient begins to find a sense of interiority and sub-
jectivity through interaction with a therapist who is curious about the
mental functioning of both patient and therapist and through their
alternative perspectives on shared experiences. An MBT therapist
would not be likely to interpret that a particular feeling the patient is
having has its origins in childhood experiences with a parent.
By contrast, TFP sees unintegrated anger as a core problem.
Therapists trained in this modality address the splitting off of anger
and its associated self and object representations. Through the use
of interpreting transference developments, they attempt to integrate
anger and the object and self-representations associated with it into
whole object rather than split off part-object relations (Gunderson
et al, 2007). Given these differences, how do we understand that both
MBT and TFP are effective in promoting mentalizing and improving
the symptoms of BPD?
There are several possible answers: 1) all therapeutic approaches
provide a systematic conceptual framework that organizes the internal
chaos of the borderline patient. Patients with BPD characteristically are

in a healthcare system that is chaotic. Because of the splitting mecha-
nism typical of borderline patients, they often receive highly disparate
advice from different treaters and diverse treatment agencies. They
may feel pulled from all angles by their healthcare system or even
thrown out of the system because they are thought to be “manipula-
tors” or “splitters.” Any therapeutic strategy based on an overarch-
ing theoretical premise makes them feel there is a coherent treatment
plan that offers hope.
2) Different borderline patients may respond to different elements
of the therapeutic action. BPD has a diverse etiology that involves
such things as childhood abuse, childhood neglect, highly confusing
and problematic family interactions that do not involve overt abuse,
genetic vulnerability, neuropsychological difficulties, and the influ-
ence of Axis I disorders that are more than often present (Gabbard,
2005). While we lack sufficient data to determine which patients
with BPD are likely to respond to which components of therapeu-
tic action, the work of Blatt and Ford (1994) suggests that this form
of research is possible. They have delineated two broad subgroups
of character pathology that require different therapeutic strategies.
The anaclitic type is mainly concerned about relationships with oth-
ers, and these individuals have longings to be nurtured, protected,
and loved. They appear to respond more to the relational aspect
of psychotherapy than to insight delivered through interpretation.
On the other hand, the introjective subtype is primarily focused on
self-development, and these individuals struggle with feelings of
unworthiness, failure, and inferiority. They are highly self-critical,
perfectionistic, and competitive, and they appear to do better with a
predominately interpretative approach.
3) The therapeutic action may largely be attributed to secondary
strategies that are not emphasized by the therapist. Gabbard and Westen
(2003) have identified a number of these that may receive less atten-
tion than transference interpretation and the therapeutic relationship.
Various forms of confrontation carry implicit or explicit suggestions for
change. For example, therapists frequently confront dysfunctional beliefs
in the same way they confront problematic behaviours in the borderline
patient. While cognitive therapy emphasizes this approach, dynamic
therapy does not, but few therapists would deny that it is involved
in the psychoanalytic psychotherapy of BPD. Therapists also engage
in directive interventions that are designed to address the patient’s

conscious problem solving or decision-making processes. This effort
to help the patient solve problems may assist the patient in making
more adaptive life choices or also help them master strong affect states
by using more explicit reasoning. Exposure, one of the central mecha-
nisms of change in behavioural treatments, is almost always present in
dynamic psychotherapy of BPD, even though few dynamic therapists
write about it. In brief, exposure involves presenting the patient with a
situation that provokes anxiety and assisting the patient in confronting
the situation until it no longer creates anxiety because the patient has
habituated to it. The diminution of transference anxieties over time is
in part related to exposure, as the patient recognizes that the original
fears of being criticized or attacked by the therapist are unrealistic. At
the same time, the therapist encourages the patient to confront feared
situations outside the therapy. Judicious self-disclosure is yet another
mode of action. The therapist may share a particular feeling with the
patient to promote mentalizing. The careful use of self-disclosure may
help the patient see that her own perception of the therapist is sim-
ply a representation rather than an absolute truth. Finally, affirmation
may be critically important for patients who have experienced severe
trauma (Killingmo, 1989). Such patients may have experienced parents
who invalidated their experiences, and the therapist’s affirmative vali-
dation of the patient’s experience can be highly beneficial.
4) The other possibility is that the nature of the therapeutic alliance
is responsible for improvement in the patient. Norcross (2000) notes
that psychotherapy research indicates that the therapeutic relation-
ship accounts for most of the outcome variance—technique generally
accounts for only 12–15% of the variance across different kinds of
therapy. The therapeutic alliance, often defined as the degree to which
the patient feels helped by the therapist and is able to collaborate with
the therapist in pursuit of common therapeutic goals (Gabbard, 2004),
has been shown in research to be the most potent predictor of outcome
in psychotherapy (Horvath and Symonds, 1991; Martin et al, 2000).
The role of the therapeutic alliance

Considerations of the therapeutic alliance provide a context for con-
sidering the role that transference interpretation plays. It is possible
that the emphasis on the frequency or centrality of transference inter-
pretation may be misplaced. Timing may be of much greater impor-

tance. Gabbard et al (1994) studied psychotherapy process involving
audiotapes of long-term dynamic psychotherapy with three BPD
patients. One group of investigators in the project looked at the impact
of the therapist’s interventions on the therapeutic alliance. A second
group collaborated on identifying the interventions used to effect
the therapeutic alliance. These investigators found that transference
interpretation had greater impact on the therapeutic alliance—both
positive and negative—than other interventions. They concluded that
transference interpretation is a high-risk, high-gain intervention in the
psychotherapy of BPD patients.
When the researchers looked at the interventions made by the
therapist leading up to the transference interpretation, they found
that the most effective interpretations of transference, i.e., those that
had a positive impact on the therapeutic alliance, had something in
common. The way had been paved for the interpretation by a series of
empathic, validating, and even supportive interventions that created
a holding environment in Winnicott’s sense. The patient felt under-
stood and validated. A surgeon needs anaesthesia to operate, and
the psychotherapist of a borderline patient needs a solid therapeutic
alliance to interpret transference. Hence the therapeutic alliance and
transference interpretation may work synergistically. In this regard,
Høglend et al’s study (2006) could be understood as demonstrating
that interpretive work in the therapeutic relationship strengthens the
therapeutic alliance. Patients with poor object relations may be able to
see the therapist as a trusting, helpful figure, when the distortions in
the relationship are clarified and understood (Gabbard, 2006).
The therapeutic alliance, though, can work independently of trans-
ference interpretation, and the therapeutic action doesn’t necessarily
depend on their linkage. The relationship between therapist and patient
can be strengthened through experiential means without resorting to
interpretation or clarification within the transference. The therapist’s
role as a witness of the patient’s internal experience may itself be thera-
peutic (Poland, 2000). By listening non-judgmentally to the patient’s
narrative, the patient is provided with an experience of someone who
is “present” with them and able to bear the affect states that the patient
finds unbearable. Wallerstein (1986) studied the original Menninger
Foundation psychotherapy research project patients in a 30-year
follow-up. Although these patients were not rigorously diagnosed at
the time, most would now be diagnosed as BPD. Wallerstein found

that supportive treatments appear to be as effective and as durable as
expressive treatments in patients with poor object relations.
Among the mechanisms of therapeutic action he identified in
these patients who had successful supportive treatments, he noted
that many “transferred their transference” to someone else. In other
words, these patients may have found a supportive romantic partner
who could contain their affect states and love them non-judgmentally
in such a way that the relationship itself was healing independent of
the transference to the therapist. He also noted that some patients
improved through transference cure—i.e., they improved to gain
the therapist’s approval and unconditional positive regard. Others
became “therapeutic lifers,” patients who never really terminated
but continued to see their therapist at intervals varying from months
to years. As long as these patients knew that no definitive termina-
tion was planned, they functioned well, but faced with the possibility
of terminating, they would experience a recurrence of symptoms.
Neurobiological factors
In looking at the research in recent years on the neurobiological
correlates of BPD, we may discover some clues as to the types of
psychotherapeutic interventions that are helpful. Examining neuro-
biological correlates is not an exercise in reductionism. Rather, it is an
attempt to expand or understand psychodynamic therapy interventions
by investigating how they work on the brain. For example, patients
with BPD who have histories of childhood trauma have been shown
to have hyperreactive amygdala responses (Herpertz et al, 2001). The
amygdala is part of the limbic system and serves to increase vigilance
and to evaluate the potential for a novel or dangerous situation. This
hyperreactivity extends to faces. Two different studies (Donegan et al,
2003; Wagner and Linehan, 1999) found that patients with BPD, com-
pared with control subjects, show significantly greater left amygdalar
activation to varied facial expressions. Of even greater importance,
however, was the tendency for patients with BPD to attribute nega-
tive qualities to neutral faces. Standardized pictures of neutral faces
were regarded as threatening, untrustworthy, and possibly nefarious
by BPD subjects but not by controls. Hence a hyperreactive amygdala
may be involved in the predisposition to be hypervigilant and over-
reactive to relatively benign emotional expressions. This misreading

of neutral facial expressions is probably related to the transference
misreadings that occur in psychotherapy of patients with borderline
personality disorder. They tend to develop “bad object” transferences
even when the therapist is behaving professionally and empathically.
Another factor that influences the development of the negative
transference in BPD is a hyperreactive hypothalamic-pituitary-adrenal
(HPA) axis. Rinne et al (2002) studied 39 female BPD patients who
were given combined dexamethasone/corticoptropin-releasing hor-
mone (CRH) tests, using 11 healthy subjects as controls. Twenty-four
of these women had histories of sustained childhood abuse. Fifteen of
them had no histories of childhood abuse. When the authors exam-
ined the results, the chronically abused BPD patients had signifi-
cantly enhanced adrenocorticotropic hormone (ACTH) and cortisol
responses to the dexamethasone/CRH challenge compared with non-
abused subjects. They concluded that a history of sustained childhood
abuse is associated with hyperresponsiveness of ACTH release.
Along with the misinterpretation of faces associated with a hyper-
reactive amygdale, we can infer that this hypervigilance related to
the overly active HPA axis contributes to a specific form of object
relatedness. This paradigm is illustrated in Figure 1 below.
An affect state of hypervigilant anxiety links a perception of oth-
ers as persecuting to perception of the self as victimized.
One of the implications for psychotherapy is that the patient’s quasi-
delusional conviction that the therapist is up to something malevolent
must tactfully be challenged. Consider the following vignette:
Ms. A, a 27-year-old patient with BPD, was ending a session with

me after doing some good work on understanding her affective
storms. As she took her coat off the coat hanger on the back of
my office door, she got her left arm stuck trying to slip it into the
sleeve. I moved over to assist her by holding up the collar of her
coat so she could more easily get her arm through the sleeve. She
erupted in rage and shouted, “I can do it myself!” I backed off
and told her it was fine if she preferred to do it on her own. She
then left the session without making further comment.
When she returned the following week, she made no men-
tion of the incident. I brought up what had happened, and she
said that it no longer applied to her since she didn’t feel that
way today; hence there was no reason to discuss it. She said,
“Besides, that’s not me. I’m not like that.” I explained to her that
in fact, there was a part of her that was like that. She reluctantly
reflected on the last session. She said that her perception was
that I was treating her like a small child who didn’t know how to
put on her coat. I asked, “Is there any other possible perspective
on this situation besides that one?” She said that she was sure
that was how I had viewed her. I persisted in exploring other
options with her. Ultimately, she conceded, now that she was no
longer affectively distressed, that it was possible that the thera-
pist had other intentions. She went on to say that she hated the
way her mother had infantilized her and didn’t want that to be
repeated with me. I also offered an interpretive understanding
after several minutes of exploring it with her: “It could be that
if you acknowledge that the “not me” part of you is here now,
you’re concerned that that’s all I’ll see. That would worry you
that all the loving, positive parts of you would be destroyed by
that rage, and I would be driven away.” The patient contem-
plated the possibility and said she would have to think about it.
In this vignette, I challenged the patient’s emotional certainty—

namely, that she was viewing me in the only way possible—i.e., as
an infantilizing mother. I helped her explore other possibilities to
enhance her mentalizing capacity about her own subjective state
and that of others. After paving the way, I also offered an interpre-
tive understanding of her fears in the transference—namely, that if
she integrated the “bad” part of her with the more positive, loving
part of her, the hate would destroy the love and I would be driven
away. Hence a major effort was made to help the patient reflect on
what had transpired and see other possible perspectives.
Both TFP and MBT encourage reflection by the patient on

the perceptions and conclusions that the therapist draws from
interactions. Ochsner et al (2002) have shown that actively rethink-
ing or reappraising feelings activates the prefrontal area of the brain
that modulates amygdalar-based negative feelings such as fear.
Hence one possibility in terms of therapeutic action is that the reflec-
tion and contemplation of affective states and their meaning may
increase the prefrontal control of the amygdalar hyperreactivity.
At least one study not involving borderline personality disorder
suggests that conscious effort to think may increase the prefron-
tal volume. Peterson et al (1998) found that in Tourette’s patients,
some were able to consciously suppress the motor tics when they
had a premonitory urge that they were coming. Others were not
good at consciously suppressing them. Those who made a stronger
effort to consciously suppress the tics actually increased the vol-
ume of the frontal cortex compared to those who were not able to
consciously suppress the motor tics, according to functional MRI
scans. Whether a similar change in prefrontal volume is part of the
therapeutic action with borderline personality disorder remains to
be studied.
Further research suggests there may actually be a frontolimbic
network that is central to the emotional dysregulations in BPD
(Schmahl and Bremner, 2006). This network consists of the anterior
cingulated cortex (ACC), orbitofrontal cortex (OFC), dorsolateral
prefrontal cortex (DPC), hippocampus, and amygdala. The ACC
may be regarded as the brain area involved in mediating emotional
control, and studies show that it is deactivated in response to stress-
ful stimuli in BPD. Hence ACC dysfunction is probably a key com-
ponent in the emotional dysregulation seen in BPD.
Silbersweig et al (2007) designed an ingenious study to examine
the mechanisms involved in frontolimbic dysfunction. BPD patients
were asked to push a button for words in standard font but not
for those in italicized font. BPD patients, as expected, were more
impulsive than controls, particularly when the italicized words were
negative. In contrast to controls, BPD patients showed increased
amygdalar reaction and decreased activity in the subgenual cingu-
lated and the medial OFC. Also in response to negative words, the
BPD subjects showed increased activity in the dorsal ACC. Hence
even though there were not able to exercise impulse control, this
finding suggested that they were aware that they needed to devote
other resources to monitoring it.
We can conclude, then, that neuroimaging data implicates the
prefrontal cortex and the ACC as target areas for psychotherapeu-
tic intervention to help decrease emotional dysregulation in BPD
patients.
Another contribution to understanding neurobiological corre-
lates of the therapeutic action involves timetables for change in the
neurobiology of learning. Wiltgen et al (2004) stressed that insight
has separate and different effects than repeated experience has on
changing what has been learned in the past. Insight based on hip-
pocampal learning provides quick new ways of looking at new
information and adapting to new situations. However, other neu-
ronal connections are based on implicit, nonhippocampal learning
and have never been conscious nor do they have the capacity to be
easily retrieved by shifting one’s attention. These types of neuronal
associations develop through intense repeated experiences early in
life are likely to remain strong, despite interpretation and insight.
Hence explicit and declarative memory systems may change with
insight, while implicit and procedural memories may require mul-
tiple exposures over an extended period of time for change to be
achieved (Folensbee, 2007).
Structural change is often regarded as strengthening of the ego or
modification of the superego. However, with our growing knowl-
edge of neural networks, we also know that changes can be under-
stood in terms of what happens in the brain. Through repeated
experiences, certain representations of object and self, connected by
an affect state, are embedded in neural networks. Those that occur
on a regular basis, such as a father who repeatedly hits his son when
angry, will become activated automatically when there is a threat.
Over time, a psychotherapist offers a new model of relationship for
internalization. In this way, the neural network associated with the
old object and self-representation gradually weakens, while new
associative linkages are occurring that are strengthened through
repeated exposure to the psychotherapist, who is a benign and caring
instead of an abusive one. The capacity for conscious self-reflection
allows the patient to override unconscious dynamics once they are
recognized and to begin resetting some of the relevant connections.
Hence the old neural networks do not disappear but are relatively
weakened while the new neural networks, containing the new object
relationship of the therapy, is strengthened.
Conclusion
Summarizing what we know about therapeutic action, we can con-
clude that there is no single path to therapeutic change. Diverse
models of psychotherapy appear to be effective with patients who
have borderline personality disorder. Some principles of change
and some techniques for eliciting change are likely to be useful for
all patients, whereas others may be useful only for some (Gabbard
and Westen, 2003). Moreover, the research suggests that patients
with impaired object relations may respond well to interpretive
techniques, so it is not accurate to assume that strictly supportive
techniques are necessary for all patients with borderline psychopa-
thology. Nor is it accurate to conclude that transference interpreta-
tion is essential for change.
In his classic 1912 paper on technique, Freud suggested that
“For when all is said and done, it is impossible to destroy anyone
in absentia or in effigy” (p. 108). The implication was that analytic
cure involved eradicating the transference. However, our increasing
knowledge from the neurosciences as well as follow-up data from
studies of psychoanalysis and psychoanalytic psychotherapy, we
know that transference is never destroyed and that such ambitious
goals would be unreasonable. Rather, structural change involves
weakening old networks while strengthening new ones formed in
the therapy and other positive relationships.
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CHAPTER TWO
Transference Focused
Psychotherapy (TFP)
Otto F. Kernberg
T
ransference Focused Psychotherapy (TFP) was based upon
the Menninger Foundation’s psychotherapy research project
(Kernberg et al., 1972), that indicated that the optimal treat-
ment of patients with severe personality disorders or “low ego
strength” was a psychoanalytic psychotherapy, with systematic
interpretation of the transference in the hours, and the provision of
as much external support as the patient required outside the hours
to permit the treatment to develop successfully. In contrast, neither
the treatment with standard psychoanalysis nor with a purely sup-
portive modality based on psychoanalytic principles was as effec-
tive. On this basis, at the Personality Disorders Institute of the Weill
Cornell Medical College and The New York Hospital, we developed
a psychoanalytic psychotherapy centered upon the principle of sys-
tematic interpretation of the transference, and the setting up of a
treatment structure—including limit setting when needed, in order
to protect the patient and the treatment from the severe acting out
that is practically unavoidable in the treatment of these patients.
These efforts, over a period of approximately 15 years, culminated
in the development of a manualized psychoanalytic psychotherapy,
Transference Focused Psychotherapy, that fulfilled these general
21
characteristics mentioned above. We tested the possibility of training

psychotherapists in carrying out this manualized treatment, and, after
sufficient adherence and competence in carrying out that treatment
was confirmed, carried out a set of psychotherapy research projects
that, at first, confirmed the efficacy of this treatment in comparison
to treatment as usual for borderline patients, and then a randomized,
controlled trial comparing TFP to Dialectic Behavior Therapy and to
a supportive psychotherapy based on a psychoanalytic model. All
three treatments were manualized, carried out by therapists who
were convinced about the helpfulness of this model and proficient
in carrying it out. The findings revealed the efficacy of all three forms
of therapy, and showed significant differences regarding the treat-
ment of suicidal and parasuicidal symptoms, more effective with TFP
and DBT than with Supportive Psychotherapy. TFP was effective in
reducing various aspects of aggressive affects and behaviour of these
patients in comparison to the other modalities (Kernberg et al., 2008).
At various points of our developing work we studied the pos-
sibility of applying the principles of TFP to psychoanalytic group
psychotherapy, and developed a tentative model that seemed clini-
cally satisfactory. We have applied this mostly to a day-hospital set-
ting, and in sporadic attempts to apply it to an in-patient setting as
well. While clinicians involved in this effort have felt encouraged to
pursue it further, we have not yet carried out empirical research on
the efficacy of such a group psychotherapy, and the present paper
is a first effort to spell out, the general model of this form of group
psychotherapy and its relationship to other related models. I shall
first present an outline of the basic principles of TFP as applied to
individual patients, and then present an overview about how these
principles apply to a corresponding TFP group psychotherapy.
Overview of TFP for individual patients

We evolved a differentiation of overall, long range treatment objec-
tives and corresponding “treatment strategies,” the systematization
of interventions in each session that are conditions necessary for
working with a borderline patient population or “treatment tactics”,
adopting specific instruments of psychoanalytic treatment through-
out its course, or “treatment techniques”. In what follows, I shall
outline these treatment strategies, tactics and techniques.
T R A N S F E R E N C E F O C U S E D P S Y C H OT H E R A P Y ( T F P ) 23
Strategies
Our assumption was that patients with severe personality disorders
or borderline personality organization suffer from the syndrome of
identity diffusion, that is, a chronic, stable lack of integration of the
concept of self and of the concept of significant others, and that the
ultimate cause of that syndrome was the failure of psychological inte-
gration resulting from the predominance of aggressive internalized
object relations over idealized ones. In an effort to protect the idealized
segment of the self and object representations, these patients’ ego was
fixated at a level of primitive dissociative or splitting mechanisms and
their reinforcement by a variety of other primitive defensive opera-
tions predating the dominance of repression, namely, projective iden-
tification, omnipotence and omnipotent control, devaluation, denial,
and primitive idealization. Identity diffusion is reflected clinically in
the incapacity to accurately assess self and others in depth, to com-
mit in depth to work or a profession, to establish and maintain stable
intimate relationships, and in a lack of the normal subtlety of under-
standing and tact in interpersonal situations. Primitive defensive
operations, which correspond to patients’ split psychological struc-
ture and identity diffusion, are manifest in patient’s behavior and are
an important feature of their maladaptive dealing with negative affect
and conflictual interpersonal situations, contributing fundamentally
to chaos and breakdown in intimacy, in work, in creativity, and in
social life. In an earlier paper, I (Kernberg, 2006) have described in
detail, the etiology, psychopathology, empirical research and clinical
assessment of the syndrome of identity diffusion.
The main strategy in the transference focused psychotherapy
(TFP) of borderline personality organization consists in the facili-
tation of the (re)activation in the treatment of split-off internalized
object relations of contrasting persecutory and idealized natures that
are then observed and interpreted in the transference. TFP is carried
out in face to face sessions, a minimum of two and usually not more
than three sessions a week. The patient is instructed to carry out free
association (in a detailed, precise way), and the therapist restricts his
role to careful observation of the activation of regressive, split-off
relations in the transference, and to help identify them and interpret
their segregation in the light of these patients’ enormous difficulty
in reflecting on their own behavior and on the interactions they get
involved in. The interpretation of these split-off object relations is

based upon the assumption that each of them reflects a dyadic unit
of a self-representation, an object-representation and a dominant
affect linking them, and that the activation of these dyadic relation-
ships determines the patient’s perception of the therapist and occurs
with rapid role reversals in the transference, so that the patient
may identify with a primitive self-representation while projecting
a corresponding object representation onto the therapist, while,
ten minutes later, for example, the patient identifies with the object
representation while projecting the self-representation onto the
therapist. Engaging the patient’s observing ego in this phenomenon
paves the way for interpreting the conflicts that keep these dyads,
and corresponding views of self and other, separate and exagger-
ated. Until these representations are integrated into more nuanced
and modulated ones, the patient will continue to perceive himself
and others in exaggerated, distorted and rapidly shifting terms.
The oscillation or alternative distribution of the roles of the dyad
has to be differentiated from the split between opposite dyads carry-
ing opposite (idealizing and persecutory) affective charges. The final
step of interpretation consists in linking of the dissociated positive and
negative transferences, leading to an integration of the mutually split-
off idealized and persecutory segments of experience with the corre-
sponding resolution of identity diffusion. The interpretation of these
split-off relationships occurs in a characteristic sequence of three steps.
Step one is the formulation of the total relationship that seems to be
activated at that point, using metaphorical statements to present the
situation as completely as possible in a way that can be understood
by the patient, and the clarification of who enacts what role in that
interaction. The therapist’s comments are based on his observations,
his countertransference utilization, and on clarifications that have been
sought of the patient’s experience of the relationship at each moment.
Step two consists in the observation of the interchange of the cor-
responding roles between patient and therapist, an extremely impor-
tant step that permits the patient, throughout time, to understand his
unconscious identification with the object representation as well as
the self representation, leading to a gradual awareness of the mutual
complementarity of these two roles. Step two is carried out in the
clarification and confrontation of both the oscillating poles of a given
dyad. However, since the idealized and persecutory relationships that
are activated remain typically split-off from each other in different

dyads, the patient becomes more able to recognize the extreme dyadic
nature of each of them while still maintaining the split or dissociated
nature that separates all good from all bad relationships. Understand-
ing the motivation for keeping these dyads separate is one of the main
objectives of the interpretive work, the focus of the next step.
Step three, finally, consists in an interpretive linking of the mutu-
ally dissociated positive and negative transferences, the transfer-
ences reflecting the idealized and persecutory relationships, thus
leading to an integration of the mutually split-off idealized and per-
secutory segments of experience, the corresponding resolution of
identity diffusion, and the modulation of intense affect dispositions
as primitive euphoric or hypomanic affects are integrated with their
corresponding fearful, persecutory, aggressive opposites. This third
step brings about a significant integration of the patient’s ego iden-
tity, as an integrated view of self—more complex, rich and nuanced
than the simplistic and extreme split-off representations—and a cor-
responding integrated view of significant others replace their split-
off previous nature, and an experience of appropriate depressive
affects, reflecting the capacity for acknowledging one’s own aggres-
sion that had previously been projected or experienced as dysphoric
affect, with concern, guilt, and the wish to repair good relationships
damaged in fantasy or reality, becoming dominant.
Step one of this sequence begins in the first therapy session, and
step two follows relatively quickly after the first few weeks and
months of treatment. Step three characterizes the mid and advanced
stages of the psychotherapy. At the same time, however, this three-
step sequence is a highly repetitive process. Some step three interpre-
tations may become possible relatively early, and step one, two and
three may recycle again and again, it first taking weeks to develop
the entire sequence, then the course of a few sessions, and, in the
advanced stages of the treatment, all three steps eventually may be
elaborated in the course of the same session.
The overall strategy mentioned, namely the resolution of identity
diffusion and the integration of mutually split-off idealized and perse-
cutory relationships, is facilitated by the fact that unconscious conflicts
are activated in the transference mostly in the patient’s behavior rather
than in the emergence of preconscious subjective experiences reflect-
ing unconscious fantasy. The intolerance of overwhelming emotional
experiences is expressed in the tendency to replace such emotional

experiences by acting out, in the case of most borderline patients, and
somatization, in some other personality disorders (Green, A., 1993).
The fact that primitive conflicts manifest themselves in dissociated
behavior rather than in the content of free association is a fundamental
feature of these cases that facilitates transference analysis with a rela-
tively low frequency of sessions, while the very intensity of those con-
flicts facilitates the full analysis of these transference developments.
What is important in these cases is establishing very clear boundaries
and conditions of the treatment situation, so that a “normal” relation-
ship is defined in the therapy that immediately enters into contrast
with the distortions in the therapeutic relationship derived from the
activation of primitive transferences. This leads to the discussion of a
second major aspect of the treatment: the tactics used by the therapist
in each session that create the conditions necessary for the use of inter-
pretation and the other techniques of treatment.
Tactics
The tactics are rules of engagement that allow for the application of
psychoanalytic technique in a modified way that corresponds to the
nature of the transference developments in these cases. The tactics
are: 1) setting the treatment contract, 2) choosing the priority theme
to address in the material the patient is presenting, 3) maintaining
an appropriate balance between, on the one hand, expanding the
incompatible views of reality between the patient and therapist in
preparation for interpretation and, on the other, establishing com-
mon elements of shared reality, and 4) regulating the intensity of
affective involvement.
In the establishment of an initial treatment contract, in addition
to the usual arrangements for psychoanalytic treatment, urgent
difficulties in the borderline patient’s life that may threaten the
patient’s physical integrity or survival, or other people’s physical
integrity or survival, or the very continuation of the treatment, all
are taken up and structured, in the sense of setting up conditions
under which the treatment can be carried out that involve certain
responsibilities for the patient and certain responsibilities for the
therapist. What is important in these structuring arrangements at
the beginning of the treatment is first, that the therapeutic structure
eliminate the secondary gain of treatment, and second that, in a

situation where limits or restrictions need to be established in order
to preserve the patient’s life or the treatment, the transference impli-
cations of these restrictions or limit-settings need to be interpreted
immediately. The combination of limit-setting and interpretation of
the corresponding transference development is an essential, highly
effective, and at times life saving tactic of the treatment. Yeomans,
et al. (1992) have described in detail the techniques and vicissitudes
of initial contract setting; and the manual of the technical aspects
of Transference Focused Psychotherapy (Clarkin, Yeomans, and
Kernberg, 2006) describes in detail the priorities to address in carrying
out the therapy.
With regard to choosing which theme to address at any given
moment in the material the patient brings to the session, the most
important tactic is the general analytic rule that interpretation has to
be carried out where the affect is most intense: affect dominance deter-
mines the focus of the interpretation. The most intense affect may be
expressed in the patient’s subjective experience, in the patient’s non-
verbal behavior, or, at times, in the countertransference—in the face
of what on the surface seems a completely frozen or affectless situa-
tion (Kernberg, 2004). The simultaneous attention, by the therapist,
to the patient’s verbal communication, non-verbal behavior, and the
countertransference permits diagnosing what the dominant affect is
at the moment—and the corresponding object relation activated in
the treatment situation. Every affect is considered to be the manifes-
tation of an underlying object relation.
The second most important consideration in determining the
selection of what is interpreted is the nature of the transference.
When major affect development coincides with transference devel-
opment that becomes easy to determine, but there are times where
most affect occurs related to extra transferential conditions or the
patient’s external world. Such affective dominance in the patient’s
external world, of course, always has transference implications
as well; the focus, however, has to start on the external affectively
invested situation, only shifting into a transference interpretation
when the corresponding transference development clearly occupies
the centre of the patient’s present interaction with the analyst. This is
an important tactic derived from Fenichel’s (1941) technical recom-
mendations, and reflects a flexibility of this approach, that focuses
simultaneously on the transference and on developments in these

patients’ external life at any time.
Still another tactical approach relates to certain general priorities
that need to be taken up immediately, whether they reflect affective
dominance or not in the session, although they usually do so any-
way. These priorities include, by order of importance: 1) suicidal or
homicidal behaviour, 2) threats to the disruption of the treatment, 3)
severe acting out in the session or outside, that threaten the patient’s
life or the treatment, 4) dishonesty, 5) trivialization of the content
of the hour and 6) pervasive narcissistic resistances, that must be
resolved by consistent analysis of the transference implications of the
pathological grandiose self (Kernberg, 1984, Clarkin, Yeomans and
Kernberg, 2006). When none of these priorities seems dominant at
the moment in the hour, the general tactic of affective dominance and
transference analysis prevails.
An important tactical aspect of a treatment involves conditions of
severe regression, including affects storms, micropsychotic episodes,
negative therapeutic reactions, and “incompatible realities”. We
have developed specific technical approaches to these situations; the
description of all of which would exceed the limits of this paper.
Techniques
While “strategies” refer to overall, long range goals and their imple-
mentation in transference analysis, and “tactics” to particular inter-
ventions in concrete hours of treatment, “techniques” refers to the
general, consistent application of technical instruments derived
from psychoanalytic technique. The main technical instruments of
Transference Focused Psychotherapy (TFP) are those referred to by
Gill (1954) as the essential techniques of psychoanalysis, namely,
interpretation, transference analysis, and technical neutrality. If psy-
choanalysis consists in the facilitation of a regressive transference
neurosis and the resolution of this transference neurosis by inter-
pretation alone carried out by the psychoanalyst from a position of
technical neutrality, TFP may be defined, in terms of its technical
utilization, by these same three instruments, somewhat modified,
however, as we shall mention below, and the important contribu-
tion of countertransference analysis as an additional major technical
instrument.
The use of interpretation focuses particularly on the early phases

of the interpretive process, namely, clarification of the subjective
experience of the patient, (clarification of what is in the patient’s mind
rather than clarifying information to him), and confrontation, in the
sense of a tactful drawing of attention to any inconsistencies or con-
tradictions in the patient’s communication—either between what the
patient says at one point in contrast to another, between verbal and
non-verbal communication, or between the patient’s communication
and what is evoked in the countertransference. Non-verbal aspects
of behaviour become extremely important in the psychoanalytic psy-
chotherapy of severe personality disorders. Interpretation per se, that
is, the establishment of hypotheses regarding the unconscious func-
tions of what has been brought forth by clarification and confron-
tation follows these two techniques. Interpretation as a hypothesis
about unconscious meaning refers, first of all, to interpretation of
unconscious meaning in the “here and now”, the “present uncon-
scious” (Sandler & Sandler, 1987), in contrast to genetic interpreta-
tions that link the unconscious meaning in the “here and now” with
assumed unconscious meanings in the “there and then”, that become
important only in advanced stages of the treatment of severe per-
sonality disorders. Interpretation, in short, is applied systematically,
but with heavy emphasis on its preliminary phases: clarification and
confrontation, and the interpretation of the “present unconscious”.
Transference analysis differs from the analysis of the transference
in standard psychoanalysis in that, as mentioned before, it is always
closely linked with the analysis of the patient’s problems in exter-
nal reality, in order to avoid the dissociation of the psychotherapy
sessions from the patient’s external life. Transference analysis also
includes an implied concern for the long range treatment goals that,
characteristically, are not focused upon in standard psychoanalysis,
except if they emerge in the transference. In TFP, an ongoing concern
regarding dominant problems in the patient’s life is reflected in the
occasional introduction of reference to major conflicts that brought
the patient into treatment or that have been discovered in the course
of the treatment, bringing such conflicts into the treatment situa-
tion even if they are not transference-dominant at that point. This
introduction of “extra transference material” follows the therapist’s
assessment that a significant splitting operation is in process, shield-
ing a certain important conflict in the patient’s external life from
exploration in the treatment. Here the therapist’s overview of the

total treatment situation and the total life situation of the patient
may determine that he introduce a subject matter “arbitrarily”, (at
times, at least in the patient’s mind), and then focus on the trans-
ference development that occurs as a consequence of introducing
such a major life theme. While transference analysis starts from ses-
sion one, and, in this regard the treatment has significant similarities
with Kleinian technique, (both because of the dominant emphasis
on transference analysis and on primitive defenses and object rela-
tions), this bringing in of external reality is a fundamental differ-
ence from Kleinian and, to some extent, also from ego psychological
psychoanalysis.
Technical neutrality, as has probably become evident from what
has been said before, is an ideal point of departure within the treat-
ment at large and within each session, but at times needs to be dis-
rupted because of the urgent requirement for limit-setting and even
in connection with the introduction of a major life problem of the
patient that, at such point, would seem a non-neutral intervention
of the therapist. Such deviation from technical neutrality may be
indispensable in order to protect the boundaries of the treatment
situation, protect the patient from severe suicidal and other self-
destructive behavior, and requires a particular approach in order
to restore technical neutrality once it has been abandoned. What
we do, following an intervention that clearly signifies a temporary
deviation from technical neutrality, (for example, by taking meas-
ures to control a patient’s accumulation of medication with suicidal
intentions), is the analysis of the transferential consequences of our
intervention, to a point where these transferential developments can
be resolved and then be followed with the analysis of the transfer-
ence implications of the reasons that forced the therapist to move
away from technical neutrality. Technical neutrality, in short, fluc-
tuates throughout the treatment, but is constantly worked on and
reinstated as a major process goal.
The utilization of countertransference as a major therapeutic
tool has already been referred to as an important source of infor-
mation about affectively dominant issues in the hour. The inten-
sity of the countertransferences evoked by patients with severe
character pathology and consequent severely regressive behavior
and acting out in the transference requires an ongoing alertness to
countertransference developments that the therapist has to tolerate

in himself/herself, even under conditions of significant regression
in countertransference fantasies and impulses of an aggressive,
dependent, or sexual kind. That internal tolerance of counter-
transference permits its analysis in terms of the nature of the self
representation or the object representation that is being projected
onto the therapist at that point, facilitating full interpretation of the
dyadic relationship in the transference, so that countertransference
is utilized in the therapist’s mind for transference clarification. It is
important that countertransference not be communicated directly
to the patient but worked into transference interpretations. In this
regard TFP follows strictly analytic criteria typical for the ego psy-
chological, Kleinian, British Independent, and French approaches.
At times, partial acting out of the countertransference is unavoid-
able, and the therapist has to be honest in acknowledging the real-
ity of what his behavior shows to the patient, without exceeding
this communication with guilt determined “confessions” or deny-
ing the reality of a behavioural response on the therapist’s part that
has become obvious to the patient. This, in essence, is not different
from what standard psychoanalytic technique would expect from
the analyst, except that the very intensity and dominant nature of
countertransference information is characteristic of the process of
TFP with severe personality disorders.
These then are the essential elements of the techniques of TFP. It
also needs to be said that the frequency of interpretive interventions,
at whatever level of regression, is high in comparison with transfer-
ence interpretation in psychoanalysis. As Green (2000) has pointed
out, the avoidance of traumatogenic associations drives borderline
patients to jump from one subject to the next, thus expressing their
“central phobic position”, and may seem bewildering to an analyst
used to expect the gradual development of a specific theme in free
association, thus leading to clarify the subject matter that is being
explored. Here, waiting for such a gradual deepening of free asso-
ciation is useless, because of this defensive jump from one subject to
the next, also related to the splitting operations that affect the very
language of the patient (Bion, 1968).
The corresponding technical approach in TFP consists of an effort
to interpret rapidly the implication of each of the fragments that
emerge in the hours, with the intention of establishing continuity
by the very nature of the interpretive interventions that gradually

establish a continuity of their own. This approach may be compared
to the interpretive work with dreams, where the interpretation of
apparently isolated fragments of the manifest dream content leads
gradually to the latent dream content that establishes the continuity
between the apparently disparate elements of the manifest content.
Indications and contraindications

The most general indication for Transference Focused Psychother-
apy (TFP) is for patients with borderline personality organization,
that is, presenting severe identity diffusion, severe breakdown in
work and intimate relationships, in their social life, and with specific
symptoms linked to their particular personality disorder. This indica-
tion includes most personality disorders functioning at a borderline
level, such as, the borderline personality disorder per se, the more
severe cases of histrionic personality disorder, paranoid personal-
ity disorders, schizoid personality disorders, narcissistic personality
disorders functioning on an overt borderline level, (that is, having
all the symptoms of borderline personality disorder and narcissistic
personality disorder at the same time), and patients functioning at
a borderline level with severe complications typical for these cases,
if and when such complications can be treated first and controlled.
These include alcoholism, drug dependency, severe eating disorders,
particularly severe anorexia nervosa, patients with antisocial behav-
ior but definitely not with an antisocial personality proper (that has
no indication for psychotherapeutic treatment at all), schizotypal
disorders, and severe hypochondriasis. In all individual cases, we
evaluate first whether, even for such severe personality disorders,
psychoanalysis may be the treatment of choice, which is the case for
many histrionic personality disorders. The broad spectrum of severe
personality disorders, who, in addition, usually suffer from severe,
chronic anxiety, characterologically based depression, somatization,
phobic symptoms, and dissociative reactions, are optimal candidates
for TFP, which thus expands the total realm of patients that can be
treated with a psychoanalytically based approach.
The main contraindications include, as mentioned before, the anti-
social personality proper, and some narcissistic patients with severe
antisocial features, as well as patients with chronic dishonesty that
affects their capacity for verbal communication, such as pervasively

dominant pseudologia fantastica: in short, severe degrees of chronic
dishonesty that limit the capacity for honest communication and
make the resolution of these psychopathic transferences very dif-
ficult. In contrast, patients with aggressive, provocative, irresponsi-
ble social behavior who, however, still are able to experience some
degree of loyalty, investment in friendship and work, are optimal
candidates for TFP.
Another major contraindication is overwhelming secondary gain
of illness, provided by financial social support, supportive housing,
financial means provided to many patients with severe personality
disorders, who, unfortunately, are treated as if they were chronic schiz-
ophrenic patients, and whose capacity to lead a parasitic life depend-
ing on the State or on wealthy families becomes a major life sustaining
goal. Patients without any social life at all, reduced for many years to
staying in their room, watching television, and drifting in some way
through life also have a reserved prognosis but in many cases can be
treated if an adequate treatment contract is in place. Patients should
optimally have a normal IQ in order to undergo TFP.
There are patients in whom an inordinate amount of self-directed
aggression expresses self-destruction as a major life goal, and the
wishes to destroy themselves may be more powerful than the wishes
to live and be treated. Some of these patients can be recognized
before the treatment starts, others only in the course of the treatment,
although a long series of extremely severe suicidal attempts and a
long history of what seems almost willful destruction of life oppor-
tunities may signal this condition. The same is true for patients with
the most severe degree of negative therapeutic reaction reflecting a
profound identification with a battering object, and patients with
the syndrome of malignant narcissism, where self-destructiveness
implies the only possible triumph over an otherwise envied external
world not suffering from the same conditions that they do. Many
of the patients with contraindications for TFP psychotherapy may
have an indication for supportive psychotherapy, a subject that goes
beyond the realm of this particular communication, but to which
our Personality Disorders Institute has contributed significantly
(Rockland, 1992, Appelbaum, 2006).
This completes the outline of Transference Focused Psychother-
apy for individual patients.
References
Appelbaum, A.H. (2006). Supportive Psychoanalytic Psychotherapy for
Borderline Patients: an Empirical Approach. In: The American Journal
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Clarkin, J.F., Yeomans F.E. & Kernberg O.F. (2006). Psychotherapy for
Borderline Personality: Focusing on Object Relations. Washington, DC:
American Psychiatric.
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Patient: A Contract-based Approach. New York, NY: Basic Books.
CHAPTER THREE
The mentalization based approach

to psychotherapy for borderline
Peter Fonagy, Mary Target and Anthony Bateman
Introduction
Our approach to understanding self-pathology in personality
disorder assumes that the capacity to mentalize, that is, the capac-
ity to conceive of mental states as explanations of behaviour in one-
self and in others, is a key determinant of self-organisation. Along
with contributory capacities of affect regulation and attention control
mechanisms, the capacity for mentalization is acquired in the context
of early attachment relationships. Disturbances of attachment rela-
tionships will therefore disrupt the normal emergence of these key
social-cognitive capacities and create profound vulnerabilities in the
context of social relationships. Ours is fundamentally a psychoana-
lytic approach but we have elaborated our model of social develop-
ment on the basis of empirical observations as well as clinical work.
We define mentalization as a form of mostly preconscious imagi-
native mental activity, namely, perceiving and interpreting human
behaviour in terms of intentional mental states (e.g., needs, desires,
feelings, beliefs, goals, purposes, and reasons). Mentalizing is imagi-
native because we have to imagine what other people might be think-
ing or feeling; an important indicator of high quality of mentalization
35
is the awareness that we cannot know absolutely what is in someone

else’s mind. We suggest that a similar kind of imaginative leap is
required to understand one’s own mental experience, particularly in
relation to emotionally charged issues. In order to conceive of others
as having a mind, the individual needs a symbolic representational
system for mental states and also must be able to selectively acti-
vate states of mind in line with particular intentions, which requires
attentional control.
The ability to understand the self as a mental agent grows out of
interpersonal experience, particularly primary object relationships
(Fonagy, 2003). The baby’s experience of himself as having a mind
or self is not a genetic given; it evolves from infancy through child-
hood, and its development critically depends upon interaction with
more mature minds, assuming these are benign, reflective, and suf-
ficiently attuned. Mentalization involves both a self-reflective and
an interpersonal component. It is underpinned by a large number
of specific cognitive skills, including an understanding of emotional
states, attention and effortful control, and the capacity to make judg-
ments about subjective states as well as thinking explicitly about
states of mind—what we might call mentalization proper. In com-
bination, these functions enable the child to distinguish inner from
outer reality and internal mental and emotional processes from
interpersonal events.
This paper addresses the complex relation of attachment and
mentalization. We discuss the role of mentalizing in the develop-
ment of the agentive sense of self, and consider the contribution of
attachment trauma to the development of psychopathology by vir-
tue of undermining mentalizing capacity. We then give an overview
of Mentalization Based Therapy (MBT), a fully manualised psycho-
analytically oriented treatment for BPD based on this model, and
finally summarise evidence for its effectiveness.
The interpersonal interpretive function

The capacity to interpret human behaviour (see Bogdan, 1997)
requires the intentional stance: ‘treating the object whose
behaviour you want to predict as a rational agent with beliefs
and desires’ (Dennett, 1987 p. 15). We label the capacity to
T H E M E N TA L I Z AT I O N BA S E D A P P R OAC H TO P S Y C H OT H E R A P Y 37
adopt this stance the interpersonal interpretive function (IIF), an

evolutionary-developmental function of attachment. The IIF
is a cluster of mental functions for processing and interpreting
new interpersonal experiences that includes mentalization and
the cluster of psychological processes on which effective men-
talizing depends (Fonagy, 2003). Four emotional processing and
control mechanisms contribute to the developmental unfolding
of interpretive function: labelling and understanding affect,
arousal regulation, effortful control, and specific mentalizing
capacities (Fonagy and Target, 2002).
Since the mind needs to adapt to ever more challenging competitive

conditions, the capacity for mentalization cannot be fixed by genetics
or constitution. The social brain must continuously reach higher and
higher levels of sophistication to stay on top. Evolution has charged
attachment relationships with ensuring the full development of the
social brain. The capacity for mentalization, along with many other
social-cognitive capacities, evolves out of the experience of social
interaction with caregivers. Increased sophistication in social cog-
nition evolved hand in hand with apparently unrelated aspects of
development, such as increased helplessness in infancy, a prolonga-
tion of childhood, and the emergence of intensive parenting.
We have proposed a mechanism for this process rooted in
dialectic models of self-development (Cavell, 1991; Davidson,
1983). Our approach explicitly rejects the classical Cartesian
assumption that mental states are apprehended by introspection;
on the contrary, mental states are discovered through contingent
mirroring interactions with the caregiver (Gergely and Watson, 1999).
Therefore early disruption of affectional bonds will not only set up
maladaptive attachment patterns (e.g. Waters et al., 2000) but will also
undermine a range of capacities vital to normal social development.
Understanding minds is difficult if one does not know what it is like
to be understood as a person with a mind. Our argument may seem
to place an excessive burden upon the caregiver-infant relationship,
but we must remember that placing the social development of a
human infant in the hands of one adult is a recent phenomenon
compared to the previous average of four relatives who had a genetic
stake in the child’s survival (Hrdy, 2000). Recent neurobiological
evidence discussed next buttresses the ecological view of attachment

relationships as pivotally linked to mentalizing capacities.
The neurobiology of attachment

The neurobiology of attachment is now fairly well understood. It is
linked to the mesocorticolimbic dopaminergic reward circuit, which
also plays a key role in mediating the process of physical (as well
as emotional) addiction. It is highly unlikely that nature created a
brain system specifically to subserve cocaine and alcohol abuse. It
is more likely that addictions are the accidental by-product of the
activation of a biological system underpinning the crucial evolution-
ary function of attachment (Insel, 1997; MacLean, 1990; Panksepp,
1998). Attachment can be thought of as an ‘addictive disorder’
(Insel, 2003). Changes in attachment behaviour, such as falling in
love, which are stimulated by social/sexual activity, entail the acti-
vation of an oxytocin and vasopressin sensitive circuit within the
anterior hypothalamus (MPOA) linked to the VTA and the nucleus
accumbens (Insel, 2003). fMRI studies indicate specific activation of
the same pathways in the brain of somebody seeing their own baby
or partner, compared to another familiar baby or other people’s
partners (Nitschke et al., 2004).
In two separate imaging studies, Bartels and Zeki (Bartels and
Zeki, 2000, 2004), reported that the activation of areas mediating
maternal and/or romantic attachments appeared simultaneously to
suppress brain activity in several brain regions in two systems both
responsible for different aspects of cognitive regulation and control
but also including those associated with making social judgements
and mentalizing. Bartels and Zeki (2004) suggest grouping these
reciprocally active areas into two functional regions. The first (let us
refer to it as system A) includes the middle prefrontal, inferior pari-
etal and middle temporal cortices mainly in the right hemisphere, as
well as the posterior cingulate cortex. These areas are specialised for
attention and long-term memory (Cabeza and Nyberg, 2000), and
have variable involvement in both positive (Maddock, 1999) and
negative (Mayberg et al., 1999) emotions. Their role in both cognition
and emotion suggests that these areas may be specifically respon-
sible for integrating emotion and cognition (e.g. emotional encod-
ing of episodic memories). Further, these areas may play a role in
recalling emotion-related material and generating emotion-related

imagery that may be relevant in relation to understanding the typol-
ogy of attachment (Maddock, 1999).
The second set of areas deactivated by the activation of the attach-
ment system includes the temporal poles, parietotemporal junction,
amygdala, and mesial prefrontal cortex (let us call this system B).
Activation of these areas is consistently linked to negative affect,
judgements of social trustworthiness, moral judgements, ‘theory of
mind’ tasks, attention to one’s own emotions, and in particular, they
constitute the primary neural network underlying our ability to iden-
tify mental states (both thoughts and feelings) in other people (Frith
and Frith, 2003; Gallagher and Frith, 2003). Mentalization pertains
not just to states of mind in others but also reflecting on one’s own
emotional and belief states and consequently such tasks appear to be
associated with activation in the same neural system (Gusnard et al.,
2001). Making judgements that involve mental states has been shown
to be associated with activation of the same system. Thus intuitive
judgements of moral appropriateness (rather than moral reasoning)
are linked (Greene and Haidt, 2002) as is assessment of social trust-
worthiness based on facial expressions (Winston et al., 2002).
This suggests that being in an emotionally attached state inhibits
aspects of social cognition, including mentalizing and the capacity
accurately to see the attachment figure as a person. (Currently we
are working to perform an independent replication of this study).
The activation of the attachment system, mediated by dopamin-
ergic structures of the reward system in the presence of oxytocin
and vasopressin, inhibits neural systems that underpin the genera-
tion of negative affect. This is to be expected since a key function
of the attachment system is to moderate negative emotions in the
infant and presumably to continue to do so in later in development
(Sroufe, 1996). Equally consistent with expectations, is the suppres-
sion of social and moral judgements (probably mediated by the
second of the two regulatory systems) associated with the activation
of the attachment system. Judgements of social trustworthiness and
morality serve to distance us from others but become less relevant
and may indeed interfere with our relationships with those to whom
we are strongly attached (Belsky, 1999a; Simpson, 1999).
The configuration described by Bartels and Zeki has critical
developmental implications. Attachment has been selected by
evolution as the principal ‘training ground’ for the acquisition

of mentalization because attachment is a marker for shared
genetic material, reciprocal relationships and altruism. It is a non-
competitive relationship in which the aim is not to outsmart and
thus learning about minds can be safely practiced. Missing out on
early attachment experience (as for the Romanian orphans) creates
a long term vulnerability from which the child may never recover—
the capacity for mentalization is never fully established, leaving
the child vulnerable to later trauma and unable to cope fully with
attachment relationships (e.g. Rutter and O’Connor, 2004). More
importantly, trauma, by activating attachment will often decouple
the capacity for mentalization. This of course is further exacerbated
when the trauma is attachment trauma.
Implications of attachment-mentalization reciprocity

The apparently reciprocal relationship of mentalization and
attachment may at first appear to contradict our earlier assump-
tion that mentalization and secure attachment are positively
correlated. Further scrutiny suggests greater complexity but no
inconsistency. It is possible, taking an evolutionary perspective,
that the parent’s capacity to mentalize the infant or child serves
to reduce the child’s experienced need to monitor the parent
for trustworthiness. This relaxation of the interpersonal barrier
facilitates the emergence of a strong attachment bond. While at
first sight the precocious emergence of theory of mind in chil-
dren who were securely attached in infancy (e.g. Meins, 1997)
may seem inconsistent with the inverse relationship between
attachment and mentalization, it is to be expected that in indi-
viduals whose attachment is secure, there are likely to be fewer
calls over time for the activation of the attachment system. This
in turn, given the inhibitory effect of the activation of the attach-
ment system on mentalization related brain activity, might
account for the precocious development of mentalization.
The capacity for mentalization in the context of attachment is likely

to be in certain respects independent of the capacity to mentalize
about interpersonal experiences outside the attachment context
(Fonagy and Target, 1997). Our specific measure of mentalisation
in the attachment context, reflective function (Fonagy et al.,

1998) is predictive of behavioural outcomes that other measures
of mentalization do not correlate with. For example, in a quasi-
longitudinal study based on interviews and chart reviews with
young adults some of whom had suffered trauma, we found that the
impact of trauma on mentalization in attachment contexts mediated
outcome measured as the quality of adult romantic relationships but
mentalization measured independently of the attachment context
using the Reading the Mind in the Eyes test did not (Fonagy et al.,
2003a). It seems that measuring mentalization in the context of
attachment might measure a unique aspect of social behaviour.
The key consideration is probably that securely attached children
do not need to activate their attachment system as often and have
greater opportunity to ‘practice’ mentalization in the context of the
child-caregiver relationship. Belsky’s (1999b) evolutionary model of
attachment classification is helpful here. When resources are scarce
and insecure attachment strategies are possibly most adaptive,
children probably need to monitor the unpredictable caregivers’
mental states quite carefully, are forced to find alternative social
contexts to acquire social cognitive capacities, and thus they
deprive themselves of some developmental learning opportunities
of understanding minds in abstract ways independent of physical
reality.
The development of an agentive self: The social acquisition

of social cognition
An overview of the model of contingent mirroring
The evolutionary neurobiological speculations above imply that chil-
dren’s care giving environments play a key role in their development
as social beings. How are we to conceive of the actions of these envi-
ronmental influences? Our model relies on the child’s inbuilt capac-
ity to detect aspects of his world that react contingently to his own
actions. In his first months the child begins to understand that he is
a physical agent whose actions can bring about changes in bodies
with which he has immediate physical contact (Leslie, 1994). Devel-
oping alongside this is the child’s understanding of himself as a
social agent. Through interactions with the caregiver (from birth) the
baby learns that his behaviour affects his caregiver’s behaviour and
emotions (Neisser, 1988). Both these early forms of self-awareness
probably evolve through the workings of an innate contingency
detection mechanism that enables the infant to analyse the probabil-
ity of causal links between his actions and stimulus events (Watson,
1994). The child’s initial preoccupation with perfectly response-con-
tingent stimulation (provided by the proprioceptive sensory feedback
that the self’s actions always generate) allows him to differentiate his
agentive self as a separate entity in the environment and to construct
a primary representation of the bodily self.
At about 3–4 months, infants switch from preferring perfect con-

tingency to preferring high-but-imperfect contingencies thereafter
(Bahrick and Watson, 1985)—the level of contingency that is char-
acteristic of an attuned caregiver’s empathic mirroring responses
to the infant’s displays of emotion. Repeated experience of such
affect-reflective caregiver reactions is essential for the infant to
begin to be able to differentiate his/her internal self-states: a proc-
ess we termed ‘social biofeedback’ (Gergely and Watson, 1996).
A congenial and secure attachment relationship can vitally con-
tribute to the emergence of early mentalization capacities allowing
the infant to ‘discover’ or ‘find’ his/her psychological self in the
social world (Gergely, 2001). The discovery of the representational
or psychological self (what we may think of as full mentalization)
is probably based in the same mechanism coming to understand
and regulate emotion and be securely attached.
Let us take the development of an understanding of affects as an

example. We assume that at first infants are not introspectively aware
of different emotion states. Rather, their representations of these emo-
tions are primarily based on stimuli received from the external world.
Babies learn to differentiate the internal patterns of physiological and
visceral stimulation that accompany different emotions by observ-
ing their caregivers’ facial or vocal mirroring responses to these (e.g.
Legerstee and Varghese, 2001; e.g. Mitchell, 1993). Firstly, the baby
comes to associate his control over the parents’ mirroring displays
with the resulting improvement in his emotional state, leading, even-
tually, to an experience of the self as a regulating agent. Secondly,
the establishment of a second order representation of affect states
creates the basis for affect regulation and impulse control: affects
can be manipulated and discharged internally as well as through
action, they can also be experienced as something recognizable and
hence shared. If the parent’s affect expressions are not contingent on
the infant’s affect this will undermine the appropriate labelling of
internal states which may, in turn, remain confusing, experienced as
unsymbolized and hard to regulate.
If the capacity to understand and regulate emotion is to develop
two conditions need to be met: (a) reasonable congruency of mirroring
whereby the caregiver accurately matches the infant’s mental state
and (b) ‘markedness’ of the mirroring, whereby the caregiver is able
to express an affect while indicating that she is not expressing her own
feelings (Gergely and Watson, 1999). Consequently two difficulties
may arise: (a) in the case of incongruent mirroring the infant’s
representation of internal state will not correspond to a constitutional
self state (nothing real) and a predisposition to a narcissistic structure
might be established perhaps analogous to Winnicott’s notion of
‘false-self’ (Winnicott, 1965) and (b) in cases of un-marked mirroring
the caregiver’s expression may be seen as externalisation of the
infant’s experience and a predisposition to experiencing emotion
through other people (as in a borderline personality structure) might
be established (Fonagy et al., 2002). An expression congruent with the
baby’s state, but lacking markedness, may overwhelm the infant. It is
felt to be the parent’s own real emotion, making the child’s experience
seem contagious and escalating rather than regulating his state.
The secure caregiver soothes by combining mirroring with a
display that is incompatible with the child’s feelings (thus implying
contact with distance and coping). This formulation of sensitivity has
much in common with Bion’s (1962) notion of the role of the mother’s
capacity to mentally “contain” the affect state that feels intolerable
to the baby, and respond in a manner that acknowledges the child’s
mental state, yet serves to modulate unmanageable feelings (see
below). Well-regulated affect in the infant parent couple is thought to
be internalized by the child to form the bases of a secure attachment
bond and internal working model (Sroufe, 1996). Ratings of the
quality of reflective function of each parent during pregnancy were
found independently to predict the child’s later security of attachment
in the London Parent-Child Project (Fonagy et al., 1992). However,
this finding is somewhat limited since only the AAI RF measure was
examined in relation to infant attachment (Fonagy et al., 1991; Fonagy

et al., 1994). Thus the parents’ capacity to mentalize was measured in
relation to their own childhood and their capacity to do likewise with
their child had been assumed rather than observed.
The stages of acquiring mentalization (a Theory of Mind)

The emergence of mentalizing function follows a well-researched
developmental line that identifies ‘fixation points’:
(a) During the second half of the first year of life, the child begins
to construct causal relations that connect actions to their agents
on the one hand and to the world on the other. Infants around 9
months begin to look at actions in terms of the actor’s underlying
intentions (Baldwin et al., 2001). This is the beginning of their
understanding of themselves as teleological agents who can
choose the most efficient way to bring about a goal from a range
of alternatives (Csibra and Gergely, 1998). At this stage agency is
understood in terms of purely physical actions and constraints.
Infants expect actors to behave rationally, given physically
apparent goal states and the physical constraints of the situation
that are already understood by the infant (Gergely and Csibra,
2003). There is no implication here that the infant has an idea
about the mental state of the object. He/she is simply judging
rational behaviour in terms of the physical constraints that prevail
and that which is obvious in terms of the physical end state which
the object has reached. We have suggested a connection between
the focus on understanding actions in terms of their physical as
opposed to mental outcomes (a teleological stance) and the mode
of experience of agency that we often see in the self-destructive
acts of individuals with borderline personality disorder (BPD)
(Fonagy et al., 2000). Thus slight changes in the physical world can
trigger elaborate conclusions concerning states of mind. Patients
frequently cannot accept anything other than a modification in the
realm of the physical as a true index of the intentions of the other.
(b) During the second year, children develop a mentalistic
understanding of agency. They understand that they and others
are intentional agents whose actions are caused by prior states of
mind such as desires (Wellman and Phillips, 2000) and that their
actions can bring about changes in minds as well as bodies (e.g. by
pointing Corkum and Moore, 1995). Shared imaginative play is

enjoyable and exciting for toddlers and may be the basis for the
development of collaborative, co-operative skills (Brown et al.,
1996). Fifteen months old children can distinguish between an
action’s intended goal and its accidental consequences (Meltzoff,
1995). At this stage the capacity for emotion regulation comes
to reflect the prior and current relationship with the primary
caregiver (Calkins and Johnson, 1998). Most importantly, children
begin to acquire an internal state language and the ability to
reason non-egocentrically about feelings and desires in others
(Repacholi and Gopnik, 1997). Paradoxically, this becomes evident
not only through the increase in joint goal directed activity but
also through teasing and provocation of younger siblings (Dunn,
1988). However, functional awareness of minds does not yet
enable the child to represent mental states independent of physical
reality and therefore the distinction between internal and external,
appearance and reality is not yet fully achieved (Flavell and Miller,
1998), making internal reality sometimes far more compelling
and at other times inconsequential relative to an awareness of
the physical world. We have referred to these states as psychic
equivalence and pretend modes respectively (see below).
(c) Around three to four years of age, understanding of agency in
terms of mental causation begins to include the representation of
epistemic mind states (beliefs). The young child thus understands
himself as a representational agent, he knows that people do
not always feel what they appear to feel, they show emotional
reactions to an event that are influenced by their current mood
or even by earlier emotional experiences which were linked to
similar events (Flavell and Miller, 1998). The preschool child’s
mental states are representational in nature (Wellman, 1990). This
transforms their social interactions so their understanding of
emotions comes to be associated with empathic behaviour (Zahn-
Waxler et al., 1992) and more positive peer relations (Dunn and
Cutting, 1999). Most children come to understand that human
behaviour can be influenced by transient mental states (such as
thoughts and feelings) as well as by stable characteristics (such as
personality or capability) and this creates the basis for a structure
to underpin an emerging self-concept (Flavell, 1999). They also
come to attribute mistaken beliefs to themselves and to others,
which enriches their repertoire of social interaction with tricks,
jokes and deception (Sodian and Frith, 1992; Sodian et al., 1992).
A meta-analytic review of in excess of 500 tests showed that by
and large children younger than three fail the false-belief task and
as the child’s age increases they are increasingly likely to pass
(Wellman et al., 2001), suggesting that mentalizing abilities take
a quantum leap forward around age four. The early acquisition of
false belief is associated with more elaborate capacity to pretend
play (Taylor and Carlson, 1997), greater connectedness in
conversation (Slomkowski and Dunn, 1996) and teacher rating of
social competence (Lalonde and Chandler, 1995). Notably, also at
this time the child shifts from a preference for playing with adults
to playing with peers (Dunn, 1994). We understand this shift as
bringing to a close the time when mentalization was acquired
through the agency of an adult mind and opening a lifelong phase
of seeking to enhance the capacity to understand self and others
in mental state terms through linking with individuals who share
one’s interest and humour.
(d) In the sixth year, we see related advances such as the child’s ability
to relate memories of his intentional activities and experiences
into a coherent causal-temporal organisation, leading to the
establishment of the temporally extended self (Povinelli and
Eddy, 1995). Full experience of agency in social interaction can
emerge only when actions of the self and other can be understood
as initiated and guided by assumptions concerning the emotions,
desires and beliefs of both. Further theory of mind skills that
become part of the child’s repertoire at this stage include second
order theory of mind (the capacity to understand mistaken
beliefs about beliefs), mixed emotions (e.g. understanding being
in a conflict), the way expectations or biases might influence
the interpretation of ambiguous events, and the capacity for
subtle forms of social deceptions (e.g. white lies). As these skills
are acquired the need for physical violence begins to decline
(Tremblay, 2000; Tremblay et al., 1999) and relational aggression
increases (Cote et al., 2002; Nagin and Tremblay, 2001).
Relationship influences on the acquisition of mentalization

Our claim that attachment relationships are vital to the normal
acquisition of mentalization challenges nativist assumptions. The
nativistic position assumes that children’s social environments can
trigger but cannot determine the development of theory of mind

(Baron-Cohen, 1995; Leslie, 1994). There is some evidence that the
timetable of theory of mind development is fixed and universal (Avis
and Harris, 1991). However, the bulk of the evidence is inconsistent
with the assumption of a universal timetable. More recent studies
find ample evidence for substantial cultural differences, not just in
the rate of emergence of theory of mind skills but also the order
of their emergence (Wellman et al., 2001). Many findings suggest
that the nature of family interactions, the quality of parental
control (e.g. Vinden, 2001), parental discourse about emotions
(e.g. Meins et al., 2002), the depth of parental discussion involving
affect (Dunn et al., 1991) and parents’ beliefs about parenting (e.g.
Ruffman et al., 1999) are all strongly associated with the child’s
acquisition of mentalization. The role of family members in this
developmental achievement is further highlighted by the finding
that the presence of older siblings in the family appears to improve
the child’s performance on a range of false-belief tasks (e.g. Ruffman
et al., 1998). In sum, the ability to give meaning to psychological
experiences evolves as a result of our discovery of the mind behind
others’ actions, which develops optimally in a relatively safe and
secure social context.
Much that is known about correlates and predictors of early
ToM development is consistent with the assumption that the
attachment relationship plays an important role in the acquisition
of mentalization. For example, family-wide talk about negative
emotions, often precipitated by the child’s own emotions, predicts
later success on tests of emotion understanding (Dunn and Brown,
2001). The capacity to reflect on intense emotion is a marker of
secure attachment (Sroufe, 1996). Similar considerations may explain
the finding that the number of references to thoughts and beliefs
and the relationship specificity of children’s real-life accounts of
negative emotions correlate with early ToM acquisition (false belief
performance) (Hughes and Dunn, 2002). Similarly, parents whose
disciplinary strategies focus on mental states (e.g. a victim’s feelings,
or the non-intentional nature of transgressions) have children who
succeed in ToM tasks earlier (e.g. Charman et al., 2002)
Relationship influences on the development of mentalization are
probably limited and specific rather than broad and unqualified.
Three key limitations to simplistic linking of mentalization and
positive relationship quality should be kept in mind (Hughes and
Leekham, 2004): (1) The possession of the capacity to mentalize is

neither a guarantee that it will be used to serve pro-social ends,
nor a guarantee of protection from malign interpersonal influence.
The acquisition of the capacity to mentalize may, for example, open
the door to more malicious teasing (e.g. Dunn, 1988), increase the
individual’s sensitivity to relational aggression (Cutting and Dunn,
2002), or even mean that they take a lead in bullying others (Sutton
et al., 1999). (2) While, as we have seen, broadly, positive emotion
promotes the emergence of mentalization (Dunn, 1999), negative
emotion can be an equally powerful facilitator. For example, children
engage in deception that is indicative of mentalizing in emotionally
charged conflict situations (Newton et al., 2000). (3) The impact
of relationships on the development of mentalization is probably
highly complex involving numerous aspects of relational influences
(e.g. quality of language of mental states, quality of emotional
interaction, themes of discourse, amount of shared pretend play,
negotiations of conflict, humour in the family, discourse with peers,
etc) probably affecting several components of the mentalizing
function (joint attention, understanding of affect states, capacity
for emotion regulation, language competence, competence with
specific grammatical structures such as sentential complements, etc.)
(Hughes and Leekham, 2004).
Subjectivity before mentalization

How does the child experience subjectivity before he recognises
that internal states are representations of reality? In describing the
normal development of mentalizing in the child of two to five years
(Fonagy and Target, 1996; Target and Fonagy, 1996), we suggest that
there is a transition from a split mode of experience to mentalization.
We hypothesize that the very young child equates the internal world
with the external. What exists in the mind must exist out there and
what exists out there must also exist in the mind. At this stage there
is no room yet for alternative perspectives. “How I see it is how it
is”. The toddler’s or young pre-school child’s insistence that “there
is a Tiger under the bed” is not allayed by parental reassurance.
This ‘psychic equivalence’, as a mode of experiencing the internal
world, can cause intense distress, since the experience of a fantasy
as potentially real can be terrifying. The acquisition of a sense of
pretend in relation to mental states is therefore essential. While

playing, the child knows that internal experience may not reflect
external reality (e.g. Bartsch and Wellman, 1989; Dias and Harris,
1990), but then the internal state is thought to have no implications
for the outside world (“pretend mode”).
Normally at around four years old, the child integrates these
modes to arrive at mentalization, or reflective mode, in which men-
tal states can be experienced as representations. Inner and outer real-
ity can then be seen as linked, yet differing in important ways, and
no longer have to be either equated or dissociated from each other
(Gopnik, 1993). The child discovers that ‘seeing-leads-to-knowing’;
if you have seen something in a box, you know something about
what’s in the box (Pratt and Bryant, 1990). They can begin to work
out from gaze direction what a person is thinking about, thus making
use of the eyes of another person to make a mentalistic interpre-
tation (Baron-Cohen and Cross, 1992). There are, however, circum-
stances under which pre-mentalistic forms of subjectivity re-emerge
to dominate social cognition years after the acquisition of full men-
talization. We shall consider these in section 5.
Mentalization normally comes about through the child’s experi-
ence of his mental states being reflected on, prototypically through
secure play with a parent or older child, which facilitates integra-
tion of the pretend and psychic equivalence modes. This interper-
sonal process is perhaps an elaboration of the complex mirroring the
parent offered earlier. In playfulness, the caregiver gives the child’s
ideas and feelings (when he is “only pretending”) a link with reality,
by indicating an alternative perspective outside the child’s mind.
The parent or older child also shows that reality may be distorted
by acting upon it in playful ways, and through this playfulness a
pretend but real mental experience may be introduced.
If the child’s capacity to perceive mental states in himself and oth-
ers depends on his observation of the mental world of his caregiver,
clearly children require a number of adults with an interest in their
mental state, who can be trusted (i.e. with whom an attachment
bond exists), to support the development of their subjectivity from
a pre-mentalizing to a fully mentalizing mode. In this regard, in
past initiatives, perhaps we have placed too much emphasis on par-
ents (particularly mothers). It follows from the evolutionary model
presented in section 2 and here that the child’s brain is experience
expectant from a range of benign adults willing to take the peda-

gogic stance towards their subjectivity. Thus, teachers, neighbours,
older siblings as well as parental figures could play important roles
in optimizing the child’s capacity for mentalization. Children can
perceive and conceive of their mental states to the extent that the
behaviour of those around them has implied that they have them.
This can happen through an almost unlimited set of methods rang-
ing from shared pretend playing with the child (empirically shown
to be associated with early mentalization), and many ordinary inter-
actions (such as conversations and peer interaction) will also involve
shared thinking about an idea.
Disorganized attachment and the unmentalized (alien) self

In children whose attachment is disorganized mentalization may
be evident, but it does not play the positive role in self-organization
that it does in securely or even in insecurely attached children. The
child with disorganised attachment is forced to look not for the
representation of his own mental states in the mind of the other,
but the mental states of that other which threaten to undermine his
agentive sense of self. These mental states can create an alien presence
within his self-representation, so unbearable that his attachment
behaviour becomes focused on re-externalising these parts of the
self onto attachment figures, rather than on the internalization of a
capacity for containment of affects and other intentional states.
Disorganized infants, even if interpersonally perceptive, fail to
integrate this emotional awareness with their self-organization. There
may be a number of linked reasons for this: a) the child needs to use
disproportionate resources to understand the parent’s behaviour,
at the expense of reflecting on self-states; b) the caregiver of the
disorganized infant is likely to be less contingent in responding to
the infant’s self-state, and further to show systematic biases in her
perception and reflection of his state; c) the mental state of the caregiver
of the disorganized infant may evoke intense anxiety through
either frightening or fearful behaviour towards the child, including
inexplicable fear of the child himself. These factors combine, perhaps,
to make children whose attachment system is disorganized become
keen readers of the caregiver’s mind under certain circumstances,
but (we suggest) poor readers of their own mental states.
Trauma related loss of the capacity to conceive

of mental states
Adults with a history of childhood attachment trauma often seem
unable to understand how others think or feel. We have hypothesized
that childhood maltreatment undermines mentalization. When com-
bined with the enfeebled affect representation, poor affect control
systems and disorganised self structure that can result from a deeply
insecure early environment, trauma has profound effects: (a) It inhib-
its playfulness which is essential for the adequate unfolding of the
interpersonal interpretive function (Dunn et al., 2000); (b) it interferes
directly with affect regulation and attentional control systems (Arntz
et al., 2000); (c) most importantly, in vulnerable individuals, it can lead
to an unconsciously motivated failure of mentalization. This failure is
a defensive adaptive manoeuvre: the child seeks to protect himself
from the frankly malevolent and dangerous states of mind of the
abuser by decoupling his capacity to conceive of mental states, at
least in attachment contexts (Fonagy, 1991). (d) We believe that adult
social functioning is impaired by childhood and adolescent adver-
sity to the extent that adversity causes a breakdown of attachment
related mentalization (Fonagy et al., 2003a). There is considerable evi-
dence that maltreated children have specific mentalization deficits and
that individuals with BPD are poor at mentalization following severe
experiences of maltreatment (Fonagy et al., 1996). Children cannot
learn words for feelings (Beeghly and Cicchetti, 1994), and adults have
more difficulty recognising facial expressions, the more severe their
childhood maltreatment (Fonagy et al., 2003a). What is the clinical
picture like when trauma brings about a partial and temporary col-
lapse of mentalization? We observed an apparent lack of imagination
about the mental world of others, a naiveté or cluelessness about what
others think or feel that can verge on confusion, and a correspond-
ing absence of insight into the way that the traumatized person’s own
mind works.
Many maltreated children grow up into adequately function-
ing adults. While maltreatment places children at increased risk for
developing psychopathology, only a small proportion will prospec-
tively need mental health services (Widom, 1999). It is possible that
early maltreatment reduces the individual’s opportunity fully to
develop mentalizing skills, leaving them with inadequate capacities
to identify and avoid risks for further interpersonal trauma. In

dysfunctional attachment contexts, particularly when children are
victims of abuse, they may learn to interpret parental initiation of
communicative attention-directing behaviours as a cue that poten-
tially harmful interactions are likely to follow. In consequence,
they may defensively inhibit the mentalistic interpretation of such
cues; this may finally lead to the defensive disruption of their own
metacognitive monitoring procedures in all subsequent intimate
relationships (Fonagy et al., 2003b).
The equation of inner and outer

The collapse of mentalization in the face of trauma entails a loss of
awareness of the relationship between internal and external reality
(Fonagy and Target, 2000). Modes of representing the internal world
re-emerge that developmentally precede an awareness that thoughts,
feelings and wishes are part of the mind. The 2–3 year old as we saw,
not yet experiencing his mind as truly representational, assumes in
the mode of psychic equivalence that what he thinks also exists in the
physical world. Post-traumatic subjective experience (the flashback)
is similarly compelling, resistant to argument and feels dangerous
until it becomes mentalized. Often survivors of trauma simply refuse
to think about their experience because thinking about it means reliv-
ing it. Aspects of the notion of psychic equivalence evidently overlap
with descriptions of paranoid-schizoid forms of thinking particularly
as formulated by Wilfred Bion in the ‘Elements of Psychoanalysis’ (Bion,
1963), and symbolic equation as formulated by Hanna Segal (1957).
Separation from reality

As we saw, the pretend mode is a developmental complement to
psychic equivalence. Not yet able to conceive of internal experience
as mental, the child’s fantasies are dramatically divided off from
the external world. Small children cannot simultaneously pretend
(even though they know it is not real) and engage with normal
reality; asking them if their pretend gun is a gun or a stick spoils
the game. Following trauma and the constriction of mentalization
we see the intrusion of the pretend mode, particularly in dissocia-
tive experiences. In dissociated thinking, nothing can be linked to
anything—the principle of the ‘pretend mode’, in which fantasy is

cut off from the real world, is extended so that nothing has impli-
cations (Fonagy and Target, 2000). Patients report ‘blanking out’,
‘clamming up’ or remembering their traumatic experiences only
in dreams. The most characteristic feature of traumatization is the
oscillation between psychic equivalence and pretend modes of expe-
riencing the internal world.
‘I believe it when I see it’

A third pre-mentalistic aspect of psychic reality is the re-emergence
of a teleological mode of thought. This mode of understanding the
world antedates even language. Infants as young as 9 months are
able to attribute goals to people and to objects that seem to behave
purposefully, but these goals are not yet truly mental, they are tied
to what is observable. The return of this teleological mode of thought
is perhaps the most painful aspect of a subjectivity stripped of
mentalization.
Following trauma, verbal reassurance means little. Interacting
with others at a mental level has been replaced by attempts at alter-
ing thoughts and feelings through action. Trauma, certainly physical
and sexual abuse, is by definition teleological. It is hardly surprising
that the victim feels that the mind of another can only be altered in
this same mode, through a physical act, threat or seduction. Follow-
ing trauma we all need physical assurances of security.
The impact of attachment trauma on mentalization:

The hyperactivation of attachment
Attachment is normally the ideal ‘training ground’ for the develop-
ment of mentalization because it is safe and non-competitive. This
biological configuration, which is so adaptive in the context of nor-
mal development, becomes immensely destructive in the presence of
attachment trauma. Attachment trauma hyperactivates the attachment
system because the person to whom the child looks for reassurance
and protection is the one causing fear. The devastating psychic impact
of attachment trauma is the combined result of the inhibition of men-
talization by attachment and the hyperactivation of the attachment
system by trauma. This context demands extraordinary mentalizing
capacities from the child, yet the hyperactivation of the attachment

system will have inhibited whatever limited capacity he has.
The coincidence of trauma and attachment creates a biological
vicious cycle. Trauma normally leads a child to try to get close to
the attachment figure. Where the child depends on an attachment
figure who maltreats them, there is a risk of an escalating sequence
of further maltreatment, increased distress and an ever-greater inner
need for the attachment figure. The inhibition of mentalization in
a traumatising, hyperactivated attachment relationship is always
likely to lead to a prementalistic psychic reality, largely split into
psychic equivalence and pretend modes. Because the memory of the
trauma feels currently real there is a constant danger of re-trauma-
tisation from inside. The traumatised child often begins to fear his
own mind. The inhibition of mentalization is also clearly an intra-
psychic adaptation to traumatic attachment. The frankly malevolent
mental state of the abuser terrifies the helpless child. The parents’
abuse undermines the child’s capacity to mentalize, because it is no
longer safe for the child, for example, to think about wishing, if this
implies recognising his parent’s wish to harm him. Because he can-
not use the model of the other to understand himself, diffusion of
identity and dissociation often follows.
The impact of attachment trauma on mentalization:

The biology of being frazzled
The impact of trauma on mentalization is intermittent. As above,
sometimes mentalization disappears because an attachment rela-
tionship intensifies. At other times, being stressed (for example
touching on a sensitive issue) can trigger what feel like wild, unjus-
tified reactions. Six years ago, in a hallmark paper entitled “The biol-
ogy of being frazzled”, Amy Arnsten (1998) explained why (see also
Arnsten et al., 1999; Mayes, 2000). At the risk of simplifying highly
complex pioneering neuroscientific work, Arnsten’s Dual Arousal
Systems Model delineates two complementary, independent arousal
systems: the prefrontal and posterior cortical and subcortical sys-
tems. The system that activates frontal and pre-frontal regions inhib-
its the second arousal system that normally ‘kicks in’ only at quite
high levels of arousal, when pre-frontal activity goes “offline” and
posterior cortical and subcortical functions (e.g. more automatic or
motor functions) take over.
The switch-point between the two arousal systems may be

shifted by childhood trauma. Undoubtedly, as mentalization
is located in the prefrontal cortex, this accounts for some of
the inhibition of mentalization in individuals with attachment
trauma, in response to increases in arousal that would not be
high enough to inhibit mentalization in most of us. Anticipat-
ing some of the clinical implications of our thinking, in the
light of this phenomenon it is important to monitor the trau-
matised patient’s readiness to hear comments about thoughts
and feelings. As arousal increases, in part in response to
interpretative work, traumatised patients cannot process talk
about their minds. Interpretations of the transference at these
times, however accurate they might be, are likely to be way
beyond the capacity of the patient to hear. The clinical priority
has to be work to reduce arousal so that the patient can again
think of other perspectives (mentalize). Mentalization-based
treatment—practice.
The consequences for psychodynamic therapeutic technique of this

reframing of BPD as a failure to develop a robust self-structure are
considerable particularly as many practitioners may currently prac-
tice in a way that assumes cognitive and emotional capacities in
patients that they simply don’t have. In BPD mentalization is enfee-
bled and almost absent in moments of arousal and at these times
actions represent the maladaptive restoration of a rudimentary men-
talizing function chiefly aimed at creating the illusion of self coher-
ence. Actions become a desperate attempt to protect the fragile self
against the onslaught of overwhelming threat of disintegration or
persecution from within, often quite innocently triggered by an other
(thus the reaction may often seem disproportionate to the provoca-
tion). The experience of humiliation or threat, which the individual
tries to contain within the alien part of the self, comes to represent
an existential threat and is therefore abruptly externalised. If it is
not, suicide may become the only solution in an attempt to save the
self. But if the alien self is placed outside and perceived as part of the
other, it is disowned and, if it cannot be controlled via a coercive inter-
action, may be seen as possible to destroy once and for all through
verbal attacks or violence. So the other is essential not just to create
the illusion of coherence but also to be there to be destroyed. This
re-equilibrates the individual. In this sense attacks on the other are a
gesture of hope, a wish for a new beginning, a desperate attempt to

restore a relationship, even if in reality they may have a tragic end.
This is why borderline patients require rather than enjoy relation-
ships. Relationships are necessary to stabilise the self-structure but
are also the source of greatest vulnerability because in the absence of
the other, when the relationships break down, or if the other shows
independence, the alien self returns to wreak havoc (persecute from
within) and to destabilise the self-structure. Vulnerability is greatest
in the context of attachment relationships because the activation of
attachment relationships representations (Internal Working Models,
Bowlby, 1973) are most likely to have been traumatic and thus to be
least imbued with mental state representations.
Core techniques
The focus in MBT is on stabilising the sense of self and we have
defined some core underpinning techniques to be used in the con-
text of group and individual therapy. In order to implement these
effectively greater activity on the part of the therapist is required
with more collaboration and openness than is implied in the clas-
sical analytic stance. The ‘blank analytic screen’ has no role in the
treatment of these patients. In psychodynamic treatment of border-
line patients, the therapist has to become what the patient needs him
to be, the vehicle for the alien self, the carrier of alternative but not
destabilising perspectives. And yet to become the alien self is to be
lost to the patient as a provider of different perspectives and there-
fore of no help to him. The therapist must aim to achieve a state of
equipoise between the two—allowing himself to do as required yet
trying to retain in his mind as clear and coherent an image of his
own state of mind along side that of the patients as is possible to
achieve. This is what we have called the mentalizing stance of the
therapist (Bateman and Fonagy, 2003) .
Enhancing mentalization
A therapist needs to maintain a mentalizing stance in order to help
a patient develop a capacity to mentalize. Self-directed mentalistic
questions are a useful way of ensuring that a focus on mentalizing is
maintained. Why is the patient saying this now? Why is the patient
behaving like this? What might I have done that explains the patient’s
state? Why am I feeling as I do now? What has happened recently in
the therapy or in our relationship that may justify the current state?
These are typical questions that the therapist will be asking himself
within the mentalizing therapeutic stance and is perfectly at liberty
to ask them out loud in a spirit of enquiry. This approach pervades
the entire treatment setting. So, in group therapy techniques focus
on encouraging patients to consider the mental states and motives
of other members as well as their own—‘Why do you think that she
is feeling as she does’.
Crucially, the therapist is not looking for complex ‘unconscious’
reasons, rather the answers that common sense or folk psychology
would suggest to most reasonable people. Folk psychology is the
natural and intuitive understanding of human action on the basis of
mental states that we employ ubiquitously in our interactions with
each other as well as in our efforts to understand ourselves. Folk psy-
chology includes the various mental concepts we naturally employ,
such as desires, feelings, goals, beliefs. But folk psychology is much
more than that; it encompasses the narrative structures in which
these everyday psychological concepts are embedded, namely, the
sequential stories that compose an autobiographical sense of self.
In this broad sense, as Bruner (1990) aptly put it, folk psychology
“is a culture’s account of what makes human beings tick” (p. 13).
We believe that even as professional clinicians, we rely far more on
folk psychology than scientific psychology in our interactions with
patients (Allen and Fonagy, 2002).
Focusing the therapist’s understanding of his or her interactions
with the patient on the patient’s mental state will allow the ther-
apist to link external events, however small, to powerful internal
states which are otherwise experienced by the patient as inexpli-
cable, uncontrollable and meaningless. A focus on psychological
process and the ‘here and now’ rather than on mental content in
the present and past is implicit in this approach. An important indi-
cator of underlying process and the ‘here-and now’ is the manifest
affect which is specifically targeted, identified, and explored within
an interpersonal context in MBT. The challenge for the professional
working with the patient is to maintain a mentalizing therapeutic
stance in the context of countertransference responses that may
provoke the therapist to react rather than to think. Understanding
within an interpersonal context why the situation arose in the first

place, why such an externalisation became necessary, is the likely
immediate solution to this challenge.
Interpretation and bearing in mind the deficits

Bearing in mind the limited processing capacities of borderline
patients in relation to attachment issues, patients cannot be assumed
to have a capacity to work with conflict, to express feelings through
verbalisation, to use metaphor, to resist actions, and to reflect on
content, all of which form part of standard psychoanalytic process.
These attributes depend on a stable self-structure and ability to form
secondary (symbolic) and perhaps tertiary representations (e.g. your
feelings about my thoughts about your wishes) which buffer feel-
ings, explain ideas, and give context and meaning to interpersonal
and intrapsychic process. Borderline patients’ enfeebled mentalizing
capacity and emergence of psychic equivalence means that feelings,
fantasies, thoughts, and desires are experienced with considerable
force because they cannot be symbolised, be held in a state of uncer-
tainty, and given secondary representation with meaning. Under
these circumstances the use of metaphor and the interpretation of
conflict is more likely to induce bewilderment and incomprehension
than to heighten the underlying meaning of the discourse and so the
use of these techniques is minimised in MBT.
Yet the deficit in the capacity for mentalization can be masked by
an apparent intellectual ability that lures therapists, especially dur-
ing assessment, into believing that borderline patients understand
the complexity of alternative perspectives, accept uncertainty, and
can consider difference. Sadly, these assessments are made before the
therapist has become an attachment figure for the patient and deficits
seen in BPD are to a large measure specific to attachment relation-
ships. Once the attachment system is activated by the reliability and
safety of the therapeutic setting, the patient’s mentalization is likely
to deteriorate and his or her deficits become more evident. Most obvi-
ous is the apparent lack of constancy, what may be described as the
paradoxically ephemeral nature of apparently deeply held beliefs. In
fact at one moment a borderline patient may hold a particular view
and yet at another time maintain the opposite is true and continuity
of feeling, belief, wish, and desire may be lost between therapeutic
sessions. Whilst in some patients this would lead to conflict because

two ideas, even if opposing, can be held in mind at the same time,
contemplating genuine alternatives is often experienced as toxic to
the self-structure of the borderline patient and so is avoided. Here
lies the root of what is described as ‘black and white thinking’ in the
CBT literature and is referred to as ‘splitting’ by psychoanalysts. Con-
stancy of belief and consistent experience of others elude the border-
line patient, resulting in idealisation at one moment and denigration
the next. The task of the therapist is to establish continuity between
sessions, to link different aspects of a multi-component therapy, to
help the patient recognise the discontinuity, and to scaffold the ses-
sions without holding the patient to account for sudden switches in
belief, feeling, and desire. The borderline patient does not lie but is
unable to hold in mind different representations and their accompa-
nying affects at any one time. All are equally true, and the therapist
must accept the balance between opposing perspectives and work
with both even though they appear contradictory.
Use of transference
In many respects our approach to transference owes much to that
of Otto Kernberg, John Clarkin, Frank Yeomans and their group
(Kernberg, Clarkin, and Yeomans, 2002) (Clarkin, Yeomans, and
Kernberg, 1998) (Clarkin, Foelsch, and Kernberg, 1996) (Clarkin
et al., 1999) (Kernberg, 1992). We clearly share a dynamic approach
to the understanding of mind and a therapeutic approach that
stresses understanding, interpretation and a focus on affect. How-
ever, there are also important differences and nowhere are these
differences more clear cut than in our approach to the transference.
In Transference Focussed Psychotherapy (TFP) patients are seen as
re-establishing dyadic relations with their therapists that reflect rudi-
mentary representations of self-other relationships of the past (so
called part-object relationships). Thus TFP considers the externalisa-
tion of these self-object-affect triads to be at the heart of therapeutic
interventions. For the MBT model, the role-relationships established
by the patient through the transference relationship are considered
preliminary to the externalisation of the parts of the self the patient
wishes to disown. In order to achieve a state of affairs where the
alien part of the self is experienced as outside rather than within,
the patient needs to create a relationship with the therapist through

which this externalisation may be achieved. Once it is achieved, and
unwanted parts of the self are felt to be reassuringly outside rather
than within, the patient has no interest in the relationship with the
therapist and may in fact wish to repudiate it totally. Focussing the
patient’s attention on the relationship can be felt by them as under-
mining their attempts at separating from the disowned part of them-
selves and consequently be counterproductive.
It is therefore important that exploration within the transfer-
ence is built up over time and there is a de-emphasis on recon-
struction. Transference distortion is used as a demonstration of
alternative perspectives—a contrast between the patient’s percep-
tion of the therapist or of others in the group and that of others.
At first, reference to different perspectives and internal influences
that may be driving them should be simple and to the point. Both
patient and therapist have to start from a position of ‘not know-
ing’ but trying to understand. Direct statements about the rela-
tionship between the patient and therapist may stimulate anxiety
and be experienced as abusive. Only towards the middle or end
of therapy when stable internal representations have been estab-
lished is it likely to be safe to use the ‘heat’ of the relationship
between patient and therapist in a more direct way to explore dif-
ferent perspectives.
Transference is not seen as the primary vehicle for change in the
patient’s representational system. We are not suggesting therapists
avoid transference, which is essential for effective treatment, but that
its use is incremental and moves from distance to near depending on
the patient’s level of anxiety. Most patients with severe BPD rap-
idly become anxious in intimate situations and too sharp a focus on
the patient/therapist relationship leads to panic that is manifested
as powerful and, sometimes uncontrollable, expressions of feeling.
This leads to a dissociative experience and a sense that their own
experience is invalid. If such transference interpretations are made
the patient is immediately thrown into a pretend mode and gradu-
ally patient and therapist may elaborate a world, which however
detailed and complex, has little experiential contact with reality.
Alternatively the patient either angrily and contemptuously drops-
out of therapy feeling that their problems have not been under-
stood, or mentally withdraws from treatment, or establishes a false
treatment which looks like therapy but is in fact two individuals

talking to themselves.
Retaining mental closeness

Retaining mental closeness is the primary vehicle of MBT. It is done
simply by representing accurately the current or immediately past
feeling state of the patient and its accompanying internal represen-
tations and by strictly and systematically avoiding the temptation
to enter into conversation about matters not directly linked to the
patient’s beliefs, wishes, feelings etc. The initial task in MBT is to
stabilise emotional expression because without improved control of
affect there can be no serious consideration of internal representa-
tions. Even though the converse is true to the extent that without
stable internal representations there can be no robust control of
affects, identification and expression of affect is targeted first simply
because it represents an immediate threat to continuity of therapy as
well as potentially to the patient’s life. Uncontrolled affect leads to
impulsivity and only once this is under control is it possible to focus
on internal representations and to strengthen the patient’s sense
of self.
The therapist must be able to distinguish between his own feel-
ings and those of the patient and be able consistently to demonstrate
this distinction to the patient. Specifically, feelings belonging to the
therapist must not be attributed to the patient or interpreted as such.
This repeats the developmental trauma of the patient who, as we
have suggested, takes others feelings and representations in as part
of himself but these fail to map onto his own state leading to desta-
bilisation of the self-structure or an illusory stabilisation.
A mismatch or discrepancy between the representation of the
patient’s state by the therapist and the actual state of the patient
compels patients and therapists to examine their own internal
states further and to find different ways of expressing them if
communication is to continue. In addition, the therapist has to be
able to examine his own internal states and be able to show that
they can change according to further understanding of the patient’s
state. Similar descriptions have been advanced by those who place
therapeutic emphasis upon breaches, negotiations and repairs of the
therapeutic alliance (Safran and Muran, 2000).
Working with current mental states

There can be little therapeutic gain from continually focusing in
the past. Recovering memories is now recognised as a somewhat
risky aim with BPD patients (Brenneis, 1997); Sandler, 1997 #3058].
We would wish to add to these risks, the possibility of encouraging
borderline patients to enter a pretend—psychic equivalent mode of
relating, where they (unbeknownst to the therapist) no longer use
the same circumspect subjective criteria of historical accuracy which
most of us do but rather assume that because they experience some-
thing in relation to a childhood (usually adult) figure, it is bound
to be true. To avoid these risks the focus of MBT needs to be on the
present state and how it remains influenced by events of the past
rather than on the past itself. If the patient persistently returns to the
past, the therapist needs to link back to the present, move the ther-
apy into the ‘here and now’, and consider the present experience.
Intense feelings about remembered experiences are felt in the
present and should be dealt with as a current experience. They are
not explored as a justified or unjustified reaction to a past event.
Rather, the therapist assumes that regardless of the past significance
of the experience, something (internal or external) in the current
life of the patient triggered the memory and the trigger, rather than
the memory must be the focus of the exploration.
Bridging the gaps

The absence of adequate second-order (symbolic) representations of
self-states creates a gap between the primary affective experience
of the borderline patient and its meaning as well as a continuous
and intense desire for understanding what is experienced as internal
chaos. This gap has to be bridged in therapy with a view to strength-
ening the secondary representational system.
In MBT, the therapist focuses on simple interchanges that
show how he believes the patient is experiencing him, and avoids
describing a complex mental state to the patient. Interpreting a
more complex psychological process, however accurate or inac-
curate it may be either pushes the patient into pretend mode or
creates instability in which the patient becomes more and more
uncertain and confused about himself as the contradictions and
uncertainties are pointed out. Change is generated in borderline

patients by brief, specific interpretation and clear answers to ques-
tions. Clever ideas from the therapist too early in therapy stimu-
late pretend mode and are used by the patient to stabilise himself
in a labyrinth of thought with no connection, depth, or personal
meaning and the gravest danger for the therapist is filling the gap
in this way rather than bridging it. The patient appears to make
rapid gains in therapy as he takes on and develops comments
and interpretations from the therapist. But this is an illusion and
leads to ‘pretend’ therapy which is ultimately shallow and bar-
ren (although, in our experience at least, not uncommon with this
group of patients). There are a number of clues that make it clear
that this evident high degree of mentalization is more apparent
than real. First it has an obsessive character. Second it becomes
apparent over time that there can be dramatically different men-
tal models of things which are readily exchangeable. The patient
appears unaware of this contradiction and expresses surprise if
challenged by the therapist. In general it is best not to confront
the patient with inconsistency, at least initially, since, in pretend
mode, they have no access to their previous understanding of oth-
ers. Third their elaboration is overly rich and frequently assumes
complex and improbable unrealistic aspects. Talking to them about
their own thoughts and feelings leads to rapid agreement without
obvious scrutiny and when reflectiveness occurs it doesn’t seem
to have any ramifications. Finally, there is no ‘felt feeling’ or men-
talised affectivity (Fonagy et al., 2002). The concept pertains to the
integration of emotional experience with knowledge of its origin,
relevance meaning. The patient who talks about affect which is not
felt at the same time is severing the internal connection between
second order representations and constitutional self states. The
sessions become empty.
Summary of the evidence for the effectiveness

of mentalization based therapy for borderline
We have undertaken a long-term follow-up study to evaluate the
effect of mentalization based treatment in partial hospital (MBT-PH)
compared to treatment as usual (TAU) for borderline personality
disorder (BPD) 8 years following entry to a randomized controlled

trial and 5 years after all mentalization based treatment (MBT) was
complete. Characteristics of the subjects, the methodology of the
original trial, and detail of treatment have been described (Bateman
and Fonagy 1999, 2006), as have the full findings at 8-year follow
(Bateman and Fonagy, 2008). What follows is a summary of that
material.
MBT-PH consists of 18-month individual and group psycho-
therapy in a partial hospital setting offered within a structured and
integrated programme provided by a supervised team. Expressive
therapy using art and writing groups is included. Crises are man-
aged within the team; medication is prescribed according to protocol
by a psychiatrist working in the therapy programme. The under-
standing of behaviour in terms of underlying mental states forms a
common thread running across all aspects of treatment. The focus of
therapy is on the patient’s moment-to-moment state of mind. Patient
and therapist collaboratively try to generate alternative perspectives
to the patient’s subjective experience of themselves and others by
moving from validating and supportive interventions to exploring
the therapy relationship itself as it suggests alternative understand-
ing. This psychodynamic therapy is manualised (17) and in many
respects overlaps with transference-focused psychotherapy (18).
We reported 18-month (end of intensive treatment) and 36-month
outcomes of patients treated for BPD following randomisation to
MBT-PH or TAU (15, 16). MBT-PH and TAU for 18-months were well-
characterized. Subsequent treatment was monitored. However, the
MBT-PH group continued to receive some out-patient group mental-
izing treatment (MBT-OP) between 18–36 months. No TAU patients
received the experimental treatment during this 36-month period.
Differences between groups found at the end of intensive treatment
were not only maintained during 18–36 months but increased sub-
stantially. We attributed this to the rehabilitative processes stimu-
lated by the initial MBT-PH treatment. But equally it might have
been a result of the maintenance MBT-OP treatment albeit that this
group had considerably less treatment than the control group.
All MBT treatment ended 36 months after entry into the study.
We wanted to determine whether treatment gains were maintained
over the subsequent 5 years, i.e. 8 years after randomization. The
primary outcome for this long term follow-up study was number of
suicide attempts. But in the light of the limited improvement related

to social adjustment in follow-along studies we were concerned to
establish whether the social and interpersonal improvements found
at the end of 36 months had been maintained and whether addi-
tional gains in the area of vocational achievement had been made
in either group. We also looked at continuing use of medical and
psychiatric services including emergency room (ER) visits, length
of hospitalization, out-patient psychiatric care and community sup-
port; use of medication and psychological therapies, and overall
symptom status. This paper reports on these long term outcomes for
patients who participated in the original trial.
The MBT-PH/OP group continued to do well 5 years after all
MBT treatment had ceased. The beneficial effect found at the end
of MBT-OP treatment for BPD is maintained for a long period, with
differences found in suicide attempts, service usage, global func-
tion and ZAN-BPD scores at 5 years post-discharge. It is consistent
with the possible rehabilitative effects that we observed during the
MBT-OP period. This is encouraging because positive effects of treat-
ment normally tend to diminish over time. The TAU group received
more treatment over time than the MBT group, perhaps because they
continued to have more symptoms. However in both groups GAF
scores continue to indicate deficits, with some patients continuing
to show moderate difficulties in social and occupational function-
ing. Nevertheless, when compared to the TAU group, MBT patients
were more likely to be functioning reasonably well with some mean-
ingful relationships as defined by a score higher than 60.
More striking than how well the MBT group did was how badly
the TAU group managed within services despite significant input.
They look little better on many indicators than they did at 36 months
after recruitment to the study. A few patients in the MBT sample had
made at least 1 suicide attempt during the post-discharge period
but these were almost ten times more common in the TAU group.
Associated with this were more ER visits and greater use of polyp-
harmacy. However, although number of hospital days was greater
for the TAU group than the MBT group, the percentage of patients
admitted to hospital over the post-discharge period was small
(25–33%). This pattern of results suggests not that TAU is necessar-
ily ineffective in its components but that the package or organization
is not facilitating possible natural recovery.
Naturalistic follow-up studies suggest spontaneous remission of

impulsive symptoms within 2–4 years with apparently less treatment
(21, 22). In line with these findings all patients showed improve-
ment, although not as much in terms of suicide attempts as might
be expected. The lower level of improvement observed in this popu-
lation may be because they represent a more chronic group. Most
patients had a median time in specialist services at entry to the trial
of 6 years. Whilst this study does not indicate the untreated course of
the disorder, the results suggest that quantity of treatment may not
be a good indicator of improvement and may even prevent patients
taking advantage of felicitous social and interpersonal events (23). It
is possible that TAU inadvertently interfered with patient improve-
ment as well as MBT accelerating recovery.
There is an anomaly in the results in that there is a marked differ-
ence between the size of the effects as measured by the ZAN-BPD and
the GAFs in terms of social and interpersonal function. One possible
explanation for this is that the scales offer a slightly different metric to
different aspects of interpersonal function. In the GAF, suicidal preoc-
cupation and actual attempts have a large loading and even presence
of suicidal thoughts reduces the score substantially. This was the case
for a small number of patients in the MBT group and accounts for their
larger variance on GAF scores. In contrast the interpersonal subscale
of the ZAN-BPD covers two symptoms in the interpersonal realm
of BPD, namely intense, unstable relationships and frantic efforts
to avoid abandonment which showed marked improvement in the
MBT group. A GAF of greater than 60 clearly marks a change back
to improved function and more patients in the MBT group achieved
scores above this level. A strong correlate of improvement in the MBT
group is vocational status. It is unclear whether this is a cause or con-
sequence of improvement. It is likely that symptomatic improvement
and vocational activity represent a virtuous cycle. Although we have
no evidence to this effect, we suggest MBT may be specifically helpful
in improving patient ability to manage social situations by enabling
individuals to distance themselves from the interpersonal pressures
of the work situation, anticipating other people’s thoughts and feel-
ings, and being able to understand their own reactions without over-
activation of their attachment systems (24, 25).
The strengths of this study lie in the presence of a long-term
control group, in the reliability of care records, and in our data
collection for suicide attempts which used the same rigorous criteria
as at the outset of the trial. Other follow-up studies have been
confounded by lack of controls or TAU patients being taken in to the
experimental treatment at the end of the treatment phase. However
the long term follow-up of a small sample and allegiance effects,
despite attempts being made to blind the data collection, limit the
conclusions. In addition some of the measures we used at the outset
of the trial were not repeated in this follow-up. We considered the
ZAN-BPD to be a more useful outcome measure that would reflect
the current state of the patients better than self-report questionnaire
methods. Finally the original MBT-PH intervention contained
a number of components in addition to psychological therapy.
It is therefore unclear whether psychodynamic therapy was the
essential component. In order for MBT be accepted as an evidence-
based treatment for BPD larger trials using core components of
the intervention are necessary. These are now being undertaken.
Whilst this study demonstrates that borderline patients improve
in a number of domains following MBT and that those gains are
maintained over time, global function remains somewhat impaired.
This may reflect too great a focus during treatment on symptomatic
problems at the expense of concentration on improving general
social adaptation.
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CHAPTER FOUR
Psychoanalytic group therapy with

severely disturbed patients: Benefits
and challenges
Caroline Garland
Introduction
The early stages of psychoanalytic enquiry into borderline conditions
began with clinical descriptions of a group of patients who occupied
a position midway between neurosis and psychosis. The enquiry
then went on to follow two rather different paths. One of these was
concerned with detailed psychoanalytic investigations of what were
thought to be characteristically borderline or psychotic mechanisms
of functioning, encountered in a wide variety of conditions, including
severe neurosis. These states have been described illuminatingly by,
amongst many others, Steiner (1979) and Rey (1994), both of whom
worked for many years with such patients at the Maudsley Hospital,
as well as by Bion (1967) and Rosenfeld (1987). The other approach, in
the 1960s and 70s, was influenced by Otto Kernberg’s introduction
of object relations theory to North America. His systematic approach
to psychoanalytic observations of these patients resulted in the
description of borderline organisations of the personality (e.g. 1975) on
which he based an approach to their treatment. Subsequent research
has been greatly affected by the dominance of the trend in psychia-
try towards employing descriptive research diagnostic syndromes
81
as the basic starting point of any enquiry—predominantly the DSM

definitions of borderline personality disorder. (See Gunderson, 2005,
for a fuller account.) And of course, since then many other investiga-
tors including Fonagy and Target, 1996, Bateman and Fonagy, 2004
and 2006, and Hobson and Patrick, 2005, using differing angles of
approach, and differing therapeutic approaches, have contributed
greatly to the understanding of borderline conditions. The present
paper will focus on borderline mechanisms of functioning as seen in the
patients in a psychoanalytically-orientated therapy group, and will
conclude with some recommendations and provisos.
The nature of the patients and their psychopathology

Borderline patients have troubled histories. Often they have been
projected into, both mentally and physically, via various kinds of
deprivation, neglect and abuse. Consequently for them to occupy a
stable identity, or equilibrium, in relation to the world, feels impos-
sible or dangerous. They tend to oscillate, as their name implies,
between two states, while managing at the same time to be neither
entirely one nor the other: shut in (imprisoned) or shut out (aban-
doned, rejected); too close (suffocated) or too far away (isolated);
too personal or too remote; too large and powerful, or too small and
helpless; neither entirely male, or entirely female, heterosexual or
homosexual. Frantic attempts to ‘take over’ or get inside the object
(therapist) are followed by equally desperate attempts to escape
from or destroy it. From the patient’s perspective, the object is per-
ceived to shift rapidly back and forth. At one moment it appears as
the provider of a helpful and containing structure and at the next,
it becomes something ensnaring, dangerous and persecuting. Thus
extremes of dependency and need are evoked, followed rapidly by
a sense of entrapment or claustrophobia. The concreteness and the
extreme and visible nature of these rapidly fluctuating states sug-
gest that during infancy, childhood and adolescence, the processes
that ordinarily allow the development of symbolization or emotional
containment have either not occurred, or have been extremely dif-
ficult for these patients. Representing, comprehending and linking,
planning—in short, thinking—and the making and sustaining of
relationships are all impossible if experience cannot be represented
to the self in the form of memory, dream, story or symbol. In particular,
P S Y C H OA N A LY T I C G R O U P T H E R A P Y 83
forming and maintaining affectionate, sharing or trusting relation-

ships is difficult or impossible. In Kleinian terms this represents a
pathological version of the paranoid-schizoid position.
The outcome, to quote Rey, is that, “They (borderline patients)
are demanding, controlling, manipulating, threatening and devalu-
ing towards others. They accuse society and others for their ills and
are easily persecuted. This may be associated with grandiose ideas
about themselves … When threatened by feeling small and unpro-
tected and in danger they may defend themselves by uncontrollable
rages and various forms of impulsive behaviour.” (p. 9) Splitting
and projective identification—the need to project into others unbear-
able parts of the self—together with sustained and extreme difficul-
ties in integration make these amongst the most demanding of our
patients.
All this forms part of the problem in issues of clinical manage-
ment and in making treatment decisions. Nevertheless even though
most of these patients have suffered at the hands of others, it is
neither helpful nor effective to treat them as though they were vic-
tims. The identity of chronic sufferer, or chronic complainer, can be
used to intimidate, control and project into those who try to work
with them. An aggressively aggrieved victim can force others into
a powerless sympathy, in which the hope of treatment aimed at
change is lost.
An alternative: Treatment in a group setting

As is clear, individual work with such patients will be demanding
and time-consuming in terms of both management and treatment,
often provoking considerable frustration in the therapist or nursing
staff. As one possible therapeutic approach, probably complemen-
tary to others, I shall describe some elements of work carried out at
the Tavistock Clinic with borderline and/or schizoid patients in a
group setting. How realistic is it to take on not just one such patient,
but seven or eight at a time in such a way as to provide containment
without imprisonment, tolerance without indulgence, and under-
standing without intrusion?
I hope to show through clinical material how some borderline
patients may be able to use group treatment as a means of under-
standing and modifying their own and each other’s behaviour. In a
group setting, over time and within a stable setting, this is something
they can work at with, and for, each other. Under these circumstances
they become able to observe and moderate in themselves and in
each other that most important feature of BPD, the chronic instabil-
ity and impulsivity in interpersonal relations. Correspondingly, for
some, though not all, there is a reduced tendency to respond impul-
sively or act out. Although the presence and the temperament, the
theoretical background and experience of the therapist are crucial,
interpretation of unconscious material is less important in a group
of this kind than is the maintenance of the understanding, strong,
yet flexible setting. To provide this, and to contain the group process
adequately, the therapist needs to be able to identify the childhood
origins of troublesome and fluctuating states of mind, such as the
rapid alternation in individuals between agoraphobic and claustro-
phobic states. This background understanding can help the therapist
to frame interpretations or comments that are sufficiently precise for
the patients—that is to say the group itself—to be helped to tolerate
a more sustained contact with earlier childhood anxiety situations,
which will include intense depressive, persecutory and confusional
qualities. This is hard work. By flexible I mean that it will some of
the time almost inevitably involve the therapist in work on the edge
of the normal therapeutic boundary.
One of the models I have found helpful is Bion’s (1967) differenti-
ation between psychotic and non-psychotic parts of the personality.
This provides a way of understanding the different types of func-
tioning seen in ‘borderlines’ themselves—and seen to some extent
in the group as a whole as well. For example, as will be seen in my
clinical material, Sharon is possessed by a desperate and unthink-
ing need to get out of the group, followed by a realistic recognition
that it has helped her. Eventually she is able to make a decision to
return. This kind of repeated experience shows that some borderline
patients, given the opportunity, are able to mobilize the healthier
(non-psychotic) parts of the personality not only in order to hold in
and manage the more psychotic parts, but as well to use those same
healthier capacities to bring the unworkable, ill, even psychotic
parts of their functioning to a place where they can be understood,
and possibly treated. Others are unable to do this, even though they
might want to. Clearly from the point of view of clinical manage-
ment the importance of being able to tell the difference is great, since
there is a limit to what any therapy group is able to contain—and my

clinical material will show some of the problems of over-optimism,
even, with hindsight, omnipotence, in this respect.
Containment
Clearly, the issue of containment for the patients is crucial, both of
a physical and a emotional kind. Borderline patients are not eas-
ily seen in private consulting rooms, particularly not when seven
or eight such patients are seen together. And physical containers of
course provide psychological holding as well. Physical containment
is offered by what (ideally) are the nested structures of NHS, Hospi-
tal or Clinic, CMHT, the unit, and in the case of in-patients the ward,
the therapy room. Henri Rey called the hospital ‘the stone mother’.
Individual doctors, psychologists and therapists may come and go,
retire, become ill, go on holiday or on maternity leave, but the hos-
pital endures. It survives the patient’s storms. As we know, many of
our patients have had considerable early experience of institutions
(Children’s Homes, Social Services, foster parents) which link in
terms of both structure and process with aspects of the Health Serv-
ice. Thus there is a ‘genetic’ or ‘family’ resemblance, and an emo-
tional continuity present, and this will be reflected in the nature of
the transference to the group setting. A well-functioning group will
have the ability to contain and process some of these (often split)
transferences and can in that way function as a healthy institution.
The physicality of the buildings and the structure of the NHS
also provide important containment for the therapist. Borderline
patients are quick to sense anxiety in the therapist, who is of course
the main source of psychological containment, in partnership with
his or her intellectual and theoretical stance—that provided by a
substantial personal therapy and good training. Continued contact
with colleagues (including seminars, case conferences, workshops,
conferences) is important. However, even though there may exist a
hard-working community of professionals engaged in the work of
managing and understanding such patients, in the last resort it is
the therapist’s own internal resources that are tested when he or she
must remain open to the intense emotional pressure exerted by the
patient, or patients. I emphasize ‘remaining open’ to the patient’s
internal state, because a closed or unreceptive manner aggravates
any potential turmoil. It is a difficult balancing act: not so closed

defensively (sometimes masquerading as ‘professional’) that the
patient feels shut out and frantic; not so open as to be overwhelmed
and unable to function. Anyone who has worked with severe distur-
bance knows how important these factors are and also how difficult
they are to sustain. Why then should it be easier to have several
rather than one or two of the kind of patient I have described? Why
does it not result in chaos and/or Bedlam?
Why group treatment?

I am going to outline some principles about group treatment in
general, and go on to describe those that apply in particular to
work with borderlines. Of course it is extremely important for the
therapist to be clear about the value (and the limitations) of group
therapy as a treatment modality with advantages of its own over
and above its obvious cost-effectiveness. Patients offered group
treatment may often feel they are being fobbed off with something
second best. Individual treatment is seen as first-class travel, with
the advantages of privacy and exclusivity. (However the intimacy of
individual treatment may also threaten the borderline patient with
intense claustrophobia.) A therapist offering a group can be seen as
pushing bucket-shop modes of treatment, and the anxiety is often,
in the state of intense need experienced by the patient at the consul-
tation, that having to ‘share’ a therapist with six or seven others may
aggravate the sense of deprivation. Here then is my general ration-
ale for group treatment.
a) General principles
1. Every individual’s mental life, his internal world, is founded upon
the structures he has formed as a result of his biologically and
constitutionally-influenced responses to his actual early experi-
ence. This of course means the couple, or family, and later the
school and the wider world. These early structures, or internal
object relations, are also infused with phantasy as to the nature
of the self in relation to these powerful objects. There is in this
early phantasy a continuous process of projection and introjec-
tion of aspects of these relationships, all of which contribute to
the formation of the individual’s character, strengths and vulner-

abilities. This process is largely unconscious, and is particularly
resistant to change. It is the bedrock of the personality.
2. The group becomes a microcosm in which these object
relationships can be lived out. In group therapy, internal object
relations and primitive phantasies are externalised in the room
in relation to the other members of the group, including the
therapist. A variety of internal structures, each a product of both
experience and constitution and distorted by unsatisfactory
or inadequate early experience, becomes visible in the group
arena. However, having then to tolerate and manage the ensuing
difficulties with each other is an equal task for every patient in
the room. When this kind of work goes well, it offers the chance
of providing alternative modes of response, even of shifting
internal structures in a more durable way, strengthening some
and reducing others—a move from narcissism towards social-ism.
Learning from experience is difficult for the most psychologically
intact. It is easier to learn from the objectification of experience
provided by a chance to take up the position of observer in vivo,
not simply in theory.
3. Since not everyone can speak at the same time, turns have to be
taken, and the shifting and rotating nature of the triangles (actor,
reactor, observer) present in a group is equivalent to practice
in dealing with complex Oedipal issues. Each member has the
opportunity to observe, notice and reflect on what is happening,
to take up a ‘third position’ (Britton, 1989) as well as being at
other moments part of the action that is observed by others. What
may at first feel like being excluded can, in time, come to be felt
as a valuable opportunity to take stock of the action. In taking up
the position of observer, advantages as well as disadvantages can
be discovered, finding through varying identifications differing
ways of being. In the same way, habitual observers become more
confident in taking up the position of protagonist, at claiming
their own right to be not just ‘in on the act’ but one of the actors.
Thus identifications can become more flexible and offer a greater
degree of freedom.
4. Dependence upon the therapist alone is diminished because
of the existence not only of fellow patients, but of ‘the group’
itself. Dependence on ‘the group’ can often be tolerated where
dependence on the therapist is resented and denied, leading to

an envious rejection of the therapist’s greater understanding
and psychologically-educated point of view. Group patients are
strikingly better able to bear plain speaking from fellow members
than they can from a therapist. Moreover, fellow patients often
put things more directly and bluntly than a therapist could risk.
“Why don’t you face it, you’re an alcoholic,” may not rate as a
psychologically sophisticated interpretation but nevertheless be
both accurate and effective in the particular circumstances.
b) Borderlines in groups
5. In borderline patients, that bedrock I have described is inadequate
and unstable. Often their early experience has been ill-attuned, or
neglectful to the point of traumatic, resulting in a failure of the
capacity to engage in the normal give and take of relationships.
Yet many borderline patients also have within them a capacity for
a psychologically acute and finely tuned observation of others’
behaviour. They can ‘read between the lines’ better than most,
even if the reading is often selective. When they feel the heat is on
them, this capacity is easily overwhelmed by impulsively avoid-
ant and/or chaotic behaviour; but when the heat is on another,
there is revealed a capacity to observe and understand the situ-
ation with empathy and accuracy. In short, borderline patients
seem able to tune into each other’s difficulties more acutely can
than many therapists, and without the interference of the hier-
archical structure of therapist/patient, adult/child, well-balanced
and successful vs. crazy lost cause.
6. This capacity in such patients to ‘read’ others can join up to form
something surprisingly robust, even stable, called by them ‘the
group’. Each member develops a relationship with, even an
attachment to ‘the group’ which seems to survive the disturbances
and hostilities that erupt between the individuals within it. ‘The
group’ continues to have an existence for each member whether
or not he or she attends in any particular week, offering a kind
of containment above and beyond that which can be provided by
the individual therapist. Members trust each other even if they
quarrel, because they understand each other. This description of
course is of ‘the good group’. There also exists ‘a bad or malignant
group’, which is feared and hated, and which can be experienced

as quite as claustrophobic as an individual therapist, however
much needed and depended on. Indeed it is partly the dependence
itself that renders the object so suffocating, because the patient
feels imprisoned with his own frantic needs. ‘The group’ too may
have its psychotic and non-psychotic ways aspects, or ways of
functioning. Nevertheless, good group or bad, it continues to
exist. It is there in a permanent way to be loved or hated, clung
to or avoided. It is also a shared experience, physically and
emotionally, in itself a rarity for this kind of patient. The group
exists in the mind of each member of the group, and it connects
them to and with each other.
7. So a group offers a very particular structure in which each
member can feel himself to be not only a patient, but also to have
an important role in others’ treatments. In symbolic terms, when
a patient can exist as a part of the breast, the providing object, as
well as feeling himself to be a frantic, perhaps starving infant,
there is a mitigation of envy. Inevitably when very deprived
people receive therapy from those who are less deprived, the
envy that is aroused may be conscious and realistic as well as
unconscious. Yet even unconscious envy can be modified, that of
the other infants and of the breast itself, for being the source and
provider of all goodness, full of what the infant desires and needs:
it is an indisputable fact that each and every group patient is both
baby and also part of the breast that nourishes and supports the
other babies—the therapeutic presence. Psychic nourishment is
easier to take in when one also has the opportunity to become
capable of providing it for others.
Clinical material
This is a process account of material from a long-standing group,
seven of whose eight members were at the more disturbed end of
the spectrum. Two had spent many years of their childhood and
adolescence in Care and as adults suffered from eating disorders;
one of these was also a frequent and chaotic cutter. Another with
a severe eating disorder, also a cutter, had had four pregnancies
terminated before she joined the group. Another had been taken
from her schizophrenic mother and placed in foster care, where she
was perversely abused and ill-treated by the foster father, the leader
of the local church group; another, a young man, with a menacing
schizoid air got into frequent fights, including with the police, and
had appeared in court on many occasions. Yet another was severely
depressed, silent and suicidal; In spite of these unpromising begin-
nings, I hope to convey some idea of the degree of engagement
that can characterise relations between such group patients who
have come to know each other well, as well as to give examples of
how effectively how group members can understand and interpret
their own and each others’ behaviour if given room to do so by the
therapist.
Two events had taken place in the week preceding this session.
First, I had seen this last member, Mike, an intelligent and sensitive
but severely depressed young man, for an individual session the day
before the group met. He had at his assessment interview one month
earlier expressed clear suicidal intentions and after discussion with
his GP, and with the local CMHT, he was admitted as a voluntary
patient in the psychiatric wing of the local hospital. I had been wor-
ried both that the group was too much for him, and also that he was
too much for the group, but at the point at which I took him on the
group was all that could be made available. Nevertheless the degree
of self-destructiveness apparent was hard for other patients to man-
age. He remained largely silent in my interview with him, but by
the end it was agreed between us that he would continue to attend-
ing the group, and as well would come to once monthly individual
meetings with me.
Second, Sharon (a childhood in Care, eating-disordered, a cutter)
and Joe (brought up in Care, aggressive and a powerfully built
fighter, expert in Karate) had had a bitter row before the most recent
break about Sharon’s having called Joe ‘a prat’. She’d said she found
him spooky, disturbing, that she thinks he’s weird. He’d been upset
and angry and had banged out of the room in the penultimate ses-
sion of term, not returning for the final session. Sharon herself had in
turn been upset by his response because in her world, to call some-
one a prat is merely ordinarily insulting. Everyone’s a prat really. Joe
had demanded to know why I was willing to let people get away
with insulting him in the group. It was not what he was here for.
Recently he’d been trying to distance himself from rows, confronta-
tions and fights. He’d had enough of all that in his karate club. In the
first week of the following term, the row erupted again and Sharon
hissed she was never going to come back, this group is rubbish and
anyway, he is a prat. Joe, encouraged by the others, had then tried
very hard to be sensible about it all, saying through clenched teeth
that he thought he’d over-reacted before Christmas. Sharon contin-
ued to hiss and mutter at him, at the same time feeling guilty and
angry. I commented that I thought they recognised something about
each other, the capacity for violence, which frightened them both.
Sharon then rang me during the week to underline her message: she
is NEVER EVER coming back—Joe’s an idiot (i.e. promoted from, or
perhaps demoted from ‘prat’), and so are YOU (i.e. me), and she had
had it up to here. She then rang off, cutting me off in mid-sentence.
An hour later a further message from her arrived, saying she’d for-
gotten to ask me something, and will I call her.
I called Sharon the next day, the day of the group. She was in bed,
apparently not feeling well. I left a message with the young boy that
had answered the phone, asking him to tell his mother that her call
had been returned. When I gave my name, the boy responded by
saying “Oh, she said if it’s you, to tell you she’ll be there this after-
noon …..” Here we can see the intensity of the agora-claustrophobic
dilemma: got to get out of here, followed swiftly by got to get back in.
The session
When I arrive, Sharon, Elsie, Alexa and Mike are there. They’ve all
just arrived. Sharon pulls a sheepish face at me and I smile a brief
acknowledgement. Mike is silent, staring at his hands and picking at
the skin on his fingers as usual, but I felt he looked very slightly less
tense than the week before.
Elsie and Alexa said variously: “Hello Mike! Glad you’re here,
Sharon, we thought we’d seen the last of you. What a relief.” Alexa
adds, “I’d have been furious if you hadn’t come. Rose is on her way,
I’ve just seen her driving round and round looking for somewhere
to park.”
They go on to ask how come Sharon changed her mind. This is fol-
lowed by silence. Sharon gestures a thumb towards me and pulls a
face. “I phoned Er. You say,” she says to me. I keep quiet. The others want
to know what happened, and it gets told in muffled half-sentences.
“I wasn’t going to come back NEVER. I was so angry. It was my kids
what got me to come. Said I was bein’ stupid. An’ I shouldn’t just
walk out on things, cos’ I was doin’ better than I used to. An’ then
SHE phoned me. I was so angry, SO ANGRY wiv her I wanted to cut
meself, you know, like I used to. I called Er an idiot.”
The others are excited, alarmed, delighted. “DID you, what did
she say?” A little pause. Then: “She said to come anyway.” I said
that I thought the person Sharon really had it in mind to cut was me,
to cut me up and to cut the group by not coming. She said Yeah. The
others persisted—so what made her come in the end? After a silence
I said I thought Sharon had found she could be angry with me in a
direct way, completely furious, and that we could both survive it,
and that was a relief to her. Living through these things and coming
out the other side was what was important, and I thought that was
true for many of the relationships in the room, not just Sharon’s with
me. “Yeah, where izee anyway??” she said. Joe is noticeable by his
continued and unusual absence. There is another silence.
Alexa asks, “What happened with Mike—you saw him yester-
day?” They ask him about it but he doesn’t respond. I say to Mike
that I’d like to tell the group about our meeting. Is that all right with
him? Worrying, he still doesn’t answer, but his face is slightly less
furrowed and contorted than usual. I function as an auxiliary ego
in saying that Mike is facing something difficult because the lease
on his flat comes to an end at the end of the month and the landlord
is not renewing it. He has to leave. The psychiatrist at the hospital
where he is now an in-patient has said once he’s discharged she will
get him into a men’s hostel in the local Borough if he wants her to.
They ask him, does he want her to? Mike remains silent, picking at
his fingers. The group becomes anxious.
Rose has come in during this passage. She listens and becomes
troubled by the idea of the loss of his flat. I add that there was some-
thing else that Mike said that was important, and it was that he did
not trust me. The atmosphere is very tense and serious. I had asked
him if he knew why, and he had answered, “Because everything
comes to an end.” I ask the group what they think about that.
“Yes, but it doesn’t come to an end all at once. Not completely,
not till you die. I mean Mike, you’re losing your flat but you’ll then
get somewhere else to live.” “Mike, I wish you’d talk and then we
could like really get to know you.” Alexa (who herself has made a
suicide attempt after a fourth abortion) said “I’m just glad I’m still
alive now even though it’s going to end some time.” I think with
hindsight one can hear in these exchanges their fear of Mike’s silent
but clear suicidality.
Jane comes in at this point. She has lost an extraordinary amount
of weight over the break and looks transformed, and everyone is
amazed and complimentary about it, in a flurry of comments. She
says it was the ‘flu, she just couldn’t eat. (I am unconvinced by this.)
She is relieved to see Sharon and there is a recap of how Sharon got
to be there after all this week. Then Jane goes quiet. I feel there is
something she cannot talk about, but it is not the moment to open
this up. Rose is still very preoccupied with the loss of the flat—what
does Mike feel about it? There is silence from Mike, who can only
pick his fingers and stare at the floor.
Elsie and Alexa say how important home is, and specially the cen-
tre of home, namely their own beds. Alexa says her bed smells like
home. She only really feels absolutely safe and secure under her own
duvet. When her cat, Small, was still alive, Small would climb under
the duvet and purr very loudly, and that was when she felt safest and
happiest. Rose says that she wants to know what Mike feels because
she feels very upset about the loss of her own flat (having moved her
base to the country village where her Lesbian partner lives). It’s not
she doesn’t like the cottage, but there’s nowhere in it that is really
hers. She has driven down from the Midlands that afternoon to be
at the group, and she is going to go and visit her old flat. All her old
teddies are there, looking at her reproachfully. She is laughing, but
crying at the same time. Alexa says she should take them up to the
country with her but she says she can’t, she feels too stupid. They
tease her about their mournful little eyes following her as she goes
out of the door back to the country. Rose then says suddenly she’d
thinks she’ll stay the night in her own flat. It’s not just her partner’s
cottage, she also feel excluded from her Mum’s home—one of her
brothers and one of her sisters (she is one of six) have moved back in
and her mother is ever so pleased and busy with them, and she feels
there’s nowhere now that’s really home for her.
I say that the group too has changed, with two new members in it
since last term, and that too doesn’t feel like home, like the old group,
when I am so occupied with the difficulties of the new members here.
She nods, sniffing. Alexa says that hearing Rose talk about what
it’s like for her at her partner’s is weird, because she’s got her little
brother living with her now and she absolutely hates it if he wants
to change anything. She feels she mustn’t be so hard on him. She’s
got to let him have a bit of space where he can make his own kinds
of mess. I am thinking about the loss of space in the group, and how
much room there is now for anyone’s mess.
In the middle of this Joe suddenly bursts in, panting and hot, and
begins to peel off layers of clothes—ragged, but clean sports clothes,
sweat shirts, socks; he unlaces his trainers and eventually sits there
in just a tee shirt, socks and baggy, torn leggings. Everyone is looking
at him, but he is silent, still over-heated, and so they go on talking
about Mike’s enforced move. Joe says then that it’s obvious things
are happening with Mike and he was very sorry to miss him talking.
Alexa says he wasn’t talking, and relays to Joe the situation with the
flat. Then Rose and Alexa ask Joe why he’s so late. (Sharon is looking
pointedly out of the window, chewing gum and looking bored.)
Joe says, I just forgot! I forgot it was the group day. I was having
this animated conversation with Rose and then I suddenly remem-
bered it was therapy day and I just got over here on my bike at
maximum speed. The others look at him—is this a hallucination, a
joke, or just Joe? Rose asks, giggling slightly, well what did I say?? Joe
then told a long saga, much of which was the lead-up to what Rose
was saying to him in his head. He’d been holding auditions for his
end-of-year drama production, and his teacher, on whom he relies
a great deal, was absent so he was having to make decisions about
the actors himself, which he was finding very difficult. The problem
was that one of them was very good looking, but the good-looking
one wasn’t as right for the part as the other actor. He found himself
beginning to be preoccupied with the good-looking one, wanting to
follow him after the audition to find out where he lived. He said, “I
just went into gay mode, and decided that’s what I really wanted,
a relationship with this young actor, but then I started to think but
I also want children and that’s more or less ruled out if I’m living
with a man, ‘cos you can’t have children then. And then I thought
of Rose, and how gay and Lesbian parents can have children these
days, and then Rose started saying to me but Joe you’re not ready
to have children yet, you’ve got to get yourself sorted out first, I’ve
already spent five years in this group …”
He is being serious as he recounts this long vivid day-dream,
which nevertheless has elements of a quite useful awareness of
reality in it, as well as evidence of the existence of the group in his

mind even when he is not present. The others are smiling at him
quite fondly, and listening to his saga which has no full-stops in it.
Then he suddenly said that he had found himself crying last night,
because he felt very deeply that he missed his Mum—he loves his
Mum and they had had a good time together in Ireland at Christmas,
got on very well even though his dreadful step-father was there too,
somehow they’d all got on with it together.
Rose asked him if this was recent, this feeling of missing his
Mum—“I mean do you think it’s because we had a break from the
group over the holidays?” Joe said no, he often misses her. He did
even when he was very small in Care. He can remember telling
Dr. T. (his assessor) how he used to rock himself to sleep in Care,
crying at night till he was 13 or 14. He told the group about his moth-
er’s weekend visits, how she would visit and be with him and then
leave, and he would feel terribly lonely. Perhaps all that’s being so
vivid now for him because he’s in therapy, he knows therapy is sup-
posed to open you up (the others are nodding).
This is the first time he’s talked about being brought up in Care
when Sharon has actually been in the room. She too was brought up
in Care. She is looking at him very intently, legs and arms wrapped
round her body, one hand round her face. She says suddenly that
she’d had no-one to collect her at the weekends. Some of the kids
just didn’t. When everyone else had gone off she’d be on her own,
just one or two others, kicking around the empty building. The staff
had found her something called a “social aunt and uncle” and they
would come and take her out but she never talked. She went mute
at the age of five for over a year. She was sent to a psychiatrist but
she never talked to him.
Alexa bursts out how shocking it is that she was sent to a psy-
chiatrist when it must be perfectly obvious to anyone who knows
ANYTHING about children WHY she’s mute, that she’s missing her
Mum. (This seems to me to contain an oblique reference to Mike’s
mute state.) Sharon said crossly, “No I wasn’t, I never wanted to see
her anyway!” Joe said anyway he didn’t think it was so shocking—
at least it’s an attempt to help, some offer of something, so at least
she had a chance to tell someone what she felt. Sharon said again she
never spoke to the psychiatrist. (Is Mike listening, I wonder?) But
she continued to visit her social aunt and uncle, after she got talking
a bit, and even saw them sometimes when she was quite grown-up.
They was good to her. (This is a quite lengthy passage from Sharon,
who is often largely silent.) Then she spoke directly to Joe, looking
sideways at him: “How long was you in Care?” They swap notes. I
am holding my breath. Many years for each of them: Joe from 0–8,
then 12–14, and Sharon from 2–16. There is a silence—this is felt
by the group to be a very long time, the whole of a childhood, an
adolescence.
Sharon says suddenly looking at Joe, “I know I got pissed off wiv
you, but I need you to like me, Joe, I know it’s silly, but you know
where I’m coming from. It’s why I find you spooky, it’s because
you’re like me.”
After a moment Jane says, “It’s amazing you can say that, Sharon,
I think that’s really brave.” Joe says, “Well, I need that from you too,
Sharon.” Sharon looks at me and says, “Az wo’ you said, wonni’,
vere was fings we could understand ‘bou’ each uvver ….” She goes
on to say that she thinks the group is difficult, but she knows she
needs it, it’s done her more good in 18 months than all them years of
counselling. She’s changed, her kids keep telling her. The others are
watching the two of them, Sharon and Joe, very intently.
Joe speaks to Sharon. He said that one of the things he’s begun
to recognise is that the reason abuse is so difficult is that it makes
you feel special, even though it’s harmful. That’s why he likes Bud-
dhism. It tries to help you let go of your ego, because if you can
let go of that you lose the feeling that you’re special, even specially
bad—in some ways even feeling specially bad is something people
want when there’s no other way of feeling special or even all right.
The others are quiet, trying to digest this. After a while Alexa says
in a very quiet voice she thought the group was going to be really
difficult with these new people in it, but perhaps the group has never
been as important to her before.
Session two
The following week, Rose is not there, because she and her partner are
house-hunting, looking for somewhere to buy together (this is con-
veyed in a phone message). Alexa (looking scruffy and uncared for,
as though she is sleeping rough) asks Mike if he has had to move out,
and after a long silent struggle, he says a single word, his first after
four months in the group: “Tuesday”. Everyone looks at each other,

pleased, and Sharon looks at me and smiles. However, both Alexa and
Jane begin to cry a lot in this session, apologetically, wanting very
much to be seen to be good and be strong, because they’ve been there
longest of all and they want to show the others that the group can help
them if they just stick at it. But Alexa says she has been having unpro-
tected sex again, with two men she doesn’t really know, and she is
very afraid of being pregnant, which would make her feel quite awful
in relation to Rose, and her struggles to conceive via IVF.
Elsie, more neurotic than borderline, is in her seventies and a dif-
ferent generation from the others. She talks then about how much
she regrets never having taken risks in her life, either practical or
emotional. Now she feels she is going to die, to end her life, feeling
she has wasted it. Jane is clearly in a state—is she unwell? Alexa sud-
denly starts getting cramps. It makes her feel and look relieved. She
thinks her period is about to start which would mean she can face
Rose and tell her how terrible she would have felt if she had been
pregnant. Rose does not like this. She feels she can manage her own
difficulties in trying to conceive, and if she doesn’t manage it she is
going to adopt. She doesn’t want anyone feeling sorry for her. She’s
glad Alexa isn’t pregnant for Alexa’s sake, not for hers. They speak
to Elsie about the risks and the pain of getting it wrong, but Elsie
now feels she would rather have got into a mess and into a state than
having nothing to show for her life. This is a very truthful if painful
admission for her, a shift away from her habitual envious rejection
of others’ capacity for living, however chaotically.
Jane is saying that she is terribly upset, because all her old pho-
bias have returned and she feels she is “back to square one”. I say
they feel forced into being grown-up before they feel ready by this
influx of needy new patients, and they need to remind me that they
are in many ways still at square one, as vulnerable and needy as
babies too. There is much sniffing and sharing of Kleenex.
Discussion
The process of externalization, which increases the possibility of
taking up a ‘third position’—discovering what is in oneself through
observing and recognising the same processes taking place between
others in a three-person setting—is immensely useful when it comes
to helping patients ‘see’ what’s going on inside them, and what part
they are playing in their own difficulties. It is a long way from hav-
ing a therapist tell you exactly the same thing whether in a group
or in a two-person setting. In a well-functioning group, that work
is done by patients in relation to each other within the steady long-
term environment that can be provided by a committed therapist.
And as in all forms of analytically-based treatment, the reintrojection
of lost or projected parts of the mind leads to a greater mental capac-
ity to tolerate pain and distress, and to a fuller and more integrated
personality. Unappreciated emotional intelligence is discovered and
used. This can lead to some quite unexpected side-benefits, apart
from the amelioration of object relations in general—the patient may
discover new interests in the external world, such as an increased
appetite for taking up work, or sustaining a social life.
However, I called this paper ‘benefits and challenges’. Although
I hope that my clinical material has given a glimpse of some of the
benefits, I am also aware of the great challenges inherent in dealing
with a rapid deterioration in psychic functioning. The warning signs
of Mike’s deterioration were his silence, his obliging me to speak
for him. There was then a period of months in which Mike began to
recover and to take part, revealing himself as an intelligent and sen-
sitive member of the group, but abruptly—perhaps afraid of ‘com-
ing to life’ once more, and having to give up the ‘solution’ to life that
he kept in reserve—he quite suddenly withdrew altogether. Three
weeks later, in spite of being on a 15 minute watch in the psychiatric
ward of the hospital, he committed suicide—some six months after
the material I have reported. The shock for the group, and for me,
was immense, and its reverberations felt for years. I went on won-
der if in some respects it had functioned as a suicide by proxy, in
that the amount of destructive acting out by Joe, Sharon and Alexa
diminished, always with a warning to each other you don’t want to
finish up like Mike.
The psychotic part of the personality operates on the basis of a
need for immediate solutions to various forms of breakdown in ego-
functioning. Yet an instant solution or ‘repair’ is inevitably omnipo-
tent. It may be achieved on the basis of sacrificing a piece of reality;
even—through suicide—the ego itself. This is a subjective version
of ‘sanity’ clung to by the damaged ego at the expense of the reality
principle. In this case it was a version of sanity that was preferred
to the difficult reality of putting his life together once again bit by
bit. This degree of illness cannot be contained by the group for long.
It is of course hard when you are ill yourself to cope with others’
illness. It makes demands upon the less ill members for a degree
of integration and maturity that cannot always be available. With
hindsight, there may be occasions when a patient as ill as this should
be withdrawn from the group. However, in this particular group,
the remaining members (seven out of eight) continued to grow in
strength and capacity to take on work, to bear and raise children,
and in one case to begin and sustain a lengthy professional train-
ing. In some respects perhaps, the more disturbed and ill aspects of
their own functioning were felt to have been projected into Mike and
taken away with him. Yet the group continued for another five years
without the need for further sacrifices. It makes the issue of selection
for this kind of treatment of primary importance.
Conclusions
The mutual openness and understanding that can be achieved
between even damaged members of a group venture involves not
only knowing about illness in others, but also involves the obliga-
tion to recognise aspects of the same kinds of illness in the self. Given
permission to voice thoughts and feelings that are normally private,
sometimes hidden, in a setting which is specifically designed to offer
this opportunity, human beings (even damaged or ill human beings)
reveal themselves to be subtle, sophisticated and sensitive instru-
ments for the recognition and reading of each others’ behaviours.
The task of putting into words—’publication’ of the self through
verbalising these discoveries—is one of the routes towards internal
change; and this in turn fosters change in ways of relating to others.
However, such a group must operate along certain lines.
1. It should be long–term: my own slow-open group ran for over

fifteen years. No patient should expect to spend less than three to
four years in treatment.
2. It must have a reasonably stable membership: be either a closed
or a very slow-open group.
3. It must be actively managed by the therapist, who needs to be
someone who likes this kind of work and this kind of patient.
4. Back-up support must be available. Such a group will work best

as part of a whole treatment system because of the variability in
patients’ needs at different times. It is for instance useful to have
an ‘in-patient’ option should it be necessary.
5. The therapist cannot be everything to everyone all of the time.
Shifting and modifying characteristic modes of relating is the hardest

of tasks for human beings, and there is a built-in aversion to the kind
of pain involved in real change. Some group patients will wish, and
will fight, to use the setting for the purposes of re-enactment rather
than for change. Relinquishing behaviours can be painful and fright-
ening, and the existing modes of relating may offer gratifications that
new ones do not possess. Yet if attendance can be sustained—and
this may require flexibility and hard work on the part of the therapist—
change can be seen to take place.
Finally, there is the central fact that the group itself comes to be
an important object in its own right, and own way. However it is an
object that differs from the seven or eight other people in the room
in a number of ways.
1. It belongs equally to every patient in the room.

2. It has a continuous existence. The group is alive, whether good
or bad, in the mind of each patient. Thus every patient has an
existence in the mind of every other patient and containment and
the maintenance of the therapeutic setting becomes a joint activity.
3. The group can be a loved object, by virtue of the attendance of
each of its members.
4. The group can be a hated object, assaulted and avoided, but
refound in an alive state when the patient feels less full of rage
and distress once more.
5. It is a maternal object: it remains open to the patient and it
provides emotional nourishment in the form of tolerance and
understanding. This is its ‘lap’ function.
6. It is a paternal object: it provides insight through verbal comment
and interpretation, which offers the possibility of thinking again:
of pausing the action before impulsively acting it out, much
as the action is paused on the screen of a word-processor for
consideration and editing before being printed out. This is its
‘organizer’ function.
7. These two functions operate together via the person of the

therapist, and via the patients themselves; that is to say via the
existence of the object that is the group.
8. Every member of the group can relate to it in a number of ways.
As I have indicated, being able to function as both baby and breast,
both impulsive child and thinking organizing adult, fosters the
reintrojection and integration of split parts of the personality in
the patient. Each patient possesses as well as illness a capacity for
helpful, considerate and thoughtful (non-psychotic) functions of the
personality. Being a ‘patient’ (bringing the ill parts of the personality
for treatment) is made more tolerable by each member’s also being
able to function as ‘non-psychotic’ in relation to the others.
A more ordinary developmental process begins to take place in the

group’s members as they project more normal parts of the self into
the group for public consideration of their meaning and signifi-
cance. Although the subsequent reintrojection is subject to ups and
downs, negative therapeutic reactions, there is a sense in which the
original deteriorating vicious cycles can begin to be supplanted by
something more benign. These sorts of developments are necessary
for the individual to locate him or herself in those human groups on
which, in turn, the ability ‘to work and to love’ depends. The ability
to operate as a member of a family, social or work group is one of the
central tasks of healthy personality functioning. And the converse
is also true: for human groups to function normally and well, their
members must be able to projects parts of themselves into group
organisations to form the networks of cooperation that enable fam-
ily and social organisations to function.
And as Bion has indicated in his description of the move from
narciss-ism to social-ism, a therapy group is in this way a microcosm
of society. The expectation is that those who come to be able to take
part in it will be, perhaps only marginally, perhaps only from time
to time, but still better able to take part in the complex negotiations,
the give and take, of society itself.
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CHAPTER FIVE
The fiend that sleeps but does not

die: Toward a psychoanalytic treatment
of the addictions
Stephen M. Sonnenberg
I
n this essay the author describes his views on the psychoanalytic
treatment of the addictions. He describes addiction as a serious
mental disorder, which is appropriately included as a topic in this
conference. Next, he conveys the scope of this major public health
problem, and discusses the reasons why psychoanalysis has made
so small a contribution to its understanding. This essay discusses
addiction in high functioning analytic patients, and offers a defini-
tion of what constitutes high functioning individuals. Case examples
from thirty years ago, and from the present, illustrate how today,
with more advanced knowledge, more successful analytic treat-
ment of addiction is possible. The author describes modifications in
standard analytic technique which are helpful, and which result in
analysands who remain abstinent indefinitely.
Introduction
At first blush one might wonder whether the treatment of the addic-
tions belongs in this conference where we are exploring such diffi-
cult clinical situations as the treatment of schizophrenia, borderline
personality disorder, and suicidality. I contend that it very much fits,
103
because addicted analysands often behave in suicidal ways, in some

cases might well qualify diagnostically as schizophrenics or border-
lines, and in general fundamentally challenge the treating psycho-
analyst to work effectively.
What is of particular interest to me is that while I have been prac-
ticing psychoanalysis for thirty-five years, it has only been in the
last five years that I have been able to recognize that right along my
psychoanalytic practice has been filled with analysands who suffer
from serious addictions. At the core of this presentation I shall offer
two cases. The first will illustrate how years ago, like many of my
colleagues, I missed the presence of addiction in my analysands. The
second is designed to illustrate how today I have a far different per-
spective on addiction than earlier in my professional life, and will
include a description of what I believe is an effective strategy for
treatment.
Scope of the problem

Addiction represents a major challenge to psychoanalysis, psychi-
atry, psychology, social work, and other mental health disciplines
because of the enormity of the health problem it represents. In what
I believe to be a vast underestimation, the World Health Organization
(2008) states that there are over 90 million substance abusers world
wide. Whether each of these is an addict depends to some extent on
which of the many definitions one favours. My definition equates
abuse and addiction, because I do not believe that physical depend-
ency is the crucial characteristic of the addict from a psychoana-
lytic perspective. Rather, I look for self-destructive behavior based
on poor judgment; driven, compulsive drug seeking; and a range
of sometimes subtle, sometimes not so subtle cognitive processing
deficiencies. In sum, what I am describing is what is sometimes
described as the hijacked brain, a concept which I embrace as clini-
cally very helpful (Hyman, 2005).
In addition to these many substance abuse problems there are
addictive disorders which do not involve substances. One such
category is internet addiction (Block, 2008), with three subcate-
gories already described: gaming, sexual preoccupation, and use
of websites like MySpace and You Tube, or email instant messag-
ing. Other non-substance addictions include sexual addiction,
T H E F I E N D T H AT S L E E P S B U T D O E S N OT D I E 105
gambling addiction, exercise addiction, and in my view workaholism.

Estimates about how many people are affected by such addictions
are very unreliable.
Finally, there are serious substance addictions which do not
involve drugs or alcohol. Here I would mention food addiction and
cigarette smoking. I realize that many would place this last in the
category with drugs.
What is most striking to me is that without taxing our imagina-
tions too much I believe we can make the case that even the most
seemingly benign of these conditions carries with it serious health
consequences, which actually shorten life in very significant ways.
So for that reason I think of these various forms of addiction as fall-
ing within the category of severe disturbance.
Another critical point is that today the experts among us who
study addiction recognize that we know very little about the entity
(Miller and Carroll, 2006a). This is so despite the fact that huge
amounts of money and scientific effort have been expended to
investigate this public health crisis. Among the points that experts
make is that substance and non-substance abuse are not associated
with a particular personality structure (Carroll and Miller, 2006). In
fact, most recently, addiction has been described as occurring along
side the full range of life problems and personality styles (Carroll
and Miller, 2006). Addiction can be a pernicious health problem for
a relatively high functioning person and for a derelict living on the
street. In my view much of the disagreement about addiction in the
relatively sparse psychoanalytic literature is a reflection of differ-
ent populations studied, different interventions offered, and differ-
ent venues in which studies take place (Director, 2002; Dodes, 1996;
Khantzian, 1987; Krystal, 1982; Wurmser, 1974).
It is curious that psychoanalysts have contributed so little to inves-
tigating addiction. I believe that historically analysts were taught
that addicts were not treatable psychoanalytically, so that even
when an addiction came into clinical focus the analyst observer was
motivated to ignore it. To understand more about this history within
psychoanalysis one has to go back to Freud. To begin with, early
in his scientific explorations Freud (1890, p. 299) referred to addic-
tion and alcoholism as morbid habits, similar to sexual aberrations,
associated addiction with masturbation, called masturbation a pri-
mal addiction (Freud, 1897), and suggested that addiction could not
really be cured (Freud, 1898). None of this motivated the beginning

student of psychoanalysis to develop an interest in addiction.
Then, in his six Papers on technique (1911–1915 [1914]), Freud
described a treatment method, which was destined to deter psycho-
analysts from undertaking the treatment of addiction, and to ensure
failure, and subsequent disinterest, if they were to try. What I have
in mind is Freud’s prescription in these papers that the analyst func-
tion with abstinence, anonymity, neutrality, and the absolute pres-
ervation of confidentiality. Curiously, despite writing on technique
Freud believed that the value of written material in the training of
psychoanalysts was limited, favouring the personal analytic experi-
ence as the critical measure which might equip someone to become
an analyst (Strachey, 1958). Additionally, Freud offered examples
within and outside the Papers on technique which indicated that in
his own work he did not adhere to what came to be cited as his tech-
nical canon. In the technique papers, for example, in writing on pre-
mature termination Freud was anything but neutral and abstinent
(pp. 129–130). Freud also recorded that he fed the Rat Man (Freud,
1909; Lipton, 1977, 1979), and many other examples of his departure
from his written technical prescription have been reported (Lynn and
Vaillant, 1998). But what might have been Freud’s preference was
outweighed by his technique papers, and the way what he wrote
has been interpreted and taught by those who claim to be his most
loyal followers (Eissler, 1953). Later, in my second clinical example,
by contrast, I will demonstrate why those who follow these rules
strictly are unlikely to have success treating addicts, and will then be
likely to avoid such clinical encounters.
It follows what I have so far said that since addiction is a very
broad category, and those who develop addiction represent a very
diverse population, that for this to be a meaningful essay I have to
make clear the population of addicts I have treated and studied.
Since 1977, when I graduated from a psychoanalytic training insti-
tute in the United States, I have usually had a full analytic practice.
That means I usually worked with between nine and twelve analy-
sands at a time. Back a few decades my definition of analysis was
more rigid: at least four sessions each week on the couch. Today my
definition is far more flexible, and I’ll leave it to your imagination
to consider the range of patients I calculate that I have in analysis.
But I will state unequivocally that my practice is still completely
psychoanalytic, and that means that with each analysand there

is an observable psychoanalytic process, involving mindfulness,
mentalization, introspection, self-analysis, and the analysis of the
transference-countertransference encounter. Obviously, an analy-
sand’s capacity to engage in these forms of thinking, feeling, and
observing, changes over the life of his or her analysis. But after
the opening phase, and the establishment of a therapeutic alliance
(which can take from months to years), every patient in my practice
comes for psychoanalytic exploration.
In this essay I am focusing on a particular group of individuals,
that I describe as high functioning. For a good working definition of
what I am calling high functioning I want to refer you to the Diagnostic
and statistical manual of mental disorders, Fourth edition (DSM), a publi-
cation of the American Psychiatric Association. Members of my high
functioning group of analysands have scores of eighty and above on
the Global Assessment of Functioning Scale (GAF) as it is described
in that volume, on initial evaluation. That means that “symptoms
[if present] are transient and expectable reactions to psychosocial
stressors … [and there is] no more than slight impairment in social,
occupational, or school functioning …” (American Psychiatric Asso-
ciation, 1994, p. 32). So this is a well functioning group of individu-
als, despite their addictions. I do want to add that when I look at an
analysand through a psychoanalytic lens, examining affect regula-
tion in relation to psychic conflict and such phenomena as mindful
self-analytic capacity, I bring into focus a perspective which is far
different from the behavioural emphasis of American psychiatry,
especially as it is depicted in the DSM.
The case of James Edwards

The first case I will describe was treated by me over thirty years
ago. At the time I was a young but experienced analyst. The patient
was referred to me by colleagues in another city, from which he
had moved to Washington, D.C., where I was living. He was a high
ranking United States government employee, who occupied a Sub-
Cabinet level position. When we first spoke on the phone he reported
depression over the break-up of his second marriage.
When I met with James I heard a remarkable story. He was forty-
seven years old, and African-American. He had risen from poverty
and deprivation in a ghetto in a major United States city. When

he was quite young his mother, who had previously been doting,
encouraging, and loving, began to drink and run around with men
outside her marriage. In response to mother’s behavior father, a
critical and angry man to begin with, protested vigorously, but in
vain. He would lose his temper and hit mother, which was obvi-
ously counterproductive. When James was twelve, his mother left
the family, and lived with her alcoholic boyfriend in a neighbouring
state. For the next few years James rarely saw mother, but based on
their sporadic contact was aware that she was deteriorating. Father
took up with another woman, and James had to fend for himself.
Members of his extended family lent a hand, but he was largely
unsupervised. When he was fifteen his girlfriend became pregnant,
he married her, and soon was the father of twins. That marriage
lasted for twenty years, and James became father to a second set of
twins and a fifth child.
Against great odds James fought to keep his family together,
and get an education. He worked at menial jobs within universities
in order to gain tuition remission. He was also a gifted musician,
studied part-time at a local conservatory, and eventually earned
a college degree, and became a pioneer in the area of community
arts advocacy. He developed programs involving the teaching of
fine and creative arts to ghetto children and ghetto mental health
patients.
Twelve years before I met him James’ marriage ended. He and
his first wife did not wish to remain together, but remained on cor-
dial terms. Soon after his divorce James met and married his second
wife, and they had a son. When he was offered his high level job in
D.C. he, his wife, their son, and his fifth child from his first marriage,
also a son, moved to Washington. In his new position he was to use
his skills as a community arts activist and organizer.
From the time of his move his second wife rejected him. She hated
where they lived, complaining that it was away from the “Black
action.” Eventually, a few months before I met James, she moved
out. He felt depressed, helpless, and abandoned. He was furious at
his wife, and in our extended consultation reported that he drank
“immoderately” in an effort to “take the edge off” his rage. He
reported that at such times instead of feeling calmer he felt angrier,
and would call his wife and rage at her over the phone. This, in turn,
led him to feel guilty and more depressed, and he ended up blaming
himself for her departure.
Early in the analysis James demonstrated a transference reaction
to me in which he saw me as being like his father: He believed I
would find fault in his behavior and reject him, which paralleled the
way he experienced his father after mother’s departure. He related
father’s harshness during that period, during which James was on
the receiving end of frequent and regular beatings. He also demon-
strated the belief that his experience with his wife was identical to
what his mother had done to him. He believed that both women had
left him because of his own shortcomings, particularly his anger.
Early in the analysis he came to appreciate ways in which in the
present he was re-experiencing his childhood helplessness when his
mother had left him, and his father had angrily beaten him. He real-
ized that in some ways he could actually feel happy at the possibil-
ity of a divorce, if only he could fully understand and put an end
to the ways in which he was using the present to re-experience and
rework the past, especially motivated by his guilt at what he saw as
his responsibility for the decline of both his parents.
On the surface this analysis went extremely well over its course
of seven years. However, what I will now convey, through the use
of process material, and a candid reappraisal of how I worked with
James, sheds a very different light on what went on.
He did not appear for his first analytic session, which was sched-
uled after a period of detailed and careful consultation. The next day
he appeared and after clearing up a few loose ends he lay down on
the couch. He began:
“I missed yesterday because the night before I was furious at

my wife, I started to drink, I drove to her house and I yelled at
her, I hit her, then I blacked out. It was the worst episode of its
kind I ever had, though for a number of years, especially the
last two years, this has been happening … I just can’t accept that
a Black woman can treat a Black man like that … when I was
twelve my aunt seduced me and introduced me to sex …”
I responded that this was the first time he had told me of this
sexual experience, and that he “was in the right place, that we
could talk about this.” He then became tearful, cried throughout
the rest of the session, expressing gratitude that I had said what
I had. He said “I need help … so much of what I feel toward

my wife is a rage at my aunt and my mother, at women in the
past …”
During the months that followed James began to talk about the
racism he experienced in his work. He felt that he needed the support
of his wife to deal with that, and was disappointed and angry that she
was not there to give it to him. Eventually, he became more specific
about how his peers in his Cabinet department viewed him. They
were, in his view, privileged white men, were disrespectful of his
expertise, of his mission, and of the unique education he had gained
through his own hard work over many years. He began to make anti-
white statements, and I responded by asking him how he thought I
might respond to what he was saying. He insisted that he trusted me,
that he believed I was on his side, and that I believed that what he
had to say was accurate and appropriate. When he reported that he
was afraid his boss, the Cabinet member, was going to squeeze him
out and fire him, he said that he believed I understood and agreed
with his concerns. I knew he was correct, and reacted quietly with a
sense that he had gotten the message I wished him to receive.
Then, several months later, he spoke about his uncertainty about
the analysis. He had spent the hour talking about how empty and
sad he felt inside, how miserable he felt about his wife and his sons
in Washington, and as the session drew to a close he said “I wonder
what I’m doing in analysis, I feel so unsure about how to use it, so
strange on the couch, I don’t know where I’m heading.” I interpreted
this as an expression about the general uncertainty of his future, but
did not ask about what it might have meant regarding his concrete
experience of analysis.
The next week he came in and was enraged at his boss. He told
me that there had been some kind of a leak to the press about some
important departmental issue, and that the Cabinet Secretary had
said “there’s a nigger in the woodpile somewhere …” The Secre-
tary then caught himself, looked at James, swallowed hard, and said
“… to use an expression you would use …” James was furious, but
during the next few minutes of his hour we saw a demonstration
of what we had come to expect of him: He turned on himself, and
wondered if he had behaved properly in the face of what was obvi-
ously an unpardonable insult on the part of his boss.
What followed was that for the next two weeks every session
began with a report that James had been drinking heavily at night,
had consistently contacted his wife and screamed at her for not
supporting him, and had blacked out at the end of each encounter.
He then would associate to the way his father monitored his con-
duct, and routinely beat him out of what James knew was displaced
rage at mother for abandoning father and him. And each time, as his
associations turned to his guilt and shame at his behavior, I inter-
preted his turning on himself.
James’ most successful child was a college professor, who was
informed by his estranged wife of what was going on, and visited his
father in Washington. The two had a joyous reunion, and son was sup-
portive of father. But this respite had almost no lasting effect, because
right after father and son parted James began to drink, and ended
the night screaming at his wife over the phone, and blacking out. I
made an attempt to interpret these blackouts as a defense against recall-
ing the extent of his aggression, which was freed up by his consump-
tion of alcohol to be felt and expressed. James politely agreed that might
be possible, and when I sought the opinion of two analytic colleagues
about my interpretation they thought that I was on the right track.
Some time later James came to an hour describing a conversation
he had with a neighbour who is a psychiatrist and a psychotherapist.
He felt that this man is troubled, and just doesn’t understand how
he feels, who he is. He is afraid to say anything to that neighbour,
for fear of insulting him. I ask if there’s something here that he feels
about me, that there’s something about myself or the two of us that
I just don’t get. I asked if he feared insulting me if he told me what
he really thought. James responded “I’m a compulsive drinker when
there’s alcohol around … I need to talk about the way I drink … I feel
like your interpretations, when you talk about my guilt and shame
over my rage, and the way I turn on myself, that’s not so pertinent,
relevant, correct …” That statement closed his hour, and got lost the
next day when he described, in retrospect conveniently reinforc-
ing and affirming my confidence in the approach I had taken for a
very long time, an episode of hostile aggression from childhood. He
remembered shooting his mother in the stomach with a BB gun dur-
ing one of her rare visits after her departure. This description was
filled with guilt and shame, and reinforced my view that it was in
that area of investigation that this analysis belonged.
What I want to emphasize now is that James’ analysis continued

for seven years. At the time I would not have said that his cognitive
function was impaired, that his ability to be self-reflective and thought-
ful was less than excellent. Eventually, the notion that he turned on
himself became an important aspect of how he understood himself,
and he was able to recognize that when he was exposed to racist atti-
tudes, which was a regular occurrence in his world, he responded
to that stressor with rage, before turning on himself out of a sense of
guilt and shame. He eventually reconciled with his wife, and though
their marriage remained tumultuous, it persevered. He came to pos-
sess an integrated understanding of the scars he felt from his very
dysfunctional childhood, and he could stop himself and recognize
when he would superimpose the past on the present.
What James never brought under control was his addiction to
alcohol. While he could speak about his personal history and psy-
chodynamics in a way which made sense, he never stopped drink-
ing when he was stressed. The result was that he did not perform
well in the very demanding Sub-Cabinet level job he had, and given
his high and sensitive political profile, a quiet and honourable job
change, away from Washington, was arranged. There was a big going
away party, and James was publicly praised. But, predictably, in ret-
rospect, James failed at three subsequent jobs, each time taking a new
position with less responsibility and less pay. In the end he reached
retirement age a man who had failed to live up to his potential, as a
talented public servant, a husband, or a father. He had kept in touch
with me over the years, and because of occasional phone conversa-
tions I knew all this. In the end James still turned on himself, and to
my knowledge never felt that I had let him down. Of course, this was
consistent with his defensive style. Until I came to understand, years
later, that James’ alcoholism had never been treated, that he had never
stopped drinking, and that he had never reclaimed his hijacked brain,
I could not formulate what had gone undone. Now I believe that for
all he had learned, he had never possessed the capacity to think in a
deeply self-analytic way about what he had potentially learned.
The case of stuart holcombe

Now, having described a case from three decades ago, in which I
failed to recognize and address my analysand’s addiction, I will
report on a very different clinical situation. For the last thirteen years
I have lived and practiced in Austin, Texas, a medium sized city in
central Texas, which is the state capital and the home of the very large
and quite excellent University of Texas. For all intents and purposes
until very recently I was the only training analyst in Austin, which
means that almost all my analysands were mental health profes-
sionals, known as such to each other and the broader mental health
community. For that reason I must avoid writing about one of my
own analysands. However, I am fortunate in that I also have a large
supervising and consulting practice, which includes people who
live far from Austin, and one case on which I have consulted for five
years serves to beautifully illustrate what I have learned about the
treatment of the addictions. Nevertheless, I do want to emphasize
that the case is well disguised, and of course the name of the analy-
sand is fictional.
Let me begin by telling you about the analyst with whom I
consult. From 1969 through May of 1995 I lived in Washington, D.C.
One academic activity I enjoyed in Washington was my service on
the faculty of the Uniformed Services University of the Health Sci-
ences (USUHS), also known as the “military medical school.” Part
of my work at the medical school involved supervising psychiatry
residents studying at the various military hospitals in the Washing-
ton metropolitan area. One particularly outstanding resident was a
man who had been a career soldier, serving first as an enlisted man,
then while on active duty going to college and eventually gradu-
ating from USUHS. He began training in internal medicine, before
switching to psychiatry. It was then that we first worked together.
His name is Joseph Waterbury. Years went by, I had moved away,
and Joseph became a psychoanalyst. He would send me a Christmas
card every year, with a photo updating me on the growth of his fam-
ily, and occasionally we crossed paths at a conference or congress.
Five years ago, in 2003, he called me, asking if I would consult with
him on a particularly difficult case. He reminded me that now he had
left the military, and was in private practice. He added that because
he had worked at the Bethesda Naval Hospital while on active duty,
he had taken care of many VIPs. This pattern continued when he
went into private practice. He had many high profile analysands,
some were elected officials, some were appointed officials, and some
from within the military and the press corps. The person he wanted
to discuss with me, a man named Stuart Holcombe, was an investi-

gative journalist. One reason he wanted to speak with me was that
I no longer lived in D.C., and while in theory that didn’t matter he
liked the idea that I was in some ways more removed from the scene
of the treatment and the home of the analysand than a local consult-
ant. He also wanted to speak with me because he knew that I am a
writer, and he felt that at times, when his analysand’s writing was
not going well, I might have some special insights to share with him.
I was flattered that this former resident supervisee would call on me
at this time in his life, when he himself had accomplished so much,
and we began to meet weekly over the phone.
Joseph told me that ten years earlier, in 1993, he was consulted by
Stuart, who presented with a chief complaint of depression. During
an initial period of evaluation Stuart related the following story. He
was the third son of his parents, who were educated and privileged.
Before he was born his oldest sibling had died in a freak drown-
ing accident. He asserted that he was a replacement child, but that
he could never make up for the loss experienced by his parents. In
Stuart’s opinion his inability to temper the disappointment and pro-
found sense of loss which permeated the family resulted in distant
relationships with both his parents. He said that he grew up feeling
alone and isolated. His surviving older brother was seven years his
senior, and also depressed, so that brother was unable to mitigate
Stuart’s profound aloneness.
Growing up as he did in a family in which each parent and his
older brother were self-absorbed in their unprocessed grief, Stuart
had no models on which to base his efforts to have friends out-
side the family. He did, however, grow up a very curious fellow,
always trying to figure out why his family situation was so static,
so unchanging. However, he was never drawn to psychology as a
vehicle for developing the understanding he lacked.
Stuart had been a good student, and left home for the first time
when he attended one of America’s leading universities. However,
there he proved to be a directionless student, and eventually dropped
out before receiving his degree. At that point he went to Washing-
ton, with the plan that he would try to establish himself as an inde-
pendent investigative journalist. Things went very slowly at first,
but shortly before he consulted with Joseph he enjoyed his first suc-
cess. He had gotten wind that the Washington branch of a religious
cult was being investigated by the D.C. Police for child abuse, and
he decided that he would attempt to infiltrate the cult. At that point
Joseph was quite young, still of college age, and many of the cult
members were his chronological contemporaries. He attended cult
functions, pretended to be very interested in what the cult leaders
preached, and eventually took up residence in a group home oper-
ated by the cult. There, he met a woman of similar age, and they
seemed to fall in love. He also encountered proscriptions on his con-
duct of that relationship, rules which included threats of physical
punishment and excommunication should he fail to cooperate. He
actually became quite frightened, and when he found himself una-
ble to convince his girlfriend to leave the cult with him, he slipped
away late one night. He was very surprised when cult leaders pur-
sued him, ordered him back to the group home, and threatened him
if he publicly spoke about the cult.
Stuart was not a well socialized person, and because of that was
more resistant to the kinds of group pressures to which he was
being exposed. Someone with more social skill might have been
more frightened, and would have been more tempted to return
to the group. Instead, he stayed away, and wrote his story, which
included many details of his own experience of intimidation and
abuse within the cult. His reward was that a major national news
magazine bought the story, and from then on Stuart was thought of
as a hard charging, gifted journalist. His immediate response to that
was to become depressed, and that motivated him to ask around for
suggestions about who he might see for help. Since Joseph was well
know in Washington journalistic circles, his name came up more
than once as Stuart the investigator located a potential therapist.
Eventually, Stuart called Joseph for an appointment.
In that first meeting Joseph recalled Stuart as an unusual man.
He had already earned the reputation of a skilled reporter, but to
Joseph he seemed withdrawn and irritable. Stuart explained that as
a rule he is perceived as aloof, even as unfriendly, and that his with-
drawn exterior masks his profound discomfort in any situation in
which he is required to socially mix. He added that this first inter-
view with Joseph seemed to him to be one of those awkward social
situations. Joseph decided that he would need to see Stuart several
times before he could formulate his clinical impression and make a
sensible treatment recommendation, but after three more meetings,
and still unsure of what to recommend, he explained his uncertainty

to Stuart, but recommended a trial of psychoanalysis. Stuart, always
the curious one, agreed.
At the first analytic session Joseph began to question his thera-
peutic plan. For Stuart not only appeared vacant when entering the
consulting room and lying on the couch, but once supine he fell
into silence. This lasted most of the session. That pattern contin-
ued for several weeks, during which Joseph worked hard to help
Stuart understand the source of his withdrawal once the analysis
had begun. Once again, all that the analytic pair came up with was
that withdrawal by Stuart was a function of his discomfort in inter-
personal or social situations. Joseph silently hypothesized that when
on the trail of a story Stuart was quite different, because in that situ-
ation he felt confident when acting as the aggressor.
Eventually, there was a change in Stuart’s behavior in the consult-
ing room. He began to reflect more on his childhood, and on how his
upbringing was instrumental in shaping his adult personality. But to
Joseph there was always something about Stuart that he could not
understand, and as the opening phase of analysis continued Stuart
explained more about his moods. He knew that when he was on the
trail of a good story he felt energized, capable, even powerful, but
that when there was no story on which he was working his aloof-
ness and unfriendliness came to the fore, accompanied by feelings of
depression. One thing he could not do, Stuart asserted, was to gen-
erate story ideas on his own, at such times. Investigative challenges
had to come to him.
Consistent with the minimal but identifiable progress outlined
above, the first five years of analysis were relatively unproductive.
There were no new big stories, and no substantial analytic progress.
And though there was no evidence for a clear therapeutic alliance,
Stuart continued to come to all his sessions, though often remaining
silent. Then, one day, Stuart told Joseph that he was on a new story,
involving a sex scandal in Washington. He also mentioned, almost
as an aside, that he had been snorting cocaine recreationally for the
past six months.
Stuart was now quite different in his sessions, talking rapidly
about how excited he was to be on the trail of something important
on the Washington journalistic landscape. Joseph was energized by
Stuart’s new found passion, and Stuart used his sessions to describe
in detail his uncovering of a scandal that involved important political

figures, and their paid sexual partners. Stuart revealed during this
time just how much contempt for people he could conjure up in his
mind, cynically describing the political leaders his investigation
could bring down.
When the investigation ended, again causing Stuart’s star to rise in
national journalistic circles, he once again fell into a state of depres-
sion. Then, he confessed to Joseph that he was infatuated with one
of the high priced prostitutes he had met while investigating the sex
scandal. He knew that this was a potentially poisonous relationship,
and he was restraining himself from acting on his impulse to contact
the woman. But this was not easy for him, especially because he
had never had sexual relations with a woman, nor had he ever gone
out on a date other than with his girlfriend in the sect (which, upon
reflection, was nothing more than Stuart’s journalistic contrivance).
For the first time Stuart talked with Joseph about his sexual history,
and about feeling very excited, tempted, and stressed.
Soon talk of Stuart’s infatuation stopped, as did descriptions of
depression, stress, and cocaine abuse. The analysis went back into
the doldrums, Stuart was sad and immobilized, and Joseph was
bored. But as Stuart’s luck would have it, soon a new Washington
scandal distracted him from his depression, and his former infat-
uation, if it still remained in dormancy in his mind. This scandal
involved crime in local prisons, and with the network of informants
within government that Stuart had built up during his investiga-
tion of cult activity in Washington, and sexual misbehaviour among
government leaders, he was well positioned to pursue this new
investigation vigorously.
By this time Joseph had been seeing Stuart four times a week,
on the couch, for about seven years. He had seen Stuart up, and
down, but now, aware of Stuart’s use of cocaine, he listened for signs
of euphoria, grandiosity, or paranoia. His careful attunement was
rewarded, because when Stuart’s investigation had been completed,
he confessed to Joseph in more detail than ever before what he felt
during an investigation, and how he dealt with it. Here’s what
happened.
Stuart discovered that there was an organized drug ring in neigh-
bouring state prisons and Washington’s own equivalent of a state
prison. The ring included correctional officers and inmates, the
former serving as drug couriers and distributors, and the latter as

the contacts to the suppliers. Large sums of money were changing
hands, and the betrayal of their inmate business partners by the
correctional officers resulted in several inmates going public, and
calling in the press. But Stuart had gotten a big jump on his jour-
nalist competitors, and was turning out great reporting while oth-
ers were still getting oriented to the potential revelations. However,
Stuart was chagrined, because despite his natural excitement which
accompanied his working on this great scandal, he found that he was
experiencing very high levels of stress, and that he craved cocaine
more and more. Eventually, he was snorting it uncontrollably, many
times a day. He brought it with him to the prisons he visited, and
risked getting caught in public when he snorted it in his car in what
were relatively exposed circumstances. He became fearful of this,
and confessed to Joseph his fear that he was an addict. But within a
couple of weeks he reported that this concern had receded, that he
was once again using cocaine only recreationally.
For three more years Joseph worked with Stuart, trying to acti-
vate and energize an analytic process. But he was unsuccessful, and
out of conscious desperation, along with optimism generated by the
fact that this withdrawn man came to all his sessions, Joseph called
me in as a consultant. I am often amazed at how, at such times, unex-
pected things happen in analyses. Such occurrences always make me
feel that unstated and mostly unconscious communications between
the members of the analytic pair motivate the analysand to behave
in ways which open up the analysis, and the analyst, in unconscious
anticipation of such events, to prepare for them by bringing in a
consultant.
Joseph began our work together by giving me the detailed his-
tory I have just conveyed, and I immediately raised the possibility
that Stuart was revealing only the tip of the pathological iceberg.
I speculated that stress and cocaine addiction were playing a central
role in Stuart’s life, and that Stuart was even coming to sessions
intoxicated.
At this point I urged Joseph to diligently look for signs of
Stuart’s substance abuse, in and out of analytic sessions. I explained
to Joseph that addictions were difficult to spot in high function-
ing people like Stuart. Such individuals do not usually come for
analysis complaining of being addicted. If anything, they play down
their own helplessness in the face of their use of an addicting sub-

stance, claiming that it is a recreational pursuit, and fully under
control, if they mention it at all in the initial evaluation or the sub-
sequent analysis. I added that current thinking about addiction is
that such behavior most often occurs when the individual is under
stress (Koob, 2006), and that for Stuart either work on a story, or
not having a story to investigate, constitutes a state of high stress.
I encouraged Joseph to view Stuart as having very poor judgment,
related to his cocaine addiction, and the euphoria it induced in his
poorly functioning, hijacked brain (Hyman, 2005).
I review the literature for Joseph

At this point in the consultation process I imparted some very
specific information to Joseph, information to which I have previ-
ously referred in this essay. I explained that it is my observation
that because psychoanalytic education emphasizes that addiction
is untreatable by analysis (Freud, 1890, 1897, 1898), analysts tend
to ignore the information they receive from analysands suggesting
that there is a true addiction problem. Also, I added, past failures of
one’s own or of analytic colleagues in treating addiction reinforce a
reluctance to undertake the analytic treatment of addicts.
I went on to say that in training analysts are imbued with a set
of principles of analytic technique which serve simultaneously as
ethical guidelines, creating a self-reinforcing system which inhibits
us as we attempt to work creatively and analytically with addicted
analysands (Freud, 1911–1915 [1914]); Sonnenberg, 2008). What I
had in mind, and explained in detail, is that card-carrying ana-
lysts have been overexposed in training to injunctions to practice
with strict adherence to abstinence, neutrality, anonymity, and the
pledge of absolute confidentiality, all reinforced by the concept
of undesirable parameters which supposedly poison the analytic
process (Eissler, 1953). The result of all these lessons is an ana-
lytic healer who intuitively anticipates failure because he or she
is inhibited by the technical-ethical considerations just mentioned:
Common sense then encourages him or her to avoid recognition of
addiction in a range of clinical situations he or she might encoun-
ter, or the need for the analytic treatment of addiction within one’s
practice. I urged Joseph to begin to think out of the box. I urged
him to consider that the pressure to use only interpretation as his

method of intervention might prevent him from offering Stuart an
effective analytic treatment.
Next, I reviewed for Joseph the observations made by other ana-
lysts as regards the treatment of addiction. Not surprisingly, I told
him, there is relatively little in the analytic literature about addiction,
and certainly no consensus. First, I mentioned the work of Krystal
(1982), who notes that addicts are unable to recognize and articu-
late what they feel, including feelings of pleasure. Another difficulty
Krystal identifies is the inability of addicts to regulate their affects,
an observation now better understood because of the work of Schore
(2003a,b). Krystal emphasizes that addicts have experienced very
early difficulties with their mothers, and that addiction represents
a symbolic search for a mother they can take in, internalize. Thus,
for Krystal, the drug represents a transference object. In addition,
Krystal is interested in the role of trauma in the life of the addict,
trauma which is both pre-verbal and experienced in adult life. While
there is no memory of the early, pre-verbal trauma, Krystal believes
it is trauma at the hands of the mother, who mistreated her infant.
Krystal advocates an analytic stance in which the analyst plays a
mothering role in the interaction with the patient, encouraging the
addict to develop capacities for self-care.
Next I touched on the work of Wurmser (1974). Wurmser asserts
that the addict cannot tolerate affects such as shame and guilt, and
in response to such feelings searches compulsively for drugs. Stand-
ing in distinction to Carroll and Miller (2006), who write that addicts
come from every possible personality type, Wurmser states that
addicts are self-destructive borderlines with narcissistic features.
Like Krystal, Wurmser’s perspective emphasizes that addicts are
incapable of affect regulation, and by default use an addictive sub-
stance as a self-help device in the face of an overwhelming unpleas-
urable feeling, usually involving a narcissistic injury. Wurmser
also blames the addict’s parents for not providing good models for
superego development. Wurmser minimizes the role of dependency
in discussing addiction.
I told Joseph that Khantzian (1987) is another analyst who has
studied addiction. Unlike Krystal and Wurmser, he rejects either/or
positions and embraces many theoretical and developmental per-
spectives. He focuses on the suffering of the addict, who struggles
with multiple layers of psychopathology. Like Krystal, Khantzian

emphasizes a caring relationship between therapist and addicted
patient, in which the patient learns self-care, and affect recognition
and regulation.
I now told Joseph about Dodes (1996), who describes the addict
as striving for power when he feels a sense of helplessness. To Dodes
compulsive drug use represents such a striving, and his view is that
this is the case with other compulsions. Dodes sees addiction as an
unconscious compromise formation which can be analyzed. Like
Khantzian, and unlike Krystal and Wurmser, Dodes does not focus
on early psychopathology in the addict.
Finally, I mention to Joseph the work of Director (2002). She is
a relational analyst, who emphasizes that within the analysand-
analyst relationship the addict can develop new, more effective ways
of interacting with others. This occurs as old, troubling relational
dynamics are re-enacted, early painful patterns of relating are iden-
tified as the source of these dynamics, and all this is understood.
Director asserts that under these conditions the roots of addiction
can be mastered.
After having gone through this exercise of identifying for Joseph
what other analysts have said before, I emphasize that these col-
leagues have put forth many different ideas, but not brought us to
the point where we can embrace a psychoanalytic consensus.
I also review for Joseph what non-analyst addiction experts
have to say. We do know definitively that addiction is in part a
response to genetic influence (Hasin, Hatzenbuehler, Waxman,
2006). We also know that within the central nervous system there
are centres which respond to intoxicating substances and experi-
ences of pleasure, and we also know something about the neuro-
chemistry of the brain’s response to addicting substances which
cross the blood brain barrier (Koob, 2006; Childress, 2006). I again
emphasize that this knowledge helps us to understand that in
addiction certain central nervous system functions are usurped,
and learning and memory do not work as they do under other cir-
cumstances. This means that judgment is poor, that the brain is
hijacked (Hyman, 2005). I stress that while we know a great deal,
we are not able to mount an effective treatment protocol for addic-
tion, and that psychoanalysts are as much in the dark as other men-
tal health practitioners.
I continue to summarize the critical thinking of those I consider

the experts in this field (Miller and Carroll, 2006a). I point out that
despite the identifiable risk factors, such as genes, drug use is a
gradually emerging, self-perpetuating, chosen behavior (Miller,
2006). Drug use is not an isolated psychological phenomenon, but
occurs imbedded within personal and broader societal phenomena,
including family discord, poor health, poverty, child abuse, and
various forms of psychopathology, such as mood disorders (Carroll
and Miller, 2006; Miller and Carroll, 2006a,b). Broader social issues
are of great importance, and we must be sure that when we treat
someone for addiction we are aware of how the analysand’s family,
social network, and total environment promote or discourage the
addiction. All this must be considered as we deal with Stuart. One
very critical point that the experts on addiction make is that quality
relationships can be crucial in preventing addiction and promoting
abstinence. Especially critical is the relationship with an understand-
ing, empathic, non-shaming therapist (Miller and Carroll, 2006a,b).
These experts also emphasize that addiction treatment should be
integrated with other aspects of healthcare, and not isolated in addic-
tion designated specialty clinics (Miller and Carroll, 2006b). I tell
Joseph that my view of analysis is that it is part of an holistic health-
care system. Other critical dimensions of treatment are the enhance-
ment of motivation to conquer the addiction (Miller, 2006), and the
encouragement of abstinence (Alcoholics Anonymous, 2007).
Finally, I tell Joseph about observations I have made in my own
work with analysands who struggle with addiction. In distinction to
the conventional clinical wisdom that addiction accompanies dys-
phoria, I have observed something different. First, I see it as emerg-
ing in situations where analysands are experiencing stress. Some of
these analysands have experienced acute traumatic stress at some
point in their lives, others have experienced what is sometimes
referred to as strain trauma in childhood, that is the trauma associ-
ated with chronic, though not dramatic, mistreatment from parents
who range from overtly cruel to unempathic. This observation is
also consistent with what addiction experts observe (Koob, 2006).
But even more important, in my view, is that I have observed
that addiction is more likely to be a problem in high functioning
analysands who are good at creating and experiencing pleasure,
as opposed to analysands who are better characterized as dour.
In my clinical experience dour analysands, individuals who would

describe their lives as a series of unrewarding challenges are less
likely to become addicted to anything as compared to analysands
who experience life as a series of challenging experiences which
hold the promise of pleasurable endings. Consistent with that
view are my hypotheses that addictions, both substance and non-
substance, operate psychologically and physiologically in the same
ways, at their most fundamental levels, and that substance and non-
substance addictions are ubiquitous human phenomena, and forms
of normal pleasure seeking gone wild. These addictions occur more
frequently when an individual used to experiencing pleasure cannot
achieve that usual end, and that is experienced as a stressor. In sum,
I told Joseph, for the addiction prone, high functioning analysand
about whom I am speaking, based on temperament and life experi-
ence the pleasure principle and the reality principle overlap, and the
result is poor judgment and an inability to delay gratification when
pleasure is not readily forthcoming (Sonnenberg, 2008).
At this point I refrain from explaining to Joseph what specific
measures I would employ with Stuart, and ask him to take his time
in reassessing the situation, and developing a treatment strategy.
I do say that the analysis of Stuart is at a crossroads, and that what
has been an inauthentic relationship between him and Stuart now
has the potential to become an authentic one. I say that there is room
in my mind for optimism. But all this is contingent on getting Stuart
to acknowledge his addiction, which I am almost certain is the unac-
knowledged variable in this analytic situation.
Joseph tells me at this point that while he is encouraged by my
thoughts and optimism, he feels that he has spent ten years with
an analysand who has probably been withholding a great deal of
information from him. I reiterate that in my experience that is inevi-
tably the case with high functioning analysands who struggle with
addiction.
Back to the analysis

The next week, following four more sessions with Stuart, Joseph
tells me that the two of them have spoken candidly about what has
been going on for a very long time. Stuart has acknowledged that his
addiction has been out of control for most of the time of the analysis,
and that shame (Vaillant, 1980) and his fear of Joseph throwing him
out of treatment has prevented him from being more candid. He
now tells Joseph of his long history of marijuana smoking, which
actually had much to do with his academic collapse when he went
to college. In fact, he now acknowledges that he is dually addicted
to marijuana and cocaine, and has even shot up heroin on a few
occasions.
Joseph reports that he then told Stuart that he sees this treatment
as a very long row to hoe, and he expressed his uncertainty that he
and Stuart could really form the kind of honest, open relationship
which is required if an analysis is to proceed to a successful conclu-
sion. Stuart responded that he can understand Joseph’s doubt, but
added that he is critical of Joseph for not being more aggressive in
pursuing him when he so often came to sessions intoxicated with
marijuana at the beginning of the analysis. He reminds Joseph of his
vacant silence during the first months of the analysis, and adds that
at the time he thinks he was testing Joseph to determine whether
he had any knowledge of addiction, and whether he was capable of
responding to him with the necessary assertiveness and concern he
so much needed and desired. It seemed to Joseph, and to me, that
this more honest exchange held the promise of a far more intimate
analytic relationship than what had been the case before, though
both of us reserved judgment and maintained cautious optimism,
at best.
While at this point I contemplated sharing with Joseph my own
views on the analytic treatment of addiction, I stuck with my deci-
sion to restrain myself, because I believed that it would be far better
for Joseph to build on this disillusioning experience by giving him-
self the space and time to consider what might be an effective way
to structure Stuart’s treatment. I maintained that position in part
because I know that the treatment method I advocate is controver-
sial, in part because I know that I am a very forceful person and did
not want to close off Joseph’s avenues for creative thinking, and in
part because I believed that both of us would learn the most about
how to treat addiction analytically if I respected Joseph’s opportu-
nity to absorb what had happened and to resonate with Stuart in
constructing an effective analytic environment.
About a month after Stuart, Joseph, and I had reached this very
challenging crossroad in Stuart’s treatment, Joseph came in with
a proposal which Stuart had spoken of during his last couple of

sessions. Stuart had been doing his usual investigative exploration
of what might be the right next step for him, and he had heard of
an analyst in Europe who had devised an intervention for addic-
tion which combined psychodynamic insight and hypnosis. Stuart
wanted Joseph’s blessing on this, and Joseph wondered what I had
to say about it.
I found this proposal very evocative, because I was aware that
it harkened back to the time when Freud made his original obser-
vations about the relationship of masturbation, which he called
the primary addiction, and other addictions, such as alcoholism
(Freud, 1890, 1897, 1898). For, at that time, when first considering
the possible treatment of addiction, Freud had proposed hypno-
sis as an appropriate treatment. I was also pleased that Stuart had
shown initiative in seeking an effective treatment for his addiction,
for that meant to me that he was engaging in a promising process
of motivated, self propelled change. I knew that experts in addic-
tion believed this was an important part of a healing process for an
addict (DiClemente, 2006). So I told Joseph that while this was not
what I would necessarily advocate, it was worth a try.
And off went Stuart, accompanied on this unusual journey to
Austria by Joseph. Upon his return alone from Austria here is what
Joseph told me. The Austrian analyst who Stuart had identified was
a member of the International Psychoanalytical Association, but was
also something of a maverick. He had studied Freud’s advocacy of
hypnosis as a treatment, and he believed that addiction was some-
how related to repressed infantile sexual desires and conflicts. In a
sense I thought that this view was not totally inconsistent with that
of Dodes (1996), who saw addiction as an unconscious compromise
formation which could be analyzed, as could any other compromise
formation.
So Stuart gave himself over to this analyst, and was hypno-
tized. What emerged was quite consistent with what other analytic
thinkers had to say. Krystal’s view of the role of maternal mistreat-
ment and trauma was borne out (1982), as Stuart confirmed under
hypnosis that his mother’s distance and emotional neglect had left
its mark. In keeping with the observations of Vaillant (1980) and
Wurmser (1974), under hypnosis Stuart revealed a delicate sensi-
tivity to emotions involving shame and guilt, over his inability to
control his addictive impulses. This finding was also in agreement

with Dodes’ observation that the addict strives for power when he
feels a sense of helplessness, which is what he feels in relation to his
compulsive drug desires (1996). In keeping with Kantzian’s perspec-
tive (1987), under hypnosis Stuart revealed a sensitive appreciation
of what Joseph had provided, by his steady and non-judgemental
acceptance of Stuart’s cocaine cravings. Joseph’s empathy turned
out to be critical in allowing Stuart to remain in treatment for ten
years. Finally, supporting Director’s view of the centrality of the
analytic relationship in allowing the addict to develop new ways
of interacting, hypnosis confirmed that Stuart believed that within
the analysis he had developed new skills in solving old, re-enacted
dynamics, involving his distant mother (2002).
When Stuart was not under hypnosis the Austrian doctor
explained what had been observed. These findings, like much that
is discovered when an individual undergoes conventional, con-
temporary analysis, were received by Stuart with the response that
everything seemed to confirm what he had expected, what he had
just about concluded in his self-reflective, analytic deliberations. He
was grateful for the experience in Austria, and decided that what
he needed to do was take time off for a different sort of reportorial
project. He told Joseph that he wanted to take some time to write a
memoir, and that upon its completion he would return to his analy-
sis. Joseph wished him well, and returned to Washington, and to his
consultation process with me.
I wondered to Joseph what the future might hold. I wondered if
Stuart would ever return to analysis. At this point Joseph decided to
present other analysands to me in supervision, particularly because
he had other people in analysis who he now recognized as suffering
from other, unacknowledged addictions. As we discussed these ana-
lysands it seemed appropriate to explain to Joseph what techniques
for the analysis of addicts I had developed in my own practice.
I describe my technique to Joseph

I explained to Joseph that I had developed several technical
departures which I found useful in analyzing high functioning
addicts. I began by reasserting that these individuals never came
for treatment asking for help with addiction. Indeed, they always
came for other reasons, usually did not even mention addiction or
substance or non-substance abuse in the consultation, and when
such matters arose they were always referred to as “recreational”
activities, always under the analysand’s control. When this myth
was finally exploded, and an explosion it usually was, the analy-
sand and I had to go through a process of reassessing the analysis, a
reconsideration of whether authentic, mutually committed analysis
was possible. When it was, I instituted the analytic techniques I next
described.
First, it was often necessary to modify the rule of absolute confi-
dentiality. That was the case for any number of reasons, including
the possibility that a legal process, such as a drunk driving charge
or a professional licensure review, was part of the picture. In other
instances I had learned about the analysand’s addiction because it
had been reported to me by a member of the analysand’s family, or
a business associate, who expressed a compelling need to be kept
informed of the analysand’s well-being.
I had given such situations a great deal of thought, particularly from
the perspective of the analysand’s right to autonomy, to a true sense of
agency. Upon reflection I concluded that if an analysand had created a
situation in which others needed to know something of the analysand’s
analytic progress, true agency meant that I could not protect the ana-
lysand from that personal responsibility and need to report. I realized
that when commanded by compelling outside circumstances I could
expect and require the analysand to write such a report as a condition of
our working together, and that my attesting to its validity was a further
departure from absolute confidentiality. I believe all this is consistent
with my view of what constitutes the promotion of autonomous, per-
sonally responsible analytic work. I explained all this to Joseph.
The second modification of technique I embraced was insisting
that my analysand engage in a twelve step group experience along
with analysis. I recognize that this requirement is also a departure
from strict confidentiality, since twelve step groups are not, strictly
speaking, private experiences. But I explained that I have concluded
that the kinds of interactive processes which support autonomous,
mature development are induced by group experiences, in addition
to what are now well understood individual developmental experi-
ences, whether these latter occur in the natural course of life or in
analytic treatment (Beebe and Lachmann, 2002; Miller and Carroll,
2006; Schore, 2003a,b; Siegel, 2007). For that reason, while I don’t
insist that my addicted analysand go public and join a twelve step
group immediately upon starting analysis, sooner or later I insist on
that experience as a part of treatment.
A third twelve step related modification is that I insist that for at
least some period of time in analysis my analysand remain sober. In
the case of a non-substance addiction that means abstaining from the
compulsive, addictive activity. Since I believe that the mechanism of
action of substance and non-substance addictions are identical, at
some fundamental neurobiological level, sobriety, or abstinence, are
absolutely essential if the analysand is to be able to restore his or
her hijacked brain to a state of clear thinking about the addiction, an
essential component of conquering the addiction.
Finally, a fourth modification involves the analysand acknowl-
edging that his or her brain has been hijacked, and that therefore,
lacking in good judgment, he or she must acknowledge that not only
is sobriety or abstinence essential, but that at least temporarily I am
the higher power, the individual with good judgment, to whom he
or she must defer. I do not suggest that I must always be thought of
in that way by addicted analysands, but that as long as we suspect
that their memory and learning capacities are not under good con-
trol, it is useful to defer to me as their higher power as regards the
conquest of their addiction. Of course, this, too, is a modification in
keeping with the twelve step model.
I told Joseph, in a summary of what I had just explained, that all
this was consistent with what I was trying to promote with a per-
son with whom I had previously been going through the motions,
without an authentic analytic relationship: I was trying to promote
real intimacy and cooperation, where before what had existed was
a superficial masquerade of an analytic relationship. Joseph under-
stood what I was explaining. I also emphasized to Joseph that I
saw all that I did as compatible with the teachings and programs of
Alcoholics Anonymous (2007).
Two years after Stuart’s hypnosis in Austria, and two years after
parting company with Joseph, he returned to Washington and asked
Joseph if they could resume their work together. Stuart reported that
he had not used cocaine or marijuana in two years. It was then that
Joseph said to me what has been incorporated into the title of this
essay. He said: “I have spent years, knowingly and more often
intuitively, unknowingly, trying to wean Stuart from his addictions.

I believe that now that fiend is asleep, but I know it is not dead, I
know that it has the potential to return. Here I believe Freud was
correct. An addiction may be dormant, indeed, it may never return,
but it is not medically appropriate to think of it as permanently con-
quered. That fiend can reawaken at any time.” And so, as conditions
for resuming treatment, Joseph insisted that Stuart accept all the
treatment conditions and modifications I have just described. Joseph
did this willingly, and now, three years later, I can report that Stuart
has been cocaine and marijuana free.
I can also state that Stuart’s analysis has deepened. There has
been a focus on Stuart’s early life experience with his distant mother,
and his evolving understanding of the ways that traumatic relation-
ship causes him to feel unloved and unlovable, inadequate, helpless,
and powerless. This discussion of what some would call a history of
strain trauma has resulted in Stuart understanding two very impor-
tant aspects of his history and his personality. In the past, like many
high functioning addicts, Stuart would experience a repetitive, esca-
lating cycle in analysis: when he felt particularly helpless in the face
of his addiction, and would engage in addictive behavior, he would
feel so ashamed that he would not tell his analyst about what was
happening. This led to even more addictive behaviour, and a cycle of
helplessness, shame, secrecy, and more addictive behaviour would
ensue. Now, Stuart was able to tell his analyst when he was feeling
compelling addictive urges, and abort the escalating cycle of addic-
tive behaviour.
A second area of understanding, consistent with the first, is that
Stuart came to understand that his early life experience left him
unknowing of how to use personal relationships constructively, to
feel more regulated when he was frustrated, sad, or disappointed in
himself. Now Stuart learned to use the analytic relationship in such
a way, and it became a model for other relationships, as well.
This more authentic analysis has led Stuart to a greater apprecia-
tion of the ways his drug cravings reflect his temperament, his biol-
ogy, as well as his psychodynamically influenced efforts to find and
take in a good mother. As noted, he has discussed his intense shame
at his powerlessness in the face of his addictions, and his desire for
a form of powerful self-regulation when in the past he medicated
himself with cocaine and marijuana. His analysis has taken on the
form of an authentic, two person conversation, as Stuart has been

able to express his gratitude to Joseph for his kindness, empathy,
and candour, and engage as well in an analytic conversation which
has, when appropriate, focused on Stuart’s experience of being mis-
understood by Joseph. The doubts such moments raise in Stuart,
and Stuart’s concurrent transference experience which causes him to
conflate such situations with the fear that Joseph is like his mother,
and neither cares about him nor desires to understand him, has been
an important part of analysis since Stuart’s return to treatment. All
in all, Stuart seems far better able to think self-reflectively, to mental-
ize, to self-analyze, to self-regulate, and to interact with others in a
more intimate, satisfying fashion.
Conclusion and summary

In this essay I have tried to describe my views on the analytic treat-
ment of the addictions. I began by describing my conviction that add-
iction is a serious mental disorder, which is appropriately included
as a topic in this conference on the psychoanalytic therapy of severe
disturbance. Next, I described the scope of this major public health
problem, and discussed the reasons why psychoanalysis has made so
small a contribution to its understanding. I explained that only in the
last five of my thirty-five year career as a full time, practicing psy-
choanalyst have I recognized that addicted individuals have regularly
and frequently been my analysands. I explained that I was discuss-
ing addiction in high functioning analytic patients, and I offered a
definition of what characterized high functioning individuals. I fol-
lowed this with an appropriate case example from thirty years ago,
which illustrated the way in which I was then unable to understand
and respond to my analysand’s pleas that I recognize and treat his
alcoholism. Then, using a contemporary case in which I served as a
consultant, I described the course of a more successful treatment. In
that description I believe I conveyed my current perspective on addic-
tion, which includes an integration of the views of leading experts
from within and outside of psychoanalysis. I spelled out the modifi-
cations in standard analytic technique which I employ, and the rea-
sons I believe these methods are helpful. I will emphasize at this time
that based on my personal experience, my addicted analysands do
well. They come to deeply understand themselves, the biology and
the psychology of their addictions, and they are able to conquer their
addictive tendencies, and remain abstinent indefinitely. They come
to understand the incapacities in thoughtfulness which they experi-
enced when their brains were hijacked, and appreciate the differences
in their mental functioning once they are in recovery. A corollary of all
this is that these analysands are able to experience a full range of ana-
lytic activities and gains, including a deep analytic understanding of
themselves, and rich capacities to empathize, mentalize, be mindful,
self-regulate, and self-analyze in an ongoing way. Once their addic-
tions are recognized within the analytic relationship they are able to
share a committed, intimate, authentic relationship with their analysts,
and with those relationships serving as models, deepen the intimacy
of their relationships outside of analysis. I hope that in this essay I
have provided enough specific information to be helpful to practition-
ers who in the future self-consciously undertake the psychoanalytic
treatment of addicted individuals, and that I have given those with
doubts about the efficacy of psychoanalytic treatment for the addicted
the confidence and motivation to try to be of help to that population.
And now, the truth shall be told

I am about to conclude this essay, and I have a confession to make.
The second case I reported, as I indicated, was not a case of my own,
and was disguised. I stated that this was necessary for reasons of
confidentiality, and I do want to emphasize that confidentiality was
the decisive factor in governing the way I wrote both the case pres-
entations in this essay.
For several additional reasons I chose for the high functioning
addict to be successfully analyzed one of the most popular heroes in
the history of these islands, of the UK, Sherlock Holmes. Yes, Stuart
Holcombe is Sherlock Holmes, workaholic and substance addict, a
compulsive and uncontrolled user of cocaine and morphine. Joseph
Waterbury, soldier turned internist, turned psychiatrist and psycho-
analyst, in none other than John Watson, M.D., formerly attached
as a military physician to the Fifth Northumberland Fusiliers.
The first big story, which Stuart investigates, involving a religious
cult, is loosely based on A Study in Scarlet (Doyle, 2003 [1887]), the
second, the investigation of a government sex scandal, on A scandal
in Bohemia (Doyle, 2003 [1891]), and the third, the investigation of
prison corruption on The Sign of Four (Doyle, 2003 [1890]). Stuart’s

seeking help from the Austrian psychoanalyst hypnotist, and his
subsequent absence from psychoanalytic treatment is based on
The Final Problem (Doyle, 2003 [1893]), and Nicholas Meyer’s The
seven-per-cent- solution (Meyer, 1993 [1974]). The entire description
of Stuart borrows from Austin Mitchelson’s The baker street irregu-
lar: the unauthorized biography of Sherlock Holmes (Mitchelson, 1994).
Finally, Joseph’s comment on the fiend that is asleep, a line which is
incorporated in the title of this essay, comes from The adventure of the
missing three-quarter (Doyle, 2003 [1904], p. 174).
Knowing that this is a very serious conference, dedicated to help-
ing all of us offer more effective psychoanalytic treatments to severely
disturbed individuals, I thought long and hard about whether to go
forward with the idea I had, which was to use in this essay a fictional
character as one of my two main clinical examples, and to reveal
that device only at the end of the essay. I decided to do so only after
fully assimilating the extent to which Sherlock Holmes was believed
by many readers to be a real, living person, a fact about which Sir
Arthur Conan Doyle himself commented (Doyle, 2003 [1923]).
However, there is an additional point which I wish to make
explicit, and that concerns why I concealed the identity of the sec-
ond case until the end of the essay. That point has to do with what
I think of as a blended form of Irish and British humour, and my
experience of that humour. A very dear friend of mine for fifty years,
since my university days, H. Montgomery Davis, died unexpectedly
while I was preparing this essay. Monty was a man of the theatre,
and was proud of his Orange Irish ancestral roots, his years study-
ing theatre in London, and his world class knowledge of his favour-
ite playwright, the Irishman George Bernard Shaw. In fact, Monty
was clearly a hybrid blend of Northern Ireland, Dublin, London,
and the United States.
In that friendship I always enjoyed Monty’s wry wit, and came
to understand that in the experience of his humour I learned a great
deal about life, things which I did not readily forget because they were
embedded in moments of laughter, of the unexpected punch line. So
in thinking about using Sherlock Holmes as a clinical example, and
revealing that choice only at the close of the essay, I came to think
that I might create a humorous moment, which might also cement in
memory a very important clinical lesson: A high functioning addict
might appear extremely competent in many ways, but was in fact

very severely disturbed. I came to feel that since the addict in ques-
tion was Sherlock Holmes the lesson might very well stick better
than if I wrote about an anonymous, disguised clinical case. I hope
my effort has been successful.
In closing, then, I want to thank all of you for your close attention.
To those of you who are from the United Kingdom, from these islands,
I offer special thanks, for providing me with Sherlock Holmes, a
man of great talent and purpose, a true hero of these islands, who
for much of his life suffered the scourge of addiction.
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CHAPTER SIX
Some considerations about the

psychoanalytic conceptualisation
and treatment of psychotic disorders
Franco de Masi
“If you ask me what psychoanalysis can do about psychosis, I might

give you two opposite answers: one is that psychoanalysis can do very
little, the other that it can and must do a lot.”
—Paul C. Racamier
I
would like to begin my contribution to the Belfast Conference
with some preliminary remarks that coincide with the core of my
theoretical position about the treatment of psychotic disorders.
The difficulties in the analytic therapy of psychotic patients are
not due to our individual limits, which can emerge during our pro-
fessional meetings, but depend mostly on the inherent incompatibility
between the psychotic state and traditional analytic thinking.
It is well known that the psychoanalyst who tries to treat analyti-
cally psychotic patients is subjected to many painful failures. At the
41st Congress of the International Psychoanalytical Association in
Santiago, Chile, García Badaracco drew attention to this difficulty by
noting that very few cases of recovery from psychosis are reported
in the analytic literature (Badaracco and Mariotti, 2000). This well
137
justified pessimism about the treatment of such patients should spur

us on to augment our therapeutic arsenal and to learn also from our
failures.
Failures
I consider that my past personal failures with psychotic patients
originated mostly from the fact that I was listening to them in the
same way that I was accustomed to do with neurotic patients. I was
expecting associations, dreams deserving consideration and inter-
pretation, and the kind of dependent transference similar to the one
that even disturbed patients develop.
A major change in my analytical approach to the psychosis hap-
pened after the outcome of the analytic treatment of a patient, which
I had described in a paper on Super-ego and hallucinations published
in the International Journal of Psychoanalysis (De Masi, 1997). In this
paper, written after eight years of analytic treatment, I emphasized his
improvement and the analytic work that allowed him to emerge from
his hallucinating world. After the publication of my paper this patient
had a new serious psychotic crisis, even more severe than the one which
had caused his hospitalisation before the beginning of his analysis.
This unlucky and sudden conclusion of the analytic relationship
made me think about the irreducibility of psychotic processes, and
led me to wonder how the delusion could have carved out such a
path upon which the patient embarked upon again even after eight
years of analysis.
In my opinion, the decisive fact remained that, by virtue of the
analytic work on the psychotic superego, the patient’s internal world
had undergone a positive transformation.
I actually remembered that every time I had tried, in the anal-
ysis, to raise the issue of the psychotic episode for which he had
been admitted to hospital, the patient put up a stubborn resistance,
quickly taking flight from the memory of what had happened or
trivializing it.
In reconsidering the unlucky outcome of this case, I benefited from
a statement found in a paper by Thomas Freeman (2001) who notes
that even when the psychotic episode has been overcome, the “cri-
sis” persists as a powerful destabilizing element. Terrified of having
to relive it and of becoming psychotic again, the patient is frightened
S O M E C O N S I D E R AT I O N S 139
even to remember the circumstances, let alone the development, of

the psychotic attack.1
As a matter of fact, I recognized that I had not undertaken a
systematic, in-depth analysis of the first psychotic episode, but had
concentrated instead on his need to repair the damage and on find-
ing ways for him to recover his mental functioning.
I am now convinced of importance to perform, session by session,
a systematic analysis of the delusional world, both in its past mani-
festations and in its tenacious and deceitful action in the present.
Unless we can discover how the patient creates the psychotic state,
the hallucinations, and the delusion, even the best of therapies may
be unable to avert a relapse. Like Freud, who considered transfer-
ence initially as an obstacle and afterwards as a transformational
event, we must take the delusional functioning, which is always
active underneath in the analytic process, as a normal, ubiquitous
event and the key to a possible therapeutic path.
Emotive and dynamic unconscious

When we analyze a psychotic patient we must be able to proceed in
the same way as a physicist studying the atom, who does not refer
to Newtonian Mechanics because he knows that he is dealing with a
wholly different kind of phenomenon.
To show how the growth of the emotional world has been seri-
ously hindered in the psychotic patient, I have made a distinction
between emotive unconscious and dynamic unconscious (De Masi,
2000).
Man does not come into the world with equipment fit to perceive
the emotions but he possesses the ability to develop it. As Bion says,
in order to develop such apparatus there has to be a mother who
1
The patient’s state of mind in relation to the past psychotic attack is dominated, even
years later, by terror in case the delusional reality returns. Even chance words spoken
in the analytic dialogue that trigger associations to the traumatic event arouse the
patient’s terror, owing to the sudden invasive feeling of not remembering the event
but of reliving it in the present and hence of still being trapped in psychosis.
In this situation, any association to the trauma is immediately blotted out because
it is connected with catastrophic anxiety and is therefore likely to reconstruct the
delusion. That is why the analyst finds it extremely difficult to succeed in examining
the past psychotic episode with the patient.
gives fitting answers to strengthen the baby’s emotive preconcep-

tions. The psychotic patient lacks such apparatus and cannot use the
emotive unconscious to construct psychic reality and give meaning
to human relationships.2
I assume (2006) that the psychotic state represents the extreme
development of a condition started in childhood in which the child
began to live in a parallel world, created in his imagination and kept
secret, which enabled him to interact with the environment only
superficially. This withdrawal has gradually made him unable to use
the unconscious functions in charge of registering and understand-
ing emotions, which are the carriers of intrapsychic communication.
Lack of empathy from the caregiver causes a patient to escape
into a dissociated world. Parental pathological intrusions into the
baby’s mind produces confusions or false identities and increases
the child’s psychic retreat and a compulsive need to expel unbear-
able states of mind using others as a repository (Williams, 2004).
The damaged functioning of emotive unconscious produces mon-
sters, i.e., delusions and hallucinations. This process does not work in
a mechanical or direct way: in the patient’s psychic retreat, delusional
imagination becomes a psychopathological structure that dominates
and colonizes step by step his mind until its complete invasion.
The dream-delusion
One of the clinical problems of analytic therapy of psychotic patients
is how to remove the patient from the power and fascination of the
delusional world, which is normally concealed to the analyst and
works dangerously in a secretive way. Indeed, one of the difficult
clinical issues we are confronted with in the treatment of psychotic
patients is their passive acceptance with which they let themselves
be trapped in their delusional world.
The aim of the delusional power is to create a new reality that
appears superior and desirable; this is the reason why its colonizing
action is not clear to the patient who is passively drawn toward it.
2
We can consider the emotive unconscious as an implicit knowledge that operates like
a procedural memory. The patient bound to become psychotic suffered damage in the
acquisition of this procedure during his first development and further deterioration
because of the creation of subsequent psychopathological constructions.
In a paper written with Paola Capozzi (2001) we suggested a

distinction between dream-thought and dream-delusion. We think that,
in the psychotic patient, while few dreams can be considered as
thoughts (like dreams of a neurotic patient) most dreams contain
in a nutshell the delusion itself and describe the working and the
seductive quality of delusional power.
A clinical example3
Angela is a 21 year-old patient whose psychotic onset dates back to when
she was 16. She had a mystical delusion and a state of exaltation, which
led her to confess that she had sexual intercourses with Jesus. As a child
she was shy and withdrawn in her fantasy word. After some two years of
therapy a second psychotic episode took place. The patient claimed to be
the devil and asked her therapist not to look into her eyes, for fear of con-
taminating her. The breakdown was treated at the patient’s home with the
help of a psychiatrist. Her state of severe distress made her miss some ses-
sions: Angela was afraid to leave her home because she was terrified of being
killed. Her therapist wondered about the reasons for this new breakdown
and discussed this in supervision with me.
In my opinion the therapist had worked too much on a symbolic level (con-
tent interpretations) and had been so worried for her patient that sometimes
she would not even maintain the time setting. The anxiety conveyed by the
patient might have prevented her from capturing the specific elements of the
on-going psychotic transformation and from containing them promptly.
I advised her to try and see how Angela entered her delusion and to
understand all her communications in this light. The patient attended an
art school and, because of artistic talent, she had always been considered a
little genius in her family. She had often brought her drawings to sessions
and the analyst had commented on their contents. The analytic sequence I
report here follows a partial resolution of the psychotic episode, when she
has started again to go to therapy regularly. It is at this very time that, I
believe, it is possible to help the patient understand how psychosis impinges
on her mind. In this vignette Angela shows a special capacity for insight in
this respect. During a session she recounts a dream:
“I am travelling by train with my father; it is evening. We must go to
a village and, since it is evening, I assume that we are going to spend the
3
This patient’s material was brought to me in supervision by Dr. Marina Medioli.
night away from home. During the trip my father works absorbed in his
papers and I feel uncomfortable and alone.
Then, I am in a car together with dad and Franzoni4 at the steering
wheel. I recognize Franzoni and I feel very uncomfortable to be in the car
with her. I get to a walled-in boarding school. They teach archery. At night
I am in a dormitory with other girls, and in the darkness I see a girl who
carries a luminous bow and smiles oddly at me. The following morning we
all go to the swimming pool and, for fear that my bathrobe may be stolen, I
swim in ‘dog-style’, keeping my bathrobe out of the water.”
The patient’s associations to the dream are that, when she goes to the
public swimming pool, she is afraid that she may have something stolen.
She always puts her towel and the locker key by the edge of the pool. When
her therapist suggests that the bathrobe is like a skin, the patient confirms
that she is afraid of losing her identity. Then the patient mentions the bow
and says that the smile of the girl strikes her. Actually it strikes fear into
her. Of course, there is also her fear of being killed, but the bow can be easily
recognized and seen, as it is luminous.
The session ends and the therapist addresses the patient with the mutual
commitment to think more about this dream.
In the following sessions the patient, perhaps for the first time,
brings her own contribution to the working through process:
P: You know, I have thought a lot what the bow in the dream could mean. I
have also thought that I could be the girl holding it. I remembered that,
besides her strange smile that scared me, her lips were moistened …
A: Then we can say that there was a lot of sensuality …
P: Yes, I thought the same thing; there is a strong sexual component. The
bow evoked the light, and angels and devils came to my mind. Through
the arrow that strikes me I become the light.
A: There you are. This is the delusional part that strikes, enlightens and
captivates you, making you believe that this is the only way of becom-
ing superior, an angel.
P (chuckles): Yes, you are right. It is really a crazy thing, I am a human
being, not an angel or a devil. I get transformed into them …
4
Franzoni is a mother convicted for infanticide, and she has become popular in Italy
through the mass media.
A: I was wondering whether Mrs Franzoni might represent an omnipo-

tent part, which kills the son if he is not up to her expectations. In your
dream she is the one at the steering wheel … We may think that when
you are isolated and secluded from the rest of the world this exciting
part wins you over more easily …
P: Yes, quite so … And I feel like an angel … that can always become a
devil.
A: Sure, and therefore you are afraid that somebody wants to kill you …
P: You know, I continue to go and visit the dogs (Angela has aban-
doned school and she goes regularly to the dog pound to look after
the animals), and I feel that it is something really important for me.
I thought over what you told me last time. It is true that through
them I am learning how to feel, but not only because I recognize the
feelings in the dogs. I realize that they are opening up something
inside me, like a lung that can really fill up with air … I think it is
the relationship.
I have reported these sequences to show how the delusional with-

drawal (the patient who becomes the girl with the bow) can be a pro-
tective measure against anxiety (against the lack of relationships), but
also and mostly a place of pleasure in which the patient feels like a god
able to enlighten herself with her omnipotence. In this sense, as I have
tried to show in this clinical vignette, psychotic dreams are very helpful
because while the delusion conceals and confuses, the dream communicates.
This is the true communication, the true gift that the psychotic patient
gives the analyst. Just because the patient is unaware of the danger of
the psychotic transformation, the dream opens a door into the secret
retreat where the delusional operation is put in motion. In the scene
of the boarding school, a secluded place where archery is taught,
the patient describes the exciting sensory enchantment inherent in
the delusion, the luminous and sensual bow. By allowing herself to
show in the dream her own hallucinatory reality, an idealized and
seductive reality she might not be able to resist, the patient lets the
analyst come into her hallucinatory retreat. It is important then that
the analyst sees, together with her, the other side of reality, keeping
the right distance and making sense of the hallucinatory transforma-
tion, and helps the patient differentiate herself and leave the delu-
sional enchantment of her hallucinatory retreat.
Whereas delusion is a psychopathological construction aimed to

transform psychic reality, the psychotic “dream” can become one
of the available means to communicate what is going on. This kind
of dreams, which represents the delusional pressure that colonizes
the ego (this being prone to yield to it), helps the patient to per-
ceive the danger and, in each case, to get rid of the seductive hold
of psychosis.
In the therapy of these patients, it is important to grasp the attrac-
tive force and the power of the delusional imagination, by identifying
its underlying anxieties or omnipotent wishes, with a view to decon-
structing it. I use the term deconstruct because the word “interpretation”
that we use to denote our therapeutic instrument seems unsuitable for
tackling the clinical problems posed by the power of the delusion.
I think that analysand and analyst must be able to examine and
to recognize gradually and in detail how the delusional experience
is constructed and develops. It is important to carefully peruse the
present emotional situation and the remote roots of the delusion,
linking up the various scattered fragments that have appeared and
continue to emerge during the analysis. This work must be done
constantly, session by session, over a prolonged period.
From a technical point of view, my assumption is that delusional
structures do not correspond to undigested beta-elements waiting for
transformation. There is no continuity between the unconscious thought,
which helps perceive psychic reality (K), and delusional activity (−K).
Whereas some authors (Caper, 1998) suggest a possible transition
from delusional fantasizing to the world of intuition connected with
the dream work, I consider that a radical incompatibility between
delusional imagination and thinking activity (as well as dreaming)
exists (De Masi, 2006). The delusional fantasies are non-transform-
able and indigestible elements, and cannot be “dreamed” in order
to be transformed into thoughts. They are alien to and incompatible
with psychic reality.
The psychotic patient is fascinated by this kind of perversity, by
his power to destroy psychic reality and remove any differentiation
between fantasying, delusion and reality.
Such an exercise, apparently pleasant and similar to a mental
drug, sooner or later becomes persecutory, (self-)destructive and
catastrophic because it produces a never-ending process that over-
whelms the patient himself.
The spur to coerce the mind with an addictive quest for pleasure
reaches a breaking point with no return. Then, psychotic anxiety
emerges in its full power and goes to a psychotic break-down.5
It is essential for the patient in analysis to reach a point where he
can see his psychotic construction, as it is the case with this patient.
The dreams that psychotic patients bring to analysis are very illu-
minating because they describe, frequently with great accuracy, the
psychotic functioning and the exciting and confusing power of the
delusional nucleus while the patient is struggling to achieve mental
health. In the course of the treatment we need to support those parts,
which have stayed outside of the delusional system, to prevent them
from being drawn into it and to help them see, by deconstructing the
power of delusion. This is the reason why I stress the importance of
orienting the analytic work to promote the patient’s awareness of
the meaning of his psychotic organisation, which tends to incorpo-
rate the self and destroy the sense of reality.
However, dismantling delusional proneness is a very long and
complex process because of the obstinate and constant re-emergence
of the pathological organisation that endlessly tends to carry on
plotting.
The coming back of the delusion

As a rule, once the psychotic episode is over, the patient tends to
preserve the precarious equilibrium attained, even if it involves sub-
stantial limitations. He learns to keep away from potentially destabi-
lizing emotional experiences and senses that there is a limit beyond
which he cannot push himself. To this end he maintains tight control
5
My personal opinion is that the catastrophic anxiety grips the psychotic patient only
when he loses self-sensorial pleasure or the grandiose experience created by him and
he became unable to control the process of continuously transforming his perceptive
apparatus which he had set in motion.
Before being overwhelmed by catastrophic experience of destruction of the
world and by delusional persecution centred on Prof. Flechsig, President Schreber
was caught in the sensual pleasure of being transformed in a woman during sexual
intercourse. If we don’t admit the fascinating and pleasurable feature of the psychotic
experience in his beginning we cannot understand the attraction and the “passive”
submission of the patient to it.
Often this fascinating feature of the delusional state is hidden by the patient’s
unwillingness to communicate it.
over relationships and affective cathexes that might trigger new

psychotic processes.
When the patient smashes through his personal pillars of Her-
cules, catastrophe ensues: the relapse into psychosis is facilitated
precisely by his having thrust himself forward while lacking a
progress-sustaining structure. It is rather like adding a storey to a
building constructed on inadequate foundations: the extra load
causes the entire structure to collapse.
In order to underline how the delusional experience, even after
many years of analytical work, can always recover its power I will
briefly present a patient, 35 years old now in the eighth year of treat-
ment, who was hospitalised for a paranoid episode which took place
before the beginning of his analysis. The delusional disposition still
emerges nowadays during critical periods when the patient is una-
ble to face new emotive tasks.
In his analysis Carlo has improved significantly. Many mental spaces
have opened up for him. He maintains a good dependence and communica-
tion with me. He has been able to have meaningful and stable relationships
with his peers and lately he has formed an emotionally important rela-
tionship with a young woman. Recently, due to conflicts and arguments
between them, he has decided to abandon her. During a session he says that
he decided to separate from his girlfriend, although he declares that he is
very fond of her. He feels perfectly serene. Listening to him, I am surprised
that he doesn’t feel any sorrow about his decision. In the next session Carlo
tells me he has had a delusional attack the day before (for a long time the
patient has regularly brought to analysis his delusions providing us an
opportunity to work together on them). He reports feeling anxious, as if he
had lost his bearings (he doesn’t say that the anguish might derive from the
loss of his girlfriend). On the verge of a panic attack, he phoned his mother
to be cheered up but afterwards he felt persecuted, he was afraid of being
poisoned …
Listening to him I feel puzzled and I try to find a link between his deci-
sion to separate from his girlfriend and the resurgence of the delusional
state. I hypothesize that he had obliterated his feelings and for this reason
he felt deprived of his frame of reference and the grandiose and persecu-
tory mechanisms had reappeared again. I tell him he had lost his bearings
because had annihilated psychic reality together with a potential mourn-
ing for the loss of his girlfriend. He listens to me, he meditates for a while
and says that it is true, he never thought about his girlfriend, he cancelled
her from his memory. I tell him that he erased his feelings because he felt
unable to face psychic pain. The loss of the girl created a suffering and he
had to cancel the pain and, what is more, the whole apparatus for perceiving
emotions. When he performs this operation, the “other reality” comes back
again. The patient listens to me silently and answers: “It’s true that I can’t
stand any psychic pain. I remember that, when I was a baby, I was always
very excited and I had to be in a splendid mood all the time. I think it was
to escape from all pains! My mother once told me that when I was nine
months old she abandoned me for three weeks. My parents wanted to go
on holiday and I was left in the charge of a woman whom I did not know at
all and who lived in another town. So I lost both my parents and my home.
My mother remembers that when she came back I was completely changed,
deeply depressed and without vitality.
I want to underline how in this patient, unable to stand an emo-
tive conflict, the annihilation of psychic reality causes panic and
the resurgence of persecutory imagination. He gets trapped into
the delusional world because he destroys the very same appara-
tus that could save him, allowing a potential containment of the
negative emotions and offering a way to learn from his conflictual
experience.
The loss of this emotional apparatus seems connected to an early
trauma. The patient can remember the mother’s account of the trau-
matic event of his childhood but he can neither relive it, nor think
about it or indeed learn from this experience. He can only understand
that he becomes manic or grandiose when he has to face pain but he
is still unable to feel and work through the mourning. I emphasize
that the patient entered into a psychotic state with a grandiose delu-
sion followed by persecution when he suffered an emotive trauma
after being abandoned by a friend, with whom he had an idealised
adolescent relationship.
Therapeutic progress
A durable transformation of the psychotic structure might coincide,
not only with the release of the patient from the delusional lie, but
also with his acquisition of a true identity, i.e., of an emotive readi-
ness to understand psychic reality and to face frustrations connected
with human relationships. These goals are strictly intertwined. Psy-
chotic patients do not get a true structure to their personality. Their
evanescent identity breaks down when a psychotic crisis occurs and

this often coincides with the breach of an idealized bond with a sup-
portive object. During the analysis they try to establish the same bal-
ance they had before the psychotic crisis i.e., to restore the same false
identity which makes them appear to be functioning properly. For
this reason their attempt to conform themselves to external reality
deceives people around them, even including the analyst.
We might evaluate therapeutic progress on the basis of their
development of a true personal identity.
Since Abraham and Ferenczi, many theoretical developments
have widened the clinical field of the psychotic illness and given
new strength to the analytic therapy of such patients. The analytic
literature offers the precious legacy of many analysts (to name only
a few: Federn, Fromm-Reichmann, Searles, Pao, Rosenfeld, Bene-
detti, Segal, Aulagnier, Lacan, Volkan) who worked in this field with
creative endeavour. Despite these unquestionable developments the
psychoanalytic thinking is, in my opinion, still lacking an organic
theoretical and clinical conception on the nature and dynamic of the
psychotic process. The many explorations in this field have not yet
managed to trace a useful and accurate map of knowledge.
In my clinical work I am continuously engaged in focussing on
the problematic knots, which are essential to the outcome of the
therapeutic process. I endeavour to outline some of the specific
patterns of psychotic development and try to determine how the
patient, since his childhood, starts building a prison from which it
will be very hard to escape.
I hope that in the future, the cooperation of many psychoana-
lysts and meetings like the one so well organized in Belfast by Paul
Williams and Lord Alderdice will help improve our knowledge of
the mysterious ways through which one becomes psychotic and
will offer new prospects in the treatment of this form of mental
pathology.
References
Badaracco, G., & Mariotti, P. (2000). Affect and Psychosis (Panel Report)
In Int. J. Psychoanal., 81, pp. 149–152.
Caper, R. (1998). Psychopathology of Primitive Mental States. Int. J.
Psychoanal. 79, pp. 539–551.
De Masi, F. (1997). Intimidation at the helm: Superego and allucinations

in the analytic treatment of a psychosis”.
De Masi, F. (2000a). The unconscious and psychosis. Some considera-
tions on the psychoanalytic theory of psychosis”. Int. J. Psychoanal.,
81, pp. 1–20.
De Masi, F. (2006). Vulnerabilità alla psicosi Cortina (Vulnerability to
psychosis. In press by Karnac).
De Masi, F., & Capozzi, P. (2001). Meaning of Dreams of Psychotic State.
The Intern. Journ. of Psychoanal. 82:939–52.
Freeman, T. (2001). Treating and studying schizophrenias in Williams, P.
(ed) A Language for Psychosis. Psychoanalysis of Psychotic States. London:
Whurr. pp. 54–69.
Williams, P. (2004). Incorporation of an invasive object. Int. J. Psychoanal.
85:1333–1348.
CHAPTER SEVEN
“First you were an eyebrow”

and “How do I know that
my thoughts are my thoughts?”
Bent Rosenbaum
T
his presentation will focus on some phenomenological and
psychodynamic characteristics of psychotherapy with human
beings who for shorter or longer periods of their life find
themselves trapped or imprisoned in schizophrenic modes of exist-
ence. It is my claim that difficulties in symbolisation play a major
role in the understanding of what is going on: in the mind of the
person, in the mind of the therapist, and in the clinical researcher.
Furthermore, from a developmental perspective entering the mode
of “we-ness” and acquiring a “group mind” is difficult for the per-
son with a mind in the schizophrenic mode marked by autism. The
developmental perspective is coherent with the emphasis on diffi-
culties in symbolization, and outlines for a relevant therapeutical
approach in the state of psychosis will be presented.
“If you did like me, you would be mad”

As a young resident I took my first job in the largest Danish State
Hospital, which at that time had two thousand beds and was
divided in two sections for respectively men and women, except for
the two units in which Maxwell Jones’ ideas of “therapeutic society”
151
was tried out. Through my previous interest in semiotics I had been

studying thinking and thought forms, especially in the thought dis-
orders of the psychotic states of mind. Every week I spend two or
three evenings sitting together with the patients listening to their life
stories, their thoughts and fantasies. I heard the most incredible and
fascinating things and learned how the mind in a psychotic state
viewed the world–not the least the relation between self, body and
others. One evening I sat next to a woman, age 55, who had spent
35 years in the Hospital. She was sitting on her hands and I asked
her for the reason for this behaviour. She said that she had to protect
herself against the evil spirits that came from the depth of the earth
trying to penetrate her anus. After a while I asked her whether I,
too, had to protect myself in a similar way against the evil spirits.
“Oh no”, she said, “If you did like me you would be mad”. After a
pause I said that she must be special since the evil spirits had picked
her as a victim and not me. She said that it all started with the war
(2nd world war), and then she would not say more. I was left with
a lot of tentative ideas connected to her behaviour, but without any
confirmation on any of these ideas.
I stayed in the hospital for four years and learned the functioning
of double book-keeping and dissociated minds, about the regression
to and the use of another scene of thoughts with only a few links to
the common sense world and secondary symbol-formation, about
the simultaneous pain and safety feelings of being able to isolate
oneself from others, and also that thoughts come in bits and pieces,
and through many simultaneous trains which can never be detected
fully.
In the following I shall discuss the phenomenology and psy-
chodynamics of schizophrenic modes of existence. I shall begin
with a vignette from a psychotherapy that taught me many things
in addition to my experiences from my years at the psychiatric state
hospital and other psychiatric hospital units. I shall touch upon the
problems of symbolformation, i.e., some basic structural conditions
underlying the increasing integration of apperception, emotions,
thoughts and thinking. Furthermore I will discuss the concept of
we-ness and group-identification and its importance in the develop-
ment of psychotic modes of relating to the world. In the end I shall
turn to some ideas about the supportive psychodynamic approach
to therapy with people in psychotic states.
F I R S T YO U W E R E A N E Y E B R O W 153
“First you were an eyebrow”

Approximately 2½ years into a psychoanalytic psychotherapy with
a woman who came twice a week, we were talking about trust,
mainly her ability to trust her women co-workers but also with
the twist to the possible trust in me in the therapeutic space. After
reflecting on her own words and mine she looked at me and said:
“During the first year you were an eyebrow, then you became a
doctor with a white coat and shortly after a doctor. But I am not sure
that I will ever be able to experience you as a person”.
I hesitated in my response because many thoughts that went
through my head:
• What is an eyebrow able to perceive and say, and does it have the
capacity for listening?
• What is the symbolic meaning of an eyebrow for this patient–if it
has any?
• Why the sequence of the doctor in a coat and then one without a
coat?
Did I in spite of my assumed analytical listening attitude raise

the feelings in her that she should be communicating with
someone with a non-listening, authoritarian, paternalistic
attitude?
Or was the transformation from ‘with coat’ to ‘without coat’
an indication that she experienced me as moving from a super-
ego position–punitive or controlling–towards a more caring
object raising sensual feelings in her?
Or, was her utterance it an indication of pain from her side,
telling me that however much progress we would be able to
make then I (and she) should anticipate a limit–either an exis-
tential limit which always would impede her more or less in
being able to experience immediately and subjectively that she
and I were persons, or a limit to her ability to feel that she and I
were separate individuals with background in our own history
and who would meet in respect of each other?
Did she tell me that she could not imagine any way out of the
claustrum in which she was chained and that any push toward
this would be a possible all-absorbing catastrophe?
From my time as a resident at the State Hospital I acquired the idea

that communication with minds in psychotic modes gains by start-
ing at a level of a joint perceptual field–either imagined or real-,
and thus I decided to explore the idea that an eyebrow could be an
insufficient perceptual organ. I said that I felt that as an eyebrow I
may have observed many things but I might not have been able to
listen properly to her–and I wondered what she had permitted me
to see and say from that perspective. She responded to my words
by saying that my words made her think of an episode after she
had moved from home when she visited her parents for a dinner.
The main course at that dinner was roasted lamb culotte in which
“the bone stood out as a penis without the foreskin”. She had to
leave the dinner immediately. She believed her mother understood
her reaction since she (the mother) “was made of that stuff dreams
were made of”.
I did not respond immediately to her associations since I for a
moment was stuck in the countertransferential split between on
one side being able to empathize with her fear of being attacked
by some penetrating stimuli, impressions or words–father’s gaze or
voice, memories from childhood or youth–against which she could
not defend herself, and on the other side her depressive feelings in
striving towards a state of integrating her different emotions and, by
means of the therapy, finding objects which she could trust loving.
She told me that she wanted to find a man who did not scare her
or was too demanding of her. She had not been lucky with previous
relationships to men, one of them with whom she had two children.
She could not look into a man’s eyes without feeling filthy or
invaded. The act of sexuality could be very frightening to her since
she might experience her labia enlarge to the extent that they would
fill out the whole room in which the act took place, and she would
feel suffocated. Walking into a kiosk in order to buy a packet of ciga-
rettes could lead to a feeling that the man who handed her the ciga-
rettes also wanted to rape her judging from the way “his hand was
moving”. In several sessions I had experienced her in hallucinatory
states–looking at people in the street and reading street-signs could
become a nightmare. She could for instance see a man wearing a big
black plastic bag and she would immediately believe that in this bag
were her two children cut up into small pieces. She could look at a
street sign and the words could be cut up into small fragments, which
had, or did not have, an immediate, but not-integrated, symbolic

meaning. When her children were babies it was hard for her to have
them close to her body since she could feel that they literally crept
under her skin, or ate her breast.
She thought that some of the difficulties with relationship to men
had their origin in her father’s ways of behaving when she was a
baby. In one of her memories her father would lift her in the air when
she was ½ year old and did not wear a nappy, and he would place
her behind on his nose while blowing air on her genitals. I a later
session she told me that one of his characteristics was his eyebrow.
She was brought up in a family whose members in the midst of
the 19th century were of politicians and literary people.
Her father was a captain in the army and he wanted her to be
boy-like. He punished her and wanted her to avoid sex while he
at the same time said that had she not been his daughter he would
have had sex with her. In her mind the patient had killed the father
several times together with other persons whom she found intru-
sive and abusive. “I have an inner cemetery where I can allocate
people to whom I dislike”, she told me. Sometimes she could fear
that the killing really had taken place (in outer reality) and not only
inside her mind.
Her mother was an etheric, fairy-tale like woman, living in her
own world, having creative talents for painting and storytelling. The
patient could easily identify with mother’s skills and at the same
time she felt that the mother, but not herself, was living in a fairy-
tale like world, distant from daily life activities.
My patient had never felt quite safe with her schoolmates. Dur-
ing childhood and adolescence she always communicated with “an
inner friend, which was experienced more alive than the living per-
sons in my surrounding”. In a way she was morbidly capable of
being alone, i.e., she was not capable of being alone in the mature
way that Winnicott (1958) is speaking about when he says
[Thus] the basis of the capacity to be alone is a paradox; it is

the experience of being alone while someone else is present.
(ibid, p. 417)
“Being alone” in the mature way is integrating otherness and at the

same time feeling safe regardless where my thoughts and actions
lead me to. In opposition hereto, my patient had always felt that

even though others were present she would have to exclude them
from her awareness, or she would feel that they were intruding into
her thoughts and feelings. In primary school, she had had connec-
tions to schoolmates, but always felt different from them, both below
and above their standard but never like them. She couldn’t just feel
ordinary and natural.
Psychoanalytic viewpoints have often excluded–wrongly I believe–
phenomenology from its considerations (the opposite move has
even more fiercely taken place, but that does not need to bother us
here). From a phenomenological point of view1 characteristics of my
patient’s experiences would include:
• Disturbed, automatic context-sensitive attunement to the world

Loss of evidentiality (e.g., “Erlebnis der Einfachheit im Augen-
blick” (Jaspers, 1913)), and disturbed familiarity (e.g., “Erlebnis
der Identität im Zeitverlauf” (ibid))
• Morbid awareness of inner fantasy life, and a lessened interest in
outer reality and in anchoring ones subjectivity in the social life
A strong tendency to equate immanence (that which is immedi-
ately experienced and reacted upon in thought and action) with
transcendence (that which transcends the sphere of experience).
All these phenomena undermine in a fundamental way2 the ability

to think and experience in a common sense mode. When this com-
mon sense mode is undermined then everything and every situation
1
These viewpoints rely on Karl Jasper’s work (Jaspers, 1913) and are recently developed
by Joseph Parnas (Parnas and Handest, 2003). Authors devoted to phenomenology
usually find it problematic to link these with psychoanalytic informed concepts,
although the viewpoints of Sandor Rado often are quoted by the phenomenological
psychiatrists as a basis for the understanding of the concept of schizotypical disorder.
The argument from the point of view of phenomenology is that phenomenology as a
philosophy is more basic to the understanding of human being than psychoanalysis,
which is seen as a psychology with reductionistic tendencies. Psychoanalysis takes
the opposite view that phenomenology–“to let that which shows itself be seen from
itself in the very way in which it shows itself from itself” (Heidegger, Being and
Time, 7,53; 34)–is not able to explain the in-depth phenomena which characterizes
the human mind.
2
Fundamental in the sense that we are dealing with both pre-verbal and pre-reflective
functioning.
may gain unconscious significance and is in danger of being reacted

to with feelings of strangeness, mistrust and alienation from time,
space and ones own body.
Theory of symbolisation
From the patient’s often eloquent and articulated mode of speaking
and thinking one might get the impression that the autobiographi-
cal account above, i.e., the narrations of the experienced situations
and events, the associations and so forth seem both intelligible and
coherent. But that was not the case in the patient’s understanding
of herself. From her point of view very little of what she said was
felt natural or as commonsense. Sometimes she experienced her
own story as a continuum but at other times her own feelings of her
narration was rather fragmented and they were experienced as iso-
lated thought-gestalts that only with great difficulty could be related
to a whole picture of her life situation from which she could learn
and outline perspective for her future life.
Bion conceived symbol-formation as a transformation from raw
sense impressions (which he called beta-elements) through elements
of thoughts and ideas (experiences which he called alpha-elements)
into preconscious and conscious psychological work, such as
dreaming, thinking, mourning, and learning from experience.
Thus in Bion’s conceptualisation, the patient would often confuse
sense impressions, proprioception and thoughts, and sometimes–in
moments of lack of reality testing capacity–she would evacuate
the sense impressions and perceptions into the soma, or into hal-
lucinations and hallucinatory acts. In these situations, parts of the
patient’s mind, or “the thinker who should think the thoughts”,
had broken down and as a result mostly unanchored thoughts were
being communicated in the therapeutic space. It was then hard for
her to distinguish real knowledge, in the sense of coming to know
oneself through experience (Bion’s concept of K), from its many
substitutes (see Bell, 1995: 71). Instead of experiencing the reality
of objects she would experience a kind of negative reality, a reality
stripped of depth and immediate meaningfulness. At other times,
perceptions and sensations were transformed into thoughts which
sustained her in her work and even helped her being able to form
assisting attitudes towards others–e.g., by means of protecting
herself she carried out her professional functions to everybody’s

admiration except from her own.
Lacan’s ideas of symbolformation rely on the distinction
between the Real, the Imaginary, and the Symbolic order. In gen-
eral, the relationships between these three orders account for the
individual’s capacity for thinking in a symbolic mode. A Lacanian
view would describe the psychotic patient’s ways of thinking as
being confined to imaginary modes of using signs and signifiers.
Instead of relating to and reflecting upon the words in the com-
munications, and thus creating a “third-position-distance” to the
possible and multiple meanings in the dialogue, the psychotic
is hit or imprisoned by the words hen and others utter, or he is
thinking magically about the ways they affect others, e.g., believ-
ing that others understand the words in exactly the same man-
ner as he does himself. For the psychotic, the mind is in a state
in which speech and thinking are in one way or another denied
access to full symbolicity, or to the Symbolic order. Since access
to the symbolic order is a prerequisite for the extended conscious-
ness (Damasio, 1999)3, the obstruction of this access means that
the psychotic mind has difficulties with:
• The ability to create helpful artefacts

• The ability to consider the mind of the other in different
perspectives
• The ability to sense the minds of the collective and to take into
account the interests of the other as well as of the collective
• The ability to suffer with pain as opposed to just feel pain and
react to it
• The ability to value life
• The ability to construct a sense of good and of evil distinct from
pleasure and pain
• The ability to sense beauty as opposed to just feeling pleasure
• The ability to sense a discord of feelings and a discord of abstract
ideas which is the source of the sense of truth
3
It is interesting to see how the neuroscience description of the autobiographical self
(Damasio, 1999, p. 230) goes hand in hand with the psychoanalytic description of the
appearance of the Symbolic order.
Normally, if normality has a place within psychoanalysis, the

mind will make as much use of the above abilities as possible. It will
strive for establishing an intersubjective relationship in the symbolic,
with a mutual and stable exchange of subjectively based messages
and informations between I and others. In doing so, the “I” accepts
the other’s not knowing as a given pre-condition for conveying the
messages.
In psychotic states of mind, these I-You-, or I-Other-, relationships
become vulnerable, and the vulnerability concerns the experience
of unexpected, immediate phenomena in the intersubjective space.
These phenomena are intruding into and disrupting emotional
thinking and affective experience. Single words, perceptive stim-
uli and sensations are experienced as isolated, painful, intrusions
rather than being integrated into an experience as a whole which
may serve as guidelines for the person’s thoughts and acts. These
elements may be seen as effects derived from the ‘Real’, i.e., effects of
that which cannot be symbolized and thus is experienced as anxiety,
catastrophe, abyss-like without anchorage and without time, and on
a purely perceptual level. A situation in the daily social life–going
shopping, talking to persons, or standing close to somebody in a
bus–could for my patient turn into an area with hidden bombs, and
shells, which could explode and undermine her existence. A sen-
tence, action or movement could trigger this catastrophe. In a nar-
ration of great interest to both of us, she could suddenly experience
confusion and lack of capacity to trust her own experiencing, as if
the whole system of internal connections was in danger of breaking
down in her, or already had broken down.
The danger of breakdown and its influence on symbolisation also
brings to mind Donald Meltzer’s description of two kinds of pain,
related to two kinds of internal object relations. The first kind of pain
is the confusional anxiety in which the threat against the capacity to
think is dominating. The other is the persecutory anxiety in which the
threat against being psychically alive is dominating.
Both concepts of anxiety are related to Bion’s concept of attacks
on linking (Bion 1959). These attacks exhibit themselves in under-
mining the emotional thinking, leaving to the mind a mode of
thinking that on its surface may appear logic but which beneath the
surface is characterised by cruel, abortive and private thoughts and
impressions.
These attacks make the work of the symbolic impossible and the
symbolic modes of being is experienced troublesome and painful to
the extent that a patient one day asked me with an almost desperate
tone of voice: “How do I know that my thoughts are my thoughts,
and how do I know that my I is my I”.
Schizophrenia and developmental psychopathology

One of the important contributions of psychoanalysis to the under-
standing of the human nature is its emphasis on developmental
psychopathology (Fonagy, 2003). This term, developmental psycho-
pathology, connotes dialectical relations between ‘subject’, ‘time’,
‘psychopathology’ and ‘psychic structures’. This dialectics, in addi-
tion to the special causal mechanism invented by Freud, called
‘Nachträglichkeit’, distinguish the developmental psychopathology
model of psychoanalysis from any model of linear causality, and
from simple risk factor and vulnerability models, and even from the
widely used stress-vulnerability model.
Furthermore, there is a link between developmental psychopa-
thology and symbolisation. This link has many aspects–biological,
evolutionary, physiological, psychological and cultural.
Freud depicted several entrances to the understanding of the
mechanisms and structure of the psychotic mind
1. Withdrawal of psychic investment (Versagung) followed by a

denial/of inner reality (Verleugnung/Verwerfung/forclusion)
and the establishment of another kind of reality (Freud, 1924)
2. Primary processes intruding into the secondary processes (Freud,
1900)
3. Regression in the psychic apparatus towards fragmented
memories and perceptions being the preferred ground of
experience (Freud, 1900)
4. Withdrawal of libido from thing-presentations and collapse of
thing-presentation (Dingvorstellung) and word-presentation
(Wortvorstellung) (Freud, 1915). Instead of integrating thing- and
word-presentations (and thus forming an object presentation), the
psychotic mind confuses the two–treating words and thoughts as
if they were images and un-anchored emotions
5. Problems of autoerotic, narcissistic and homosexual structure
(Freud, 1911)
I shall here dwell on the last one concerning the developmental line
from auto-erotism through narcissism and homosexuality to hetero-
sexuality4. I shall summarise a longer version, which I presented in
Scandinavian psychoanalytic Review 2006.
The short version is that although problems in the domain of
autoerotism and narcissism are often (or may be always) found in
schizophrenia, the particular demands of the homosexual structure
seem developmentally insurmountable for the person suffering from
schizophrenia. The question is of course: what do we mean by using
these concepts in the definition of the schizophrenic states? In my
answer, I take the liberty to let the concepts of autoerotism, narcis-
sism and homosexuality not only signify libidinal investment in the
different kinds of objects, but in addition let these concepts signify
fundamental identity structures for the embodied mind’s orienta-
tion in the world and in other minds. I thus hope in a simple way to
shed new light on the developmental psychopathology in the case of
some psychotic states of schizophrenia.
The structure of autoerotism signifies that the body on its surface
immediately cognises and recognizes pleasure and unpleasure as
coming either from inside or from outside. Autoerotism thus empha-
sises the basic structure of the inside/outside, especially the ability to
distinguish what is pleasurable and unpleasurable and whether these
affects and emotions originate from perceptual (exterior) or sensory/
emotional (interior) stimuli. In states of schizophrenia the distinction
between inside and outside is often obliterated, and confusion arises
as what stems from inside and what originate in the outside.
The structure of narcissism mainly concerns the mirroring of the self
in the other of similar, opposite and divergent relations. In the nar-
cissistic structure the subject envisions an object (another) outside
of itself but that object resembles the subject in major aspects. The
subject measures itself on projections of its own unconscious states
and it is thus bound to states of mirroring. However, the mirroring
4
Freud wrote: “Since our analyses show that paranoids endeavour to protect
themselves against any such sexualization of the social instinctual cathexes, we
are driven to suppose that the weak spot in their development is to be looked for
somewhere between the stages of autoerotism, narcissism and homosexuality, and
that their disposition to illness (which may perhaps be susceptible of more precise
definition) must be located in that region. A similar disposition would have to be
assigned to patients suffering from Kraepelin’s dementia praecox or (as Bleuler
named it) schizophrenia (Freud, 1911, p. 62).
is constituted by ideals (from the Other), which the subject assumes

as his own ego (ideal-ego).
The structure of narcissism can thus be seen as the basis for the
ability to establish an object outside the self, a dyadic object relation
harbouring the distinction between self and other, even though self
and other are established as related domains. In states of schizophre-
nia this basis may be undermined by a confusion of the two spheres,
a lack of separation and an experience of transitivism.
The structure of homosexuality concerns the homoerotic relation-
ship between the self/subject and the group of homogenous others
(peers, other subjects). The libidinal tie in the homoerotic structure
concerns not a dyadic relation (like in narcissism) but a link between
the subject and the group of like-minded others5. The homoerotic
identity structure concerns the being-in-the-world of homogeneity.
It is a complex experience, constituting the feelings of being part of
a group (group identity)
1. The experience of being in accordance (homologue) with the oth-

ers, i.e., being ordinary, like-minded, one amongst many;
2. The experience of being a person with individual qualities, a
subjectively marked individuality, i.e., being in some respect
unique and thus different from the others in the group.
The homoerotic identity structure commences developmentally

with the acquiring of the stable sense of we-ness (at around the age of
three years, at a time when the child is mature enough to start the
kindergarten experiences).
Acquiring we-ness capacities is a complex process in which the
mirroring processes forming the self-understanding no longer take
place in a visible mirror (employing the other as a mirror) but in
5
Freud expresses the social group as the basic scenario for the Schreber’s homoerotic
feelings in the following statements:
…
the strikingly prominent features in the causation of paranoia, …, are social humili-
ations and slights. […] the really operative factor in these social injuries lies in the part
played in them by the homosexual components of emotion … [] …. delusions never fail
to uncover these [emotional] relations [to his neighbours in society] and to trace back
the social feelings to their roots in a directly sensual erotic wish (Freud, 1911b: 60) [italics
are mine, BR]. In the end of the argument Freud distracts the argument about social
origin of affects and falls back on his ideas of libidinal investment in the parents.
an invisible one (based in the group matrix). From a developmental

perspective this step goes along with the embodiment of:
1. narrativity: I am a subject in so far I am telling stories about myself

and is subjected “to be told” by other storytellers who include me
in their stories;
2. argumentativity: I am a subject with identity in time and space in
so far that I can argue my opinion so that others can understand
what I am referring to and what the meaning and intentions are;
3. Experiencing being both unique and ordinary: being a subject
means subjecting my experiences to categorisations and
generalisations—and in that sense being a human being whose
ideas and acts are equated and exchangeable with these of other
human beings—and at the same time I am different from all the
others in one respect or another, and thus unique.
Persons in psychotic states of schizophrenia have immense diffi-

culties establishing the “group-as-a-whole”-functions of the mind.
They will experience difficulties in identifying themselves as part of
a group of like-minded, regardless whether these like-minded are
other patients, other family-members, schoolmates, friends, work-
colleagues, members of sport clubs, etc., They feel that they simulta-
neously belong and don’t belong. Just like the ego may function as a
boundary connecting subjective experiencing with the immediately
experienced world, and a third may function as a connector linking
the subject and the other, in the same way does the we-ness mode
function as a connector linking the separate individuality with the
societal whole.
Therapeutic approach
It is not so easy to learn from a psychotic mind even though the
therapist may have “learning-from-the-patient” as an under-
lying philosophy of his/her techniques. The patient is the one
who informs the therapist, who can do no more than listen with
as much empathy as his countertransference allows him to and
through this (open-minded, respectful, no-better-knowing, neu-
trally exploring) listening process motivate the patient to feel
safe in this “teaching position” from where the informations
(on situations, experiences, perceptions, etc.,) to both therapist

and patient can emerge.
Learning from the patient also demands something more that is
difficult for the psychotherapist namely to sense and not be fright-
ened about the complexities of the psychotic states and their, in
many cases, slow pace of developmental change. The changes that
take place in psychosis psychotherapy may be subtle and minimal
so that the therapist hardly senses them and looses track of them
in the course of treatment. If the therapist can manage being some-
times a few steps ahead of the patient, at other times a few steps
behind, and again at other times side by side with the patient, then
it is a very gratifying learning experience for both.
Finally, the patient’s mistrust in the dyad is an area, or may be
the area, in which the psychoanalytically informed psychotherapist
plays a major role. In the dyad, the therapist may help the patient
to perceive, apperceive, feel and think the myriads of processes this
dyad encompasses. But the long-term perspective in the develop-
ment is the integration of the patient’s thinking in the “we-ness”-
modes. Only by achieving this may the therapy help the patient to
gain a firm foothold in the symbolic order of language. This certainly
challenges the therapist’s ways of intervening.
In the following I shall dwell on some practical and technical
steps or moments in which possible curative movements of the psy-
chotic states may take place. They are psychoanalytically informed
in the sense that they fully acknowledge: the fundamental work of
the Unconscious; the transference-countertransference processes;
the libidinal investment in internal and external object relations that
may be distorted, destructive or integrated; the pre-conscious as a
transforming mediator between the radically unconscious and the
communicating consciousness. One might always dispute whether
the therapy offered is really psychoanalysis or not, but mostly such
disputes are futile. All the modifications of the psychoanalytic meth-
ods mentioned in the American psychoanalytic literature of the
1950’es (Eissler, 1953), are relevant in the clarifying and interpreting
modes of listening. In its nature the analyst’s intervention will be
supporting and enhancing the thinking processes of the patient.
In the Danish National Schizophrenia project (Rosenbaum
et al. 2005) we outlined some principle for the psychodynamic
psychotherapy (Rosenbaum and Thorgaard, 1998; Thorgaard

and Rosenbaum, 2006). They included among other elements the
following:
A focus on the non-psychotic aspects of being simultaneously

with a focus on the psychotic ones
This principle acknowledges two modes of functioning—one mode
which is thinking in spite of the grief it is to harbour the evolving
process of psychosis, and another mode which undermines the com-
mon sense of thinking, and renounces ordinary ways of mourning
the losses and feeling the pleasures, and finally taking initiatives
for change. When working with the psychotic patient, the thera-
pists should keep these two modes of functioning in mind, and
they should be able to empathise with the difficult complexities of:
symbiosis and separation; distrust and loss of trust; identity and
relational confusion; control and loss of control; care- and self-care-
failing (Thorgaard and Rosenbaum, 2006).
At the same time the therapist and patient should together develop
creative areas which can be used for thinking, counteract some of
the regression, and which as a therapeutic alliance will show itself
stable enough to resist more and more of the attacks on conscious
reasoning which appear as part of the psychotic personality. It is
recommended that the therapist, together with the patient, already
from the initial assessment sessions explores the patient’s talents,
interests, creative fantasies, and interpersonal capacities. In success-
ful therapies, the therapist may make use of viable metaphors from
this exploration to enlighten what is going on in periods, or moment,
dominated totally by the psychosis.
Entering the patient’s universe through his or her talents, inter-
ests and creative fantasies also enables patient and therapist to link
to the existence of the we-ness mode that often is frightening and
incomprehensible for the patient. The advantage of using these crea-
tive areas of experience is that the explorations of the dangers and
difficulties of experiencing the “ordinary-unique”-dialectics of the
we-ness mode might be easier for the patient to overcome when the
work is done in areas where he or she may be able to feel pleasure
and experience positive self-esteem.
Making use of the necessary modifications of the technique

Without falling into traps of deadening and moralistic, norm-
seeking countertransference, the therapist should be able to make
use of e.g.,:
– Clarifications: “Tell me more about that”, or “Tell me more

about what you saw and heard, and what you feel about it”.
Often the therapist may ask for clarifications that concerns
perceptions (hearing, seeing, tasting, sensing, moving) rather
than emotions; psychotic patients may many times have dif-
ficulties in acknowledging and describing emotions, and may
either be bewildered or feeling intruded by the request con-
cerning these;
– showing explicit empathy with the patient’s painful state
of mind: “it sounds like unbearable memories/experiences
that you are carrying with you”, “It must be hard”, or just an
empathic “Yes” affirming the patient’s emotional state. Some-
times the affirmation lies in the sound of the therapist’s voice
or in the facial expressions;
– Indirect proposals: “What would happen if you …”, “Consid-
ering the situation, could you think of any alternative thoughts
about what happened?”
– exemplifications from life experience: “Having been in a
similar situation, I thought by myself …”, “Sometimes that
kind of human behaviour is unavoidable”, “pleasure and fear
may sometimes go hand in hand, especially when one expe-
riences entering unknown land”, etc., The use of metaphors
is frequent when the therapist expresses his life experiences.
The metaphors should be seriously thought through by the
therapist either before or after using them. And metaphors
that may help entering the we-ness modes are of importance
to have in mind;
– responding to questions after having examined their pos-
sible meanings: “You asked me a question and I will respond
to it, but first you and I will investigate the meaning of the
question from your perspective, and the possible responses
you may have to it”.
A new orientation of the mind in its process of overcoming

and defending against the losses it has experienced
Living through a psychosis is not only a painful experience in itself,
but it also implies internal and external losses: losses of ideas, values,
plans of life, cohesion with friends, peers in school, university or work,
family members, etc., It is important to empathise with these losses,
face their reality, and at the same help the patient to start retelling his
life in another way. Since the psychosis retrospectively disturbs ones
whole identity and alters the image of what that identity was even
before the manifestations of the first psychotic episode, then the pos-
sibility of telling other narratives must include even those narratives
embedded in ones self-understanding in the pre-psychotic experi-
ences. Constructing ones narratives of the self in a new way can be
used as a creative counter-move against self-destruction.
The shared responsibility for the work to be done

The concept of shared responsibility is an ethical dimension that belongs
to the symbolic order, and it is too abstract to be immediately under-
stood by the psychotic mind. Searles called the first phase of therapy
the “out of contact phase” (Searles 1965), and Ogden called it “Stage
of non-experience” (Ogden 1980), and with these characteristics they
both described relationships in which shared responsibility lied very
much on the shoulders of the therapist. The share of the patient seems
primarily to come to the sessions, stay in the room and have a mini-
mal awareness of two separate persons being in the room. Sometimes
the elements of exchange relate to what is perceptually concrete and
evident, and easy to describe for the patient. At other times attitudes,
feelings, behaviour and fantasy can be drawn into the communica-
tion. An important principle in the beginning of the therapy is that the
shared responsibility is demonstrated as a non-polarised relationship
between the therapist’s and the patient’s viewpoints. Later when the
patient’s becomes more interested in the therapist’s point of view, it
will be important to listen to and emphasise new angles of the thera-
peutic material. Then a genuine analytic relationship may rise in which
the patient searches answers to questions in him-/herself, by listening
to himself in the presence of the analyst’s intervening comments.
Shared space and shared responsibility must ultimately be demon-

strated in what kind of thoughts that can be exchanged. If the patient
participates in group psychotherapy, which is highly recommendable,
many different points of views and angles of perspectives expressed
by the others in the group must be considered by the patient. From
learning-from-experience by responding responsibly to others the
patient may gain access to a more stable life in the we-ness mode.
And finally
Many other technical and methodological advices can be pointed at,
and will be in the supervision process that is always necessary when
one is doing work with persons in psychotic states of mind.
References
Bell, D.L. (1995). Knowledge and its pretenders. In Ellwood, J. (ed).
Psychosis: Understanding and treatment. London: Jessica Kingsley
pp. 70–82.
Bion, W.R. (1959). Attacks on Linking. International Journal of Psycho-
Analysis, 40:308–315.
Damasio, A. (1999). The feeling of what happens: Body, emotion and the
making of consciousness. London: William Heinemann.
Eissler, K.R. (1953). Notes Upon the Emotionality of a Schizophrenic
Patient and its Relation to Problems of Technique. Psychoanalytic
Study of the Child, 8:199–251.
Freud, S. (1900). Interpretation of Dreams. Standard Edition 4 & 5. London:
Hogarth Press.
Freud, S. (1911/1958). “Psycho-Analytic Notes on an Autobiographical
Account of a Case of Paranoia (Dementia Paranoides)”. Standard Edition 12.
Freud, S. (1915e). The Unconscious. Standard Edition 14. London: Hogarth
Press.
Freud, S. (1924b). Neurosis and psychosis. Standard Edition 19. London:
Hogarth Press.
Freud, S. (1924e). The Loss of Reality in Neurosis and Psychosis. Standard
Edition 19. London: Hogarth Press.
Freud, S. (1940a). An outline of psycho-analysis. Standard Edition 13.
Jasper, K. (1913). Allgemeine Psychopathologie. Berlin: Springer Verlag.

Ogden, T. H. (1980). On the Nature of Schizophrenic Conflict. International
Journal of Psycho-Analysis, 61:513–533.
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experience in early Schizophrenia. Comprehensive Psychiatry,
vol. 44/2:121–134.
Rosenbaum, B. (2005). Psychosis and the structure of homosexuality:
Understanding the pathogenesis of schizophrenic states of mind.
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Danish National Schizophrenia Project: Prospecive, comparative,
longitudinal treatment study of first-episode psychosis. British Jour-
nal of Psychiatry, 186:394–399.
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tion in schizophrenia. Short version of The Danish National Schizo-
phrenia Project manual for psychodynamic individual psychotherapy
with schizophrenics. Unpublished.
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therapy of chronic schizophrenia. In Collected papers on schizophrenia
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Thorgaard, L. & Rosenbaum, B. (2006). Schizophrenia: Pathogenesis and
therapy. In Johannessen, J.O. et al. (eds). Evolving Psychosis. London:
Routledge.
CHAPTER EIGHT
Pre-suicide states of mind

Donald Campbell
Freud on suicide
• During a suicide attempt the body is perceived as a separate
object—to be killed
In his paper ‘Mourning and melancholia’ (Freud, 1917) Freud observed

that in melancholia after a loss or a ‘real slight or disappointment’
coming from a person for whom there are strong ambivalent feel-
ings, the hate originally felt towards the person may be redirected
towards the self. He writes:
“It is this sadism alone that solves the riddle of the tendency to
suicide, which makes melancholia so interesting—and so danger-
ous. The analysis of melancholia now shows that the ego can kill
itself only if ... it can treat itself as an object—if it is able to direct
against itself the hostility which relates to an object and which rep-
resents the ego’s original reaction to objects in the external world”
(Freud, 1917, p. 252).
In the suicidal individuals I have analysed it is the body that is
treated as a separate object and concretely identified with the lost
171
loved and hated person. My understanding of suicidal patients is

influenced by Freud’s observations and begins with the view that in
these patients a split in the ego has resulted in a critical and punitive
super-ego perceiving the body as a separate, bad or dangerous object.
Whatever else is said about suicide, it functions as a solution born
of despair and desperation. An individual enters a pre-suicide state
whenever the normal self-preservative instinct is overcome and
their body becomes expendable. In some cases, the patient’s rejec-
tion of his or her body comes silently, or may appear only indirectly
in the material, but once this has occurred a suicide attempt may be
made at any time.
The nature and function of the suicide fantasy

• The suicide fantasy involves splitting, projection and denial
• In the suicide fantasy a dangerous mother identified with the
body
• The aim of the suicide fantasy is to kill the body so that an essen-
tial part of the self can survive in another dimension
• In the suicide fantasy the surviving self is free to fuse with an
omnipotently gratifying, desexualised mother
A pre-suicide state of mind is influenced, in varying degrees, by a

suicide fantasy, based on the self’s relation to its body and its pri-
mary objects. The fantasy may or may not become conscious, but at
the time of execution it has distorted reality and has the power of a
delusional conviction. The suicide fantasy is the motive force. A per-
son’s promise or conscious resolve to not kill him or herself, or even
a strong feeling that suicide is no longer an option, does not put them
beyond the risk of another attempt on their life. The suicide fantasy
illuminates the conflicts, which the suicidal act aims to resolve, and
the wishes that self-murder gratifies. As long as the suicide fantasy
is not understood and worked through, the individual is in danger
of resorting to suicide as a means of dealing with conflict, pain and
anxiety. For many despairing individuals, suicide is the secretly held
trump card, which insures that they will triumph over adversity.
I found that suicidal patients’ fantasies about death and their affects
and thoughts during the build up to a suicide attempt confirmed
Freud’s (1917) observation. When these patients reached the point at
P R E - S U I C I D E S TAT E S O F M I N D 173
which they intended to kill themselves, they experienced their body

as a separate object. While each patient expected his or her body
to die, they also imagined another part of them would continue to
live in a conscious body-less state, otherwise unaffected by the death
of their body. Although killing the body was an aim, it was also a
means to an end. The end was the pleasurable survival of a self that
will survive in another dimension. This survival was dependent
upon the destruction of the body (Maltsberger and Buie, 1980).
One half of the dyadic relationship embodied in the suicide fantasy
is the body experienced as a separate object. This raises two critical
questions for the professional: What is the nature of the object that is
now identified with the body? Why is that object expendable?
Self-preservative aggression and sadistic aggression

• Self-preservative aggression aims to eliminate or negate a threat-
ening object
• Sadistic aggression aims to control a threatening object
Developmentally speaking, the ego’s first line of defence is self-

preservative aggression. The aim of self-preservative aggression is to
negate the threat. However, when the object perceived as threaten-
ing the child’s survival is the same object upon which it depends for
its survival—his mother—the exercise of self-preservative aggres-
sion poses a dilemma for the child. How can the infant survive the
unmitigated and unmediated terror of the other? How is the child
to survive if it cannot afford to get rid of mother? How can it sur-
vive the consequences of its omnipotent violence? Children fashion
an ingenious solution by libidinizing their aggression towards the
mother. In this way the child changes the aim of its aggression from
eliminating mother to controlling her in a libidinally gratifying way.
Self-preservative aggression is, thereby, converted into sadism.
In a self-preservative attack where the aim is to negate a threat
(Glasser, 1979) the impact upon the object is irrelevant beyond this.
However, in a sadistic attack where the aim is to control the object
by inflicting pain and suffering, the relationship to the object must
be preserved, not eliminated. By radically altering the relationship
to the threatening object to insure that both self and object survive,
sadism offers the child a second line of defence.
As with every relationship, the two partners gradually establish

the rules by which they can control one another. However, when
something occurs which alters the balance of the relationship, it
may enter the crucial, pre-suicide phase. The potentially suicidal
patient sees the event as a betrayal of a fragile trust, which has held
the two in equilibrium, and is perceived, as a direct attack on their
psychological integrity. When psychological defences are breached,
the body is also felt to be at extreme risk. The at-risk individual
mobilises his aggression in a psychic self-defence. His aggression
may be aimed at his own body or another’s.
Body barrier
The term body barrier describes the resistance that exists in everybody
to translating a conscious fantasy of violence into physical action.
The suicidal individual has withdrawn from others in favour of the
cathexes of his own body, so that the primitive anxieties of anni-
hilation are experienced in relation to his body, which has become
identified with the engulfing or abandoning object. Violent individ-
uals attack an external object in order to break out of an engulfing
state, with the self more or less intact. A suicidal individual leaves
the external object intact and assaults an internal object, represented
by the body, identified with the abandoning or engulfing mother
who is perceived as someone who would kill by suffocation or star-
vation. The body must be killed if the self is to survive. In intra-
psychic terms, this is homicide, justifiable homicide. Just as there is a
split between the good self and the bad body, there is a split between
the hated and engulfing or abandoning primal mother, now identi-
fied with the body, and the idealised one with which the self will
fuse once the bad mother’s body has been eliminated (Campbell and
Hale, 1991).
Types of suicide fantasies and the pre-suicide state of mind

• The revenge fantasy
• The self-punishment fantasy
• The elimination fantasy
• The dicing with death fantasy
• The merging fantasy
Suicide fantasies, which elaborate the relationship between the

‘surviving self’ and the body, take at least five forms. The suicide
fantasies of revenge, self-punishment, elimination and merging that
I describe here, were elaborated by Maltsberger and Buie (1980).
I have added a fifth—the dicing with death fantasy. Although one
type of fantasy may dominate consciousness, suicide fantasies are
interdependent and at an unconscious level not mutually exclusive.
Within the patient, each fantasy is organised around a wish to gratify
pre-genital impulses, which are predominantly sadomasochistic or
oral-incorporative in nature.
First, a common suicidal fantasy is the revenge fantasy. The revenge
fantasy centres on the impact that the suicide makes on others. Here,
a conscious link to a real object is maintained more strongly than
in other suicide fantasies. The destruction of something precious to
another person is a devastating attack. A son or daughter who takes his
or her own life robs the parents of their dearest possession, knowing
that no other injury could possibly be so painful to them (Menninger,
1933). The often conscious thought in the revenge fantasy is ‘They will
be sorry’. The implicit message is that the parents have raised a child
who hates himself because they did not love him enough. The threat
of suicide to blackmail others may accompany the revenge fantasy.
This suicide fantasy has a markedly sadistic orientation, with the
surviving self’ often enjoying the role of the invisible observer of
others’ suffering, especially due to their feelings of guilt and remorse
because of the suicide. There is a sense of retaliation, revenge and
irrevocable, everlasting triumph.
A second fantasy is that of self-punishment, which is dominated
by guilt, frequently associated with masturbation, which aims to
gratify, in fantasy, incestuous wishes, and an erotisation of pain and
death. Here, the surviving self is gratified by its sadistic treatment
of its own body rather than that of others, as occurs in a revenge
fantasy. Masochistic impulses are satisfied as well, in the self’s iden-
tification with the helpless, passive, submissive body.
Case study: Self-punishment fantasy and erotisation

in a completed suicide
This sadomasochistic dynamic is evident in the complexity of those
sexually deviant practices that maintain a delicate balance between
masochistic pleasures in self-torture and the risk of death, as in the

dicing- with-death phenomenon, which I will describe later, and is
illustrated by the suicide of a man who had broken off treatment two
years prior to his death.
He was found hanged above a fallen chair and dressed only in
a raincoat surrounded by burning candles. From the patient’s ear-
lier accounts of his elaborate ritual, it was clear that the ‘surviving
self’ in his suicide fantasy was secretly identified with Joan of Arc,
a woman who victoriously led men in battle and was martyred and
reincarnated in a new dimension as a saint.
Based on my understanding of this ex-patient’s unconscious
wishes from his previous therapy, I would speculate that underly-
ing the risk-taking, sadomasochistic dynamic was an infantile wish
to get inside a woman; he was naked inside the raincoat, thereby
sharing her death. The sacrifice of his male body was the means
to that end. The candles represented her execution pyre, the noose
introduced excitement because of the real risk of death. This tragic
and extreme case illustrates the interplay between sadomasochistic
and oral incorporative impulses and the coexistence of one or more
fantasies during a pre-suicidal state.
This interplay of fantasies is particularly remarkable during the
turbulent, fluctuating time of adolescence. Adolescents who are
dominated by pre-genital needs and have had difficulty in separating
from their parents may blame their sexual bodies for the incestuous
guilt they feel over intrusive wishes. These adolescents believe that
punishment of their body by killing it is the only way to relieve them
of their guilt.
In the third fantasy, the elimination fantasy, the body is experienced
as a destroyer. In some cases, it threatens to destroy sanity, while
in other cases the body threatens to kill the self. The mechanism is
similar to that seen in paranoid cases, with its reliance upon split-
ting aspects of the self and projecting them into others, But for the
suicidal patient with an elimination fantasy, a split-off body is the
object upon which is projected murderous impulses in such a way
that the ‘me’ self then feels that it’s ‘not me’ body is occupied by an
assassin (Maltsburger and Buie, 1980).
What distinguishes this suicide fantasy from others is that the
surviving self is motivated less by malicious intent, as in the revenge
and punishment fantasies, than by primitive self-preservative
instincts. The body is not an object of sadistic attack by the self, nor
is the self-preoccupied with revenge upon others. The body must
simply be gotten rid of.
The internal dynamics are similar to those of the individual who
feels ensnared in the Core Complex to the extent that he believes his
life is at risk and reacts with self-preservative violence. In the psy-
chotic life and death struggle contained in the elimination fantasy,
the only thing that matters to the surviving self is the elimination of
the killer body to avoid total annihilation. In this fantasy, suicide is
conceived of as killing the assassin body before it kills the me self. The
elimination fantasy views suicide is an act of self-defence.
Case study: An elimination psychosis

A 19-year-old boy was tortured by unacceptable perverse fantasies
during a pre-suicide state. In a session, as the tension created by
suicidal thoughts reached the breaking point, he shouted, ‘I have got
these thoughts. (He tapped the top of his head,) Up here. I can’t get
rid of them. They are driving me mad. I just want to get a gun, put it
right here (he pushed his index finger into the top of his head), and
blast it out. POW!’
I believe that the elimination fantasy is the predominant fantasy
when suicide occurs in the context of what, in descriptive psychi-
atric terms, would be regarded as a paranoid psychotic (or schizo-
phrenic) state.
A fourth fantasy is the dicing-with-death fantasy. The patient who
is compelled to dice with death actively puts his body, or a symbolic
representative of it, at risk in order to both attract and attack the pri-
mary object. This may take obvious forms, such as driving whilst
drunk. It may be structured and socially sanctioned in activities such
as parachuting and mountaineering or motor racing, or involve vari-
ous kinds of delinquency and sexual deviancy. Whatever the risk-
taking activity, it should alert the clinician to the fact that the patient
may enter a pre-suicide state, and careful attention should be given
to the fantasies that are being gratified. Obviously, many risk-takers
do not lose touch with reality and do not exceed the limits of their
bodies, their equipment or their environment. Nevertheless, because
they maintain a delicate balance between failure and triumph, changes
in their internal state can alter that balance with fatal results.
Case study: The reckless driver

A patient who had numerous car accidents assumed that others
should look out for him. He saw no need to drive within speed limits.
He was, in Freud’s terms, ‘the exception’; that is, someone who had
unjustly suffered enough as a child and felt he had a right to a fanta-
sised mother he had never had–an omnipotent mother represented
by fate and other drivers who would anticipate his behaviour and
protect him from any danger. By putting himself at risk, he hoped to
arouse anxiety in others, especially his analyst, and provoke them to
rescue him and make him safe and secure. But this attitude towards
his body, a body that he did not value enough to protect, represented
identification with his neglectful mother, as well as his condem-
nation of her. There is a strong sadomasochistic dynamic in both
passive submission to fate, on the one hand, and actively flaunting
the risk-taking, on the other.
The fifth suicide fantasy underpinning all of the other fantasies is
a merging fantasy. Patients who harbour a merging suicidal fantasy
imagine death as a return to nature, becoming one with the uni-
verse, achieving a state of nothingness, a passport into a new world,
a blissful dreamless eternal sleep; or as a permanent sense of peace.
The patients believe that in death the self will survive in a state akin
to that of the sleeping infant. The dominant wish is to be fused ‘with
the image of the Madonna of infancy. By becoming one with her, the
suicidal patient hopes to taste again the omnipotent, timeless, mind-
less peace of his baby origins, far from the wearisome hostile inner
presence of his miserable adulthood’ (Maltsburger and Buie 1980).
However, as seen in the core complex, the wish to fuse with an
omnipotent mother is accompanied by an anxiety about the con-
sequences of fulfilling that wish, the annihilation of the self. In the
psychotic state typical of those dominated by suicidal fantasies, split-
ting of the self from the body leaves these patients believing that the
body is actually an impediment to the fulfilling of the merging fantasy.
The body is identified with the engulfing or abandoning mother and is
then eliminated. Once the body is eliminated the ‘surviving self’ is free
to fuse with the split-off, idealised, desexualised, omnipotently grati-
fying mother represented by states of oceanic bliss, dreamless eternal
sleep, a permanent sense of peace, becoming one with the universe, or
achieving a state of nothingness (Maltsberger and Buie, 1980).
The father in the pre-suicide state of mind

• The good enough pre-oedipal father sets limits on his child’s
fantasised timeless relationship with mother and represents the
world outside the exclusivity of the mother/child relationship,
e.g., the realities of time and place
• Prior to a suicide attempt father’s failure to stake a claim on his
child, which left the child with no alternative to the pathological
mother/child relationship, is revived in the transference
The clinician should not expect the suicidal patient to be entirely

conscious of their suicide fantasies, or to report conscious aspects
of their fantasies during therapy. The transference and counter-
transference may be the most reliable indicator of the form
and content of the patient’s suicide fantasies. These suicide fan-
tasies, whatever form they take, represent internalised early
pathological relationships between mother and child and father,
and will inevitably be played out in the transference and counter-
transference. In the time I have available I will focus on only one, but
important, transference dynamic—the pre-oedipal father. In my
experience, the pre-oedipal father’s role was often obscured by
the patient’s relationship with the mother, which dominated the
suicide fantasy, and by the father’s absence or ineffectiveness.
However, it was during the pre-suicide state that the internal-
ised father’s failure to intervene in the pathological mother/child
relationship became most critical. I found that the therapist was
repeatedly drawn into enacting the withdrawn or out of touch
father that, in the patient’s mind, sanctioned the suicide state
(Campbell, 1995, 2006).
In normal development, both pre-oedipal parents represent to
the child the world outside the exclusivity of the mother-infant rela-
tionship, e.g., the realities of time and place and objects. The “good-
enough” pre-oedipal father is a friendly rival with both his child
and his wife, in offering each of them a dyadic relationship that is
parallel to and competes with the mother-child unit.
The attractive and attracting father stakes a claim on his child
and, with mother’s help, enables the child to move from the exclu-
sivity of the infant-mother relationship into an inclusive position as
part of a pre-oedipal triad.
Father’s gender role identity and parental Oedipal impulses

influence the idiosyncratic nature of the claim he makes on his child.
For instance, his conscious and unconscious fantasies and anxieties
about female sexuality will affect the way he relates to his daughter
from the beginning. She may be ‘daddy’s little girl’. Gender influ-
enced relating will also play a part in the way a father helps his son
dis-identify from mother (Greenson, 1968) and father’s view of the
way his wife relates to his male offspring. The father may even be
conscious of not wanting his wife to ‘feminise’ his son. Whatever
form this process of claiming his child takes, and there will always
be infinite variations influenced by mixtures of projections and real-
ity, the child will become aware that he or she occupies a place in
father’s mind that is separate and distinct from mother.
The child also becomes aware of a place for mother in father’s
mind and a place for father in mother’s mind. Father reclaims his
wife by seducing her back to him and rekindling her adult sexuality.
The father who reclaims his wife and engages his child on his own
terms protects them both from lingering overlong in a ‘fusional’
or symbiotic state and facilitates the separation and individuation
process (Mahler and Gosliner, 1955).
The father’s twofold response supports the child’s right to an
independent existence that is separate from mother while providing
the toddler with a means of coping with its longing for her. Abelin
(1978) postulates that around eighteen months this process results in
an early triangulation in which the toddler identifies with the rival
father’s wish for mother in order to form a mental representation of a
self that is separate and longing for mother. The good-enough father
provides a model for identification as well as an alternative relation-
ship to the child’s regressive wishes to return to a ‘fusional’ state
with mother with subsequent anxieties about engulfment.
I have found in the analysis of suicidal patients that it often
becomes apparent that they perceived their fathers as either with-
drawn or actively rejecting them, and as having failed to reclaim
their wives. Each patient had felt abandoned to his or her anxiety
about surviving as a differentiated self when left with a disturbed
mother.
I was involved simultaneously in two transferences; firstly, a
dyadic primitive sado-masochistic struggle with a smothering,
‘murderous’ mother, and, secondly, as the abandoning father in a
more triangular situation. The danger is in recognising only one

transference at the expense of the other, despite the patient’s uncon-
scious invitation to do so.
Working with a pre-suicide state of mind

• There is a danger of a collusive counter-transference
• There is a risk of a sado-masochistic interaction
• There will be consequences of the patient’s narcissistic regression
The patient’s pressure to involve the therapist in the suicide sce-

nario is the primary factor in the creation of a collusive counter-
transference response to the patient’s pre-suicide state of mind. This
counter-transference takes the form of unconscious, and sometimes
conscious, wishes to negate the patient. For instance, there is a height-
ened danger during a pre-suicide state of enacting the transference
of a father who fails to stake a claim on its child, and abandons it to
a disturbed mother. Straker (1958) pointed out: “A decisive factor
in the successful suicide attempt appears to be the implied consent
or unconscious collusion between the patient and the person most
involved in the psychic struggle.” The unconscious collusion is bur-
ied in the analyst’s counter-transference.
The patient consciously and unconsciously attempts to provoke
the analyst to behave in such a way as to confirm the patient’s illu-
sory (transference) image of the analyst (Sandler, 1976) as an active
participant in a sado-masochistic interaction. When this is enacted
the analyst has unwittingly been manoeuvred into the role of the
executioner. This gives the patient justification for retaliation via a
suicide attempt.
The sadomasochistic dynamic may also manifest itself in the sub-
tle, superficially benign form of the patient’s feeling of being at peace,
which contributes to increased self-assurance and confidence (Laufer
and Laufer 1984). Depressive affects, anxieties and conflicts are no
longer communicated. This narcissistic withdrawal cuts the thera-
pist off from moods and behaviour, which would normally elicit an
empathic response of alarm or worry and may result in the sudden
loss of subjective emotional concern (Tahka, 1978) for the patient.
In a narcissistic regression, which dominated my patients during
the pre-suicide state, there is the prospect of imminently fulfilling
a merging suicide fantasy. As far as these patients were concerned,

they were already at peace because they had crossed a rational bar-
rier of self-preservation, identified the assassin/mother with their
body, and had no doubts about killing it.
The professional, burdened with anxieties about his or her
patient’s life or exhausted by the patient’s relentless attack on hope
or angry about being blackmailed (often before a holiday break from
treatment), may be tempted to retaliate by giving up on his or her
patient, or try to put the patient out of his or her mind, or use the
patient’s sense of peace to justify relaxing his or her therapeutic
vigilance. This is a frequent problem for therapists and represents
a familiar counter-transference to the patient’s pre-suicide state of
mind. You may feel like surrendering or retreating from the battle,
but it is a battle worth fighting nevertheless.
References
Abelin, E. (1978). “The role of the father in the pre-oedipal years”.
J. Amer. Psychoanal. Assn. 26:143–161.
Campbell, D. (1995). “The role of the father in a pre-suicide state”. Int.
J. Psycho-Anal. 76:315–323.
Campbell, D. (2006). “A pre-suicide state in an adolescent female”.
J Assoc Child Psychotherapy 32:3 pp. 260–272.
Campbell, D. & Hale, R. (1991). “Suicidal Acts” in Textbook of Psycho-
therapy in Psychiatric Practice, ed. J. Holmes, London: Churchill
Livingstone, pp. 287–306.
Freud, S. (1917 [1915]). Mourning and melancholia, Standard Edition. 14:
237–260. London, Hogarth Press.
Glasser, M. (1979). “Some aspects in the role of aggression in the perver-
sions”, Sexual Deviations, 2nd Edition, ed. I Rosen, Oxford U. Press,
pp. 278–305.
Laufer & Laufer (1984). Adolescence and Developmental Breakdown, New
Haven and London; Yale University Press.
Mahler, M.S. & Gosliner, B.J. (1955). “On symbiotic child psychosis,
genetic dynamic and restitutive aspects”. Psychoanal. Study Child. 10:
195–212.
Maltsberger, J.G. & Buie, D.H. (1980). “The devices of suicide”. Int.
R. Psycho-Anal. 7:61–72.
Menninger, K.A. (1933). “Psychoanalytic aspects of suicide”. Int.

J. Psycho-Anal. 14:376–390.
Sandler, J. (1976). “Counter-transference and role-responsiveness”. Int.
R. Psycho-Anal. 3:43–78.
Stekel, W. ([1910] 1967). “Symposium on Suicide” in On Suicide, ed.
P. Friedman, New York: International Universities Press, pp. 33–141.
Straker, M. (1958). “Clinical observations of suicide”. Canad. Med. Assoc.
J. 79:473–479.
Tahka, V.A. (1978). “On some narcissistic aspect of self-destructive
behaviour and their influence on its predictability”, Psychopa-
thology of Direct and Indirect Self Destruction. Psyciatra Fennica,
Supplementum 59–62.
CHAPTER NINE
Individual and large-group identities:

Does working with borderline patients
teach us anything about international
negotiations?
Vamık D. Volkan
M
any years ago, I had a peculiar experience with one of my
patients who had a severe borderline personality organi-
zation. During the third year of his analysis, Joseph began
coming to his sessions 25 minutes late. Without offering an excuse
for being late, or mentioning the subject at all, four times a week
he simply came to my office, lay on the couch with a smile on his
face, and began talking. I sensed that this unexpected behaviour pat-
tern reflected his developing “hot” split transference towards me.
To avoid interfering prematurely with this development, I waited
for several weeks before I told him that he was losing half of his
sessions each time he came to see me. I inquired if he was curious
about this development, for I certainly was. Joseph appeared very
surprised—he seemed genuinely convinced that he was attending
his full sessions.
I stayed calm and continued to encourage him to be curious about
our discrepancy regarding what time he came to my office. Slowly
I came to understand what was occurring and learned that Joseph
was, in a way, telling the truth about coming to our sessions on time.
He did in fact arrive at the scheduled time, but instead of entering
my office, he would go into the bathroom next door where he spent
185
25 minutes holding an inner conversation with me during which he

felt like an angry monster and likewise perceived me as a horrible
person. He then would get off the toilet, come to my office, lay on
the couch, and behave in an extremely friendly way and perceive me
as friendly as well.
Through his “dual” sessions, Joseph directly and fully brought
the splitting of his self- and object images into the transference rela-
tionship with me. Elsewhere I describe this case and how the patient
split his hour with me into “bad” and “good” sessions (Volkan,
1976). Although this aspect of the case was interesting, a different
aspect is also relevant to this chapter: the fact that I thought of him
as the “Penguin Man.” This name, which I kept to myself, simply
seemed to describe him, since he was stocky and waddled slightly
when he walked.
Sometime later, I realized that I had given animal names to other
long-term patients. Besides Penguin Man, there were Giraffe Lady,
Cat person, and Dogman. I discovered that each of these patients
lacked integrated identities; they had psychotic or severe borderline
personality organizations—I never gave an animal name to a person
with a neurotic personality organization. They were simply Mary or
Jack—whatever name they were born with, or one I substituted for
confidentiality when writing or talking about them.
My giving animal names to individuals with unintegrated per-
sonality organizations had a great deal to do with my countertrans-
ference towards them. I am a “replacement child” (Poznanski, 1972;
Cain and Cain, 1964; Volkan and Ast, 1997) the idealized mental
representation of an uncle who died unexpectedly before my birth
and under mysterious circumstances was deposited into my self-
representation by my mother and grandmother. I was named after
him, and in turn he was named after my great-great grandfather
who had been an important Ottoman administrator on the island
of Cyprus. This grandfather lost his fame and fortune in one day
when a British governor and his entourage arrived on the island
after the Ottomans rented Cyprus to the British and turned over the
island’s administration to them. I believe that as a child I assimilated
the combined idealized images of my uncle and my elite Ottoman
ancestor into my self-representation. Nevertheless, at times this
assimilation was shaky and I felt forced to live up to these ideal-
ized images. This induced a tension between the idealized and not
INDIVIDUAL AND LARGE-GROUP IDENTITIES 187
so idealized aspects within my internal world. In a prejudicial way

I associated my patients who had unintegrated self-representations
with animals. By doing so, I separated them from me so they would
not remind me of the tension within my own self-representation due
to my integration difficulty and the influence of the idealized images
that had been deposited in me.
When we are involved in analytic work, the analyst partly
regresses, as Stanley Olinick said, “In the service of the other.”
(1980, p. 7) We on one hand maintain an observing and working ego,
while on the other we regress in order to understand our patients’
inner worlds at their own level. In the service of my patients with unin-
tegrated self-representations, I was trying, unconsciously at first, to
assist with their struggles to find out who they were. They had iden-
tity problems and I gave them animal identities. I also created “teddy
bears,” living transitional objects (Winnicott, 1953) with which, in the
shadows of the analytic process in my office, we would play in order
to help the patients develop integrated self-representations.
Clinicians often use the term “identity” when describing patients
who fragment or divide self- and object images into “good” (libidi-
nally loaded) and “bad” (aggressively loaded) categories. The terms
“good” and “bad” themselves have prejudicial connotations. How-
ever, these terms often appear in contemporary psychoanalytic
literature when we refer to the concept of identity, something which
is relatively new in psychoanalysis. Erik Erikson (1956), one psy-
choanalyst who focused on an individual’s identity and in a sense
made it a psychoanalytic term, first used the term “ego identity,”
and then dropped the word ego and used simply “identity.” He
described a person’s identity as “both a persistent sameness within
oneself ... [and] a persistent sharing of some kind of essential char-
acter with others” (p. 57). Since this chapter also focuses on large
groups, “large-group identity” needs to be defined as well. Large-
group identity refers to the subjective experience of thousands or
millions of people who are linked by a persistent sense of sameness
while sharing characteristics with others in foreign groups.
This volume primarily examines various aspects of individuals
with severe identity disturbances. Most of these individuals pos-
sess split self- and object images and are considered to have bor-
derline personality organizations. In order to link this chapter with
the main theme of this volume, I will explore whether individual
psychoanalysis of patients with borderline personality organization

teaches us anything about psychoanalytically informed international
negotiations. I will compare working on the splitting mechanism in
individual patients with attempting to narrow the psychological
gap between fractured communities or enemy groups. Some politi-
cal leaders have made references to the necessity of examining such
psychological gaps. For example, when Egyptian President Anwar
el-Sadat spoke to the Israeli Knesset in 1977, he referred to the sig-
nificance of a psychological wall (gap) between the two countries in
the continuation of the Arab-Israeli conflict.
In today’s world, there are many “conflict resolution” practitioners
who are involved in unofficial efforts to reduce tensions between
opposing large groups, but they very seldom apply psychoanalytic
understanding of individuals and large groups in their work. There
are exceptions. In 1993, John Alderdice in a lecture entitled, Ulster on
the Couch, proposed the creation of what he called, a “political con-
sulting room” where both the surface elements as well as emotional
and unconscious issues could be addressed in order to improve the
chance of success in the Northern Ireland peace process. Mitch Elliott,
a former president of the Irish Psycho-Analytical Association, and
his colleagues describe how a psychoanalytically informed process
paralleling Alderdice’s suggestions was designed and employed
in the 1990s and what it accomplished (Elliot, 2005; Elliot, Bishop,
and Stokes, 2004). Maurice Apprey (2005) compared the method
described by Elliott and his colleagues with the psychoanalytically
informed method developed at the University of Virginia’s Center
for the Study of Mind and Human Interaction (CSMHI) (closed since
2005). Apprey stated that the first one stopped at a diagnostic level
and Elliott and his colleagues hoped that policy makers would ben-
efit from its findings. CSMHI went beyond making an assessment
of conflict by adding a facilitating team that conducted years-long
dialogues between the representatives of antagonistic large groups,
transformed their grievances and narrowed the psychological gap
between them.
Because CSMHI’s method is discussed in full detail elsewhere
(Volkan, 1999a, 2006a), I only present a brief summary here. Nick-
named the “Tree Model” to reflect that the slow growth and branch-
ing of a tree are analogous to the way this method unfolds, it has
three basic phases: assessment, dialogue, and institutionalization.

During the first phase, which includes in-depth interviews with
a wide range of members of the large groups involved, the inter-
disciplinary facilitating team of psychoanalysts, historians, politi-
cal scientists, and others begins to understand the main aspects of
the relationship between the two large groups and the surrounding
situation to be addressed. Next, influential representatives of enemy
large groups are brought together for a series of unofficial negotia-
tions over several years under the guidance of psychoanalytically
informed facilitators. This facilitating team borrows technical princi-
ples from psychoanalysis as it applies to individuals. The team does
not provide advice. Resistances against changing opposing large
groups’ “pathological” ways of protecting their large-group identi-
ties are brought to the surface, articulated, and fantasized threats to
large-group identity are interpreted so that realistic communication
can take place. By increasing understanding of the conscious and
unconscious dynamics at work on both sides, new ways of inter-
acting become possible. In order for the gained insights to have an
impact on social and political policy, as well as on the populace at
large, the final phase requires the collaborative development of con-
crete actions, programs, and institutions. By developing programs
and institutions that implement and encourage such new ways of
interacting, what is experienced at first by a few during the psy-
cho political dialogues can be spread and made available to many
more. With appropriate modifications, this approach can be applied
to a wide variety of situations to help alleviate tensions, prevent
violent conflict, heal traumatized societies, and promote peaceful
coexistence.
In cases like Joseph’s, the aim of analysis is to help the patient
to mend his or her split self- and object images in order to estab-
lish an integrated self-representation and corresponding integrated
object representations. This produces anxiety and other troublesome
emotions, which I will name later and which can be tamed through
analytic work. Does what clinicians learn in the clinical setting
about mending an individual’s internal splitting provide informa-
tion about difficulties in psycho political dialogues, such as those
that occur during the second phase of the Tree Model? This chapter
attempts to answer this question.
Individual identity
Sigmund Freud seldom referred to “identity,” and when he did, it
was in a colloquial or unsophisticated sense. One well-known refer-
ence to identity is found in a speech written by Freud (1926a) for
B’nai B’rith. In it, Freud connected his individual identity with his
large-group identity and wondered why he was bound to Jewry
since, as a non-believer, he had never been instilled with its ethnona-
tional pride or religious faith. There is a consensus that the concept
“identity” refers to a subjective experience. It can be differentiated
from related concepts such as “character” and “personality.” The
latter terms describe the impressions others perceive of the individ-
ual’s emotional expressions, modes of speech, typical actions, and
habitual ways of thinking and behaving. Traditionally, character is
a person’s ego-syntonic, habitual mode of reconciling intrapsychic
conflicts. Some authors believe that personality is an umbrella term
that covers both character and “temperament.” Temperament refers
to constitutionally determined affectomotor and cognitive tenden-
cies (Moore and Fine, 1990). If we observe someone to be habitually
clean, orderly, greedy, and to use excessive intellectualization, show
excessive ambivalence and controlled emotional expressions, we say
that this person has an obsessional character. If we observe someone
who is overtly suspicious and cautious, and whose physical appear-
ance suggests that she is constantly scanning the environment for
possible danger, we say that this person has a paranoid personality.
Unlike character and personality, which are observed and per-
ceived by others, identity refers to an individual’s inner working
model—this person, not the outsider, senses and experiences it.
Some authors (Kernberg, 1976, 1984; Volkan 1976, 1995) use the term
“personality organization” and differentiate it from the simple word
“personality.” Personality organization refers to the analyst’s theo-
retical explanation of the inner construction and affective experience
of a patient’s self-representation and the nature of this individual’s
internalized object relations. Personality organization parallels the
concept of identity, which is sensed by the individual himself.
In everyday life, adult individuals can typically refer to numer-
ous aspects of their identity related to social or professional
status—one may simultaneously perceive oneself as a mother or
father, a physician or carpenter, or someone who enjoys specific
sports or recreational activities. These facets superficially seem to fit

Erikson’s (1956) definition but do not truly reflect a person’s internal
sense of sustained sameness. If a person’s social or career identity
is threatened, the individual may or may not experience anxiety.
Anxiety is more likely to occur if the threat is connected, mostly
unconsciously, to danger signals originally described by Freud
(1926b): losing a loved one (a mothering person) or that person’s
love, a body part (castration), or self-esteem. In some cases, the anxi-
ety is severe enough for the individual to seek treatment, but it is
otherwise unlikely that changing jobs or membership in a sports
club, for example, would cause severe psychological problems that
change the structure of a person’s internal world.
On the other hand, let us consider an adult who acutely decom-
pensates and goes into psychosis. Such an individual’s unique iden-
tity is fragmenting and may have an inner sense of terror and a star
exploding into a million pieces (Pao, 1979; Glass, 1989; Volkan, 1995).
The experience of this person helps to define what I mean by “core
identity”—one that individuals are terrified of losing—and differen-
tiates it from other social or profession-related identities. Not to have
a cohesive core identity is intolerable unless the individual utilizes
primitive defences to hide it, such as fragmenting, splitting, introjec-
tive-projective relatedness, dissociation and denial. At times, when
one cannot protect oneself and faces the loss of one’s core identity, it
feels like a psychological death. When Erikson (1956) referred to the
aspect of identity that involves a persistent sense of inner sameness
he, I believe, was specifying core identity.
In “normal” development, when children become able to pos-
sess an integrated self-representation, they also begin to have a
subjective experience of a persistent sameness within themselves.
They have now formed the foundation of a core identity. During
childhood the self-representation and the corresponding core iden-
tity will be enlarged and modified with various types of identifica-
tions. Some identifications connect the child’s core identity to the
parents’ cultural and group heritage. Think of a man—let us say
he an Englishman—who is an amateur photographer. If he decides
to stop practicing photography and take up carpentry, he may call
himself a carpenter instead of a photographer, but he cannot stop
being an Englishman and become French. His Englishness is part
of his large-group identity, which is interconnected with his core
individual identity, his subjective experience of his self-representation.

Not all identifications are healthy, however. Clinical work has dem-
onstrated maladaptive childhood identifications.
Identifications and identity are related but they are not inter-
changeable concepts. As Erikson (1956) stated, identity starts when
a process of identification ends. I modify this by saying that a cohe-
sive core identity starts when identifications are assimilated within
a differentiated and integrated self-representation. Peter Blos (1979)
described in detail how an individual’s character crystallizes dur-
ing the adolescent passage. During the adolescent passage there
is a psychobiological regression and the youngster loosens up her
investments in the images of important others of her childhood and
modifies and even disregards her identifications with them. Further-
more, she adds additional identifications, this time from her peer
group or far beyond her restricted family or neighbourhood envi-
ronment. Through these there is an overhauling of her persistent
sense of inner sameness. I suggest that the formation of core identity
also finalizes during this period (Volkan, 1988).
Once a person’s core identity crystallizes, it can be defined by
looking at it from different angles. Salman Akhtar (1992, 1999)
looked at the individual’s core identity from different angles. He
stated that the sustained feeling of inner sameness is accompanied
by a temporal continuity in the self-experience: the past, the present,
and the future are integrated into a smooth continuum of remem-
bered, felt, and expected existence for the individual. The individual
core identity is connected with a realistic body image and a sense
of inner solidarity and is associated with the capacity for solitude
and clarity of one’s gender. Akhtar also connected the individual’s
core identity with large-group identity, such as a national, ethnic or
religious identity.
Akhtar’s last characteristic of an individual’s identity refers to a
link between one’s personal core identity and large-group identity.
His description of this characteristic implies that the link occurs at the
oedipal level when a child’s superego is crystallized. The child then
identifies with his parents’ prohibitions and ideals, and by exten-
sion, his large-group’s prohibitions and ideals. To support this view,
Akhtar refers to Chasseguet-Smirgel’s (1984) remark that success-
ful resolution of the Oedipus complex adds to the child’s entrance
into the father’s universe. I contend that the foundation of the
core large-group identity is created during the pre-oedipal period;

oedipal influences, however important, are added later.
Large-group identity
In the psychological literature the term “large group” sometimes
refers to 30 to 150 members who meet in order to deal with a given
psychological issue (Kernberg, 2003a, b), but I am not referring to
such gatherings. My focus is on ethnic, national, religious or politi-
cal ideological groups composed of thousands or millions of people.
In such large groups most of the individuals will never meet dur-
ing their lifetimes. In fact, they will not even know of the existence
of many others belonging to the same entity. Yet, they will share a
sense of belonging, usually a language, sentiments, nursery rhymes,
songs, dances, and representations of history. They share what John
Mack (1979) called, “cultural amplifiers,” which are concrete or
abstract symbols and signs that are only associated with a particular
large group and which are usually accepted as “superior” and as a
source of pride. The sharing of the large group’s national, ethnic or
religious elements begins in childhood. This applies also to those
who are members of a political ideological group whose parents
and the people in the childhood environment are believers in the
ideology. To become a follower of a political ideology as an adult
involves other psychological motivations.
Depending on the focus of a large group’s identity, the child’s
investment is in ethnicity (I am an Arab), religion (I am a Catholic),
nationality (I am a German), political ideology (I am a communist),
or a combination of these. A psychoanalytic examination of how a
large group’s identity evolves goes beyond the phenomenology of
large-group identity concepts. A child born in Hyderabad, India,
for example, would focus on religious/cultural issues as she devel-
ops a large-group identity, since adults there define their dominant
large-group identities according to religious affiliation (Muslim or
Hindu) (Kakar, 1996). A child born in Cyprus would absorb a domi-
nant large-group identity defined by ethnic/national/political sen-
timents, because what is currently critical in this part of the world
is whether one is Greek, Turkish or politically simply “Cypriot”
(there is no Cypriot nation), with less emphasis placed on whether
one is Greek Orthodox Christian or Sunni Muslim (Volkan, 1979).
Questions of investment in ethnicity versus religion, or nationality

versus race, or one ideology versus another are not as essential to
understanding large-group identity as are the psychodynamic proc-
esses of linking individual identity to large-group identity.
Belonging to a large group, after going through the adolescence
passage, endures throughout a lifetime. Sometimes belongingness
can be a shadow identity, as we sometimes see in persons after vol-
untary or forced migrations (Volkan, 1993a, Akhtar, 1999). Never-
theless, such belongingness never disappears. Only through some
long-lasting drastic historical event may a group evolve a new
large-group identity. For example, certain southern Slavs became
Bosniaks while under the rule of the Ottoman Empire, which lasted
for centuries.
Through early identifications with mother, father, teacher and
important persons in their environment small children begin to
“learn” that they are members of a specific large group and what cul-
tural amplifiers are theirs. Some children have parents who belong
to two different ethnic or religious groups. If an international conflict
erupts between these two large groups, these youngsters may, even
as adults, have severe psychological problems. In South Ossetia, for
example, after the initial wars between Georgians and South Osse-
tians following the collapse of the Soviet Union and before the 2008
summer tragedies there, I met persons with “mixed” lineage who
had become confused and psychologically disturbed due to their
situation (Volkan, 2006a).
There is another childhood process that more clearly creates the
precursors of children’s notions of large-group enemies and allies
and separates their large-group identity from the “others’” large-
group identity. This process also illustrates how people, without
being aware of it, need to have large-group enemies and allies, to
one degree or another, throughout their lifetime. Belonging to the
same large-group identity allows thousands or millions of people
to share the same large-group enemy and ally representations. This
childhood experience can be understood with a concept that I call
“suitable targets of externalization” (Volkan, 1988).
The object relations theory of psychoanalysis (Kernberg, 1975, 1976)
and observations of children, tells us that when children become
able to tolerate ambivalence they integrate their previously frag-
mented or split self- and object images. However, such integrations
are not totally complete. Some self- and object images remain
unintegrated and the child finds ways to deal with them in order to
avoid facing and feeling object relations tension. One psychological
method a child uses to deal with this problem is to externalize his
or her unintegrated self- and object images onto other persons, or
animate or inanimate objects. The child later may re-internalize such
images. The people in the child’s environment also help the child to
find permanent reservoirs in which to keep the externalized uninte-
grated “bad” and “good” self- and object images. Since externaliza-
tions into such reservoirs are approved by the individuals important
to the child, what is externalized will not boomerang, will not be
re-internalized by the child. Such reservoirs are the suitable targets
of externalization that become the precursors of large-group enemy
and ally representations (Volkan, 1988). A child is, to use Erikson’s
(1966) term, a “generalist” as far as nationality, ethnicity, religion or
political ideology are concerned. Once the child utilizes suitable tar-
gets of externalization, he or she ceases to be a generalist.
To illustrate this idea, let us consider Cyprus, where Greeks
and Turks lived side by side for centuries until the island was de
facto divided into two political entities in 1974. Greek farmers there
often raise pigs. Turkish children, like Greek children, invariably
are drawn to farm animals, but imagine a Turkish child wanting to
touch and love a piglet. The mothers or other important individuals
in the Turkish child’s environment would strongly discourage their
children from playing with the piglet. For Moslem Turks, the pig is
“dirty.” As a cultural amplifier for the Greeks, it does not belong to
the Turks’ large group. Now the Turkish child has found a perma-
nent reservoir for depositing unwanted, aggressively contaminated
and unintegrated “bad” self- and object images. Since Moslem Turks
do not eat pork, in a concrete sense what is externalized into the
image of the pig will not be re-internalized. When the child uncon-
sciously finds a suitable target for unintegrated “bad” self- and
object images, the precursor of the “other” becomes established in
the child’s mind at an experimental level. The Turkish child at this
point does not know what Greekness means. Sophisticated thoughts,
perceptions and emotions, and images of history about the “other”
evolve much later without the individual’s awareness that the first
symbol of the enemy was in the service of helping him or her avoid
feeling object relations tension. Since almost all Turkish children in
Cyprus will use the same target, they will share the same precursor
of the “other” who may become the “enemy” if real world problems
become complicated.
Children also are given suitable targets as reservoirs for their
“good” unintegrated self- and object relations. For example, a
Finnish child uses the sauna as such a reservoir. Only when Finnish
children grow up will they have sophisticated thoughts and feelings
about Finishness. Most shared reservoirs remain constant for a long
time, while certain historical events may shift the group’s investment
in them. In Scotland, Highland dress dates from the 13th century,
but it was an event in the 18th century that transformed the tartan
kilt into a shared reservoir of Scottishness. When England defeated
Bonnie Prince Charles at Culloden in 1746, the English banned the
wearing of the kilt in Scotland under the Act of Proscription. The
act was repealed thirty-six years later, and the kilt was adopted as
Scottish military dress. When George IV made a state visit to Scot-
land in 1882, his visit strengthened Scottish investment in the kilt,
which served to enhance Scottish unity in the face of a visit from the
figurehead of powerful England. Many Scottish families even have
their own tartan design, which they sometimes use in their personal
clothing. Efforts to suppress the wearing of the kilt have been unsuc-
cessful; the dress continues to serve as an ethnic reservoir signifying
Scottishness.
It is interesting that when there is an international conflict or a
war-like situation, members of a large group who feel victimized
regress and create adult versions of suitable targets of externaliza-
tion. In childhood, reservoirs are chosen because they have been
culturally invested in by parents and other adults who direct the
children to choose them. Adults who regress under a shared trauma,
however, choose reservoirs that symbolically relate to their threat-
ening environment. For example, when Gaza fell under the Israeli
occupation, Palestinians began to carry small stones painted with
the Palestinian flag’s colours in their pockets. When facing humili-
ating external situations, they would reach into their pockets and
touch the stones. Having the stones created a network of “we-ness”
that supported the large-group identity of Palestinians living in
Gaza at that time and separated their large-group identity from the
Israelis’ large-group identity.
Below I will describe what clinicians learn when a patient with

an unintegrated personality organization in analysis attempts to
develop a cohesive identity. Then I will illustrate how such a clini-
cal experience illuminates what happens when “neutral” facilitators
guide the representatives of opposing large groups to shrink the
psychological gap between them.
Mending splitting in individuals

In 1963, Donald Winnicott played with diagrams, using a circle
to represent 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” (p. 75). In 1969, Winnicott
added that an individual who is mature enough to be represented as
a circle is one who is capable of containing conflicts that arise from
within and without, and that it is necessary to divide this circle by
putting a line down its centre, because “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 elements”
(pp. 222–223). He continued to state that only idealists “often speak as
if there were such a thing as an individual with no line down the mid-
dle in the diagram of the person, where there is nothing but benign
forces for use for good purposes” (p. 223). According to Winnicott,
“the individual” is a relatively modern concept. Until a few hundred
years ago, he said, outside of a few exceptional “total individuals”
(p. 222) everyone was unintegrated. When he wrote his papers on this
topic he thought that even then the world was mainly composed of
individuals who could not achieve integration and be a total unit.
Winnicott’s references to unintegrated individuals reflect knowl-
edge gained through examination of the internal worlds of patients
with borderline personality organization that point to a split
between libidinally invested self- and object representations and
aggressively invested self- and object representations. A closer look
at how one’s self- and object representations evolve and become
integrated and cohesive in childhood (Kernberg, 1970, 1975, 1976,
Volkan, 1976, 1995), however, suggests a need to modify Winnicott’s
diagram of the unintegrated individual. It would be less confusing
to consider a circle with a line through its centre as representing a
mature individual who has achieved tolerance for ambivalence to

one degree or another. Since opposite halves of the circle touch each
other, metapsychologically speaking, such an individual has moved
to a higher level (neurotic) personality organization from the pre-
vious level, that of a borderline personality organization. Perhaps
a diagram representing a truly unintegrated person (as I drew—
Volkan, 1981a) would have not a line, but a definable gap between
the two halves of the circle.
The key issue during psychoanalysis of an individual with border-
line personality organization is to help the person eventually reach
a “crucial juncture” (Klein, 1946; Kernberg, 1976, 1984; Volkan, 1987,
1993; Volkan and Fowler, 2009). The term “crucial juncture” was first
used by Melanie Klein in 1946. 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 intellectual life. This is also a crucial juncture
for the choice of neurosis or psychosis” (p. 100). It is the failure to
reach natural “crucial junctures” in childhood that cause the adult
to be stuck in a personality organization in which splitting predomi-
nates as the key defence; the developmental “normal” splitting thus,
in such individuals, becomes a defensive, pathological splitting and
such patients come to treatment with this pathology. Therefore, a
natural developmental occurrence in childhood will be observed
in adults with borderline personality organization when they reach
crucial juncture experiences during analysis.
Such patients will need many crucial juncture experiences before
the integration of their self- and object representations become
crystallized. Then, the ability to have ambivalence replaces their
relating to their self- and object images in a split fashion. Such a
patient becomes a circle with a line through its centre, replacing
two separate components of a circle divided with a gap. The analyst
absorbs, tames and deals with the patient’s intense emotions prior
to and during the patient’s transformation from a split identity to an
integrated one. These emotions usually include murderous rage that
is originally directed to caretakers with disturbed mothering func-
tions, envy due to a sense that one has developmental arrests while
others moved on to higher levels of functioning, and remorse for
badly treating objects contaminated with devaluation when “bad”
images were externalized into them.
Furthermore, anxiety of losing “good” aspects when they are

ready to be integrated with the “bad” ones and guilt and mourning
over losing the former unintegrated self- and object images requires
closer examination. When a patient with borderline personality
organization arrives at crucial juncture experiences during psycho-
analytic treatment, initially he or she fears that mixing “black” and
“white” will not produce “grey” (Volkan, 1976, 1987, 1995). The indi-
vidual’s “bad” self- and object images are invested with exaggerated
aggression and the patient becomes anxious due to an unconscious
perception that during a crucial juncture experience his or her
“good” parts will be absorbed with aggression too. Or, the patient
senses that the mending will “kill” his or her “good” self- and object
images. Once when my patient Joseph was ready to have a crucial
juncture experience during a session, he suddenly got up from the
couch and “attacked” me. I protected myself and in a few minutes
he went back to lying on my couch. When he and I investigated this
incident we understood that his physically touching me was neces-
sary for him to be sure that he, representing his “good” self- and
object images, would not die when (Volkan, 1976). He never touched
me again. By being aware of the source of the patient’s anxiety, the
analyst helps the patient through emphatic explanations, interpreta-
tions, and by indirectly offering himself or herself as a model who
can take a chance on integration.
Otto Kernberg (1970) also discussed guilt and mourning dur-
ing crucial juncture experiences in individuals. He states that “the
deep admiration and love for the ideal mother” and “the hatred for
the distorted dangerous mother” meet in the transference and the
patient experiences guilt and depression “because he has mistreated
the analyst 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” (p. 81). Kernberg also emphasized the
possibility of suicidal ideation at such times. Although I am aware
that the evolution of guilt feelings and depression is part of the pro-
gression in the treatment of individuals with unintegrated personal-
ity organization, mourning itself, without much guilt feeling, is a
new experience for these patients, and its appearance signals a posi-
tive outcome (Searles, 1986).
For practical purposes, we can divide the intensive approaches to
the individual psychoanalytic treatment of patients whose defensive
responses are centred on splitting, into two styles (Volkan, 1987).

The first approach maintains the already regressed patient at a level
where he or she is able to function without further regression, with
the idea that further regression may usher in a psychotic condition.
The strategy behind this method is to focus on providing new ego
experiences for the patient, with clarifications, confrontation and
interpretations, kept within the therapeutic setting and calculated
to promote integration of opposing self- and object images. I feel
that while this approach may be therapeutic, it does not provide
for major structural change in the core of the pathological psychic
organization. Because of this, when such patients begin to have
crucial juncture experiences, they may feel intense guilt, depres-
sion, or even have suicidal ideation and may even escape from
treatment.
The second approach in the individual psychoanalytic treatment
is based on the premise that severely regressed or undeveloped
patients should experience further (therapeutic) regression, even
though such patients would most likely exhibit temporary, but ther-
apeutically controlled, transference psychosis. After such regres-
sive experiences, these patients would begin to relax their defensive
use of splitting, and replace it with developmental splitting. Bear
in mind, that all children experience developmental splitting due
to their lack of integrative function. Eventually, children are able to
reach naturally expected crucial junctures as part of their psychic
growth when, for example, they have enough identification with
their mothers’ integrative functions and when they are capable of
taming their aggression. When the child’s integrative function is
taxed and disturbed due to constitutional, internal, or environmen-
tal factors, splitting becomes permanent and is utilized defensively,
as I indicated earlier.
Once an adult patient with an unintegrated personality organi-
zation is back on the track of developmental splitting following
a therapeutic regression, “upward-evolving transference” (Boyer
1983; Volkan, 1987, 1995) develops and takes the patient to a point
where opposing self- and object representations, together with
their accompanying affects, will meet. Patients with borderline
personality organization are constantly involved in internalization-
externalization of self- and object images and introjection-projection
of various affects and thoughts. In analysis, such relatedness to the
analyst determines common transference and countertransference

developments (Volkan, 1981a, 1987). Within the realm of patient-
analyst interactions, the patient identifies with various functions
of the analyst, including identification involving the integrative
function, which supports the patient’s progressive development.
The patient’s arrival at a crucial juncture is the result of collective
accumulation within his psyche of all necessary identifications
and his developing ability to tame his aggression. The patient
who undergoes the second type of treatment is “prepared” dur-
ing the initial years of his treatment, to reach and pass through
the crucial juncture without much guilt and certainly without
much depression or suicidal thoughts. Once the patient comes
to the crucial juncture, he is ready to experience mourning over
surrendering his old unintegrated self-representation and corre-
sponding unintegrated object images (Volkan 1976, 1981b, 1987,
1993; Volkan and Fowler, 2009).
Joseph came to analysis as an adult with primitive defences
against shame and humiliation, murderous rage, and a need to be
understood and accepted as a human being—and not as a Penguin
Man—by fellow human beings. Joseph’s Christian mother from a
small conservative town in the USA was encouraged by her family
to marry a much older uneducated Jewish man who, as a new immi-
grant to the United States, first travelled from one state to another
collecting scrap metal to sell. He became very rich in this business
and married a young and beautiful woman who was not in love
with him. Joseph’s parents had come from two different cultures and
religions and there was no emotional bond to bring them together.
She had dreamed of becoming a great pianist, but had to give up this
ambition when she married. Joseph’s childhood environment, in a
sense, was split into opposing elements and he, as a child, did not
have help developing his “normal” integrative ego functions. His
mother constantly gave him enemas throughout his childhood to
make him “clean” and did not “teach” him how to integrate “good”
and “bad” self- and object images. As an adult he had a borderline
personality organization.
In analysis, a person like Joseph begins to give up his primitive
defences against and primitive adaptation to his internal conflicts.
The analyst becomes a “hot” transference figure, and the patient
experiences the analyst as important figures from his childhood,
a person on whom the patient depended and for whom he feels rage.
Such developments are part of analytic treatment, and if it is to work
properly, a “therapeutic space” has to be formed and maintained in
the analyst’s office. Let us visualize such a space with an imagined
effigy representing the analyst sitting in the middle of it. The patient
sends verbal missiles to mutilate and kill the effigy and the analyst
tolerates this. The next day, the analyst-effigy is placed in the thera-
peutic space again, showing the patient that his childhood rage did
not commit a murder. A mental game is played in this space until
the patient learns how to “kill” a symbol and not a real person, how
to relinquish devastating guilt feelings, how to tame other intense
emotions, and how to separate fantasy from reality. The patient also
learns to establish a firm continuity of time, but with an ability to
restore feelings, thinking, and perceptions to their proper places:
the past, the present, or the future. In other words, the burdens of
the past can be left behind, and a hope for a better future can be
maintained. There should be no damaging intrusions into this space.
For example, the patient does not really hit the analyst. (Joseph’s
“attacking” me and touching me was an unusual event and it
occurred only once during his entire analysis.) The patient attacks
only the analyst’s effigy. The analyst does not have real sex with the
patient who wishes to be loved, but the analyst, by protecting the
therapeutic space, shows the patient that he or she is “loved.”
Shrinking the gap between enemies

In peaceful times people usually turn their attention toward them-
selves, their families, relatives, clans, neighbours, professional and
social organizations, schools, sports clubs and local or national
politics. But when a large group is humiliated or threatened by
“others” who identify with another large group, the attacked popu-
lation abandons its routine preoccupations and becomes obsessed
with repairing, protecting and maintaining their large-group iden-
tity. It is analogous to individuals who are not constantly aware of
their breathing, but if they find themselves in a smoke-filled room
or develop pneumonia, they notice every breath they take. Similarly,
when a large group is under stress and the large-group identity is
injured or threatened, the people who belong to it, such as those
who come to negotiation tables and face enemy representatives,
become keenly aware of their “we-ness” and quickly and definitively

separate their large-group identity from the identity of the “other,”
the “enemy” large group.
During the last 30 years I have been present when influential rep-
resentatives of Arabs and Israelis, Americans and Soviets, Russians
and Estonians, Serbians and Croats, Georgians and South Osse-
tians, Turks and Greeks, and Turks and Armenians came together
for unofficial dialogues that were carried out over a number of
years in an attempt to achieve understanding and hopefully find
“entry points” for strategies and actions for peaceful co-existence I
also visited many refugee camps and met political leaders of many
countries or large groups such as Mikhail Gorbachev, Jimmy Carter,
Rauf Denktas˛, Arnolf Rüütel, Yasset, Olesegun Obasanjo, and
Abdullah Gül.
Last year I have begun a new project with Lord John Alderdice,
the former leader of Northern Ireland’s cross-community Alliance
Party and former Speaker of the Northern Ireland Assembly who
is also a psychiatrist and psychoanalyst. We are bringing repre-
sentatives from Arab Emirates, Austria, India, Iran, Israel, Jordan,
Russia, Turkey, United Kingdom and United States together to try
to understand the post-September 11, 2001 world, in particular
the Islamic-Western world split. In this, as in other projects I have
been involved with (Volkan, 1988, 1997, 2004, 2006a), participants,
as spokespersons for their large-group identities, become preoccu-
pied with large-group identity issues. In places where refugees or
internally displaced persons are living, these victims also constantly
refer to their large-group identities. This is also true, I have noticed,
of political leaders at the time of an international conflict. By listen-
ing to dialogues involving enemy representatives, dislocated per-
sons, and political leaders I have learned much about large-group
identity, large-group psychology in general and what occurs when
attempts are made to shrink the psychological gap between the
enemy representatives.
Returning to Winnicott (1963, 1969), he conceptualized the socio-
logical world as millions of people superimposed upon each other.
His belief that most individuals are unintegrated led him to exam-
ine political divisions. He suggested that much of what we call civi-
lization may become impossible at the boundaries between large
groups. He compared Berlin, which was still divided at that time, to
his diagram of a circle with a line through its centre that represents
the unintegrated individual.
Winnicott noted that some political divisions, such as the border
between England and Wales, can be looked upon in terms of geog-
raphy and mountains. But, the Berlin Wall was man-made and ugly
and could hold no association to the word “beauty” in light of our
knowledge that in the 1960s there would have been war without
the wall. However, Winnicott acknowledged a positive aspect of the
Berlin Wall. He suggested that a dividing line between opposing
forces, “at its worst postpones conflict and at its best holds opposing
forces away from each other for long periods of time so that people
may play and pursue the arts of peace. The arts of peace belong to
the temporary success of a dividing line between opposing forces;
the lull between times when the wall has ceased to segregate good
and bad” (Winnicott, 1969, p. 224). When there is anxiety and regres-
sion within large groups in conflict, a simple line between them is
not enough to protect the antagonists’ identities. They must defend
against any possibility of interpenetration.
Large-group psychology primarily deals with a shared need to
repair, protect and maintain large-group identity. Thousands or
millions of people, without being aware it, are assigned these tasks
and respond to ethnic, religious, ideological and international rela-
tions accordingly. If a foreign large group deliberately shames,
humiliates, and destroys the lives of a number of individuals in the
name of their large-group identity in, let us say, the northern part of
a country, others belonging to the same large-group identity in the
south will also feel their pain and rage. Large-group identity con-
nects people in emotional ways wherever they live. Influences and
consequences of traumas that are caused by “others” belonging to
another large-group identity do not remain regional (Volkan, 1988,
2006a). The “split” in Israel during the 2nd Lebanon War, when the
North suffered while the rest of the country continued its daily rou-
tine in an environment in which the stock markets were doing fine,
appears to contradict the idea that pain and rage are shared by all
who belong to the same large-group identity. This “split” in Israel
was possible because underneath it all, Israelis everywhere shared
chronic threats to their large-group identity.
When a large group’s identity is humiliated or threatened, people
belonging to that identity psychologically find it easy to humiliate,
victimize and kill individuals belonging to the enemy group in the

name of identity without blinking an eye. They use aggression in
order to repair, protect and maintain their large-group identity. If
people who belong to the victimized group feel helpless, they will
in this case tolerate forced or voluntary shared masochism, again in
order to hold on to their large-group identity. This abstract concept,
the “large-group” identity, becomes the central force that influences
international relations.
In their daily lives, members of a large group mostly uncon-
sciously follow two unalterable and intertwined principles (Volkan,
1988, 1997, 1999a, 2006a), principles they may become aware of if the
“other” humiliates and threatens them in the name of large-group
identity. I call the first principle the “maintenance of non-sameness.”
One large group must not be the same as, or even closely similar to,
a neighbouring large group that is perceived as an enemy. Although
antagonistic large groups usually have major differences in religion,
language and historical or mythological backgrounds, “minor differ-
ences” between antagonists can become major problems that lead to
deadly consequences. Much earlier Freud (1921, 1930) noted minor
differences among small and large groups, but did not study their
deadly consequences in international relations. When large groups
regress, any signal of similarity is perceived, often unconsciously, as
unacceptable; minor differences therefore become elevated to great
importance to protect non-sameness. Cypriot Greek farmers used
to dress like Cypriot Turkish farmers in black shirts and loose black
trousers. The Greek would put a blue or black sash around his waist
and the Turk would wear a red one. Under increased hostilities the
difference in sash colour became a matter of life or death (Volkan,
1979). Donald Horowitz (1985) reported that in 1958 Sinhalese mobs
methodically victimized only men bearing earring holes in their ears
and wearing shirts over their vertis. In the absence of differentiating
skin colour or other dissimilar characteristics, these features identi-
fied people as enemy Tamils. Thomas Butler (1993) wrote about how
in the former Yugoslavia differences in the pronunciation of certain
words by Croats and Serbs increased in significance when antago-
nism between the two groups increased. When “minor differences”
between antagonists become major problems that lead to deadly
consequences, we recognize the existence of the “maintenance of
non-sameness” principle.
Another unalterable principle in large-group relationships,

intertwined with the first one reflects the need to maintain a psy-
chological border, gap, or tangible space between large groups in
conflict. Although the demarcation and maintenance of physical
borders has always, especially in modern times, been vital to inter-
national and large-group relationships, closer examination indicates
that it is far more critical to have an effective psychological border
than a simple physical one. In 1986, when tensions between Israelis
and Jordanians were high, I visited the Allenby Bridge over the Jor-
dan River that separates the two countries. Trucks that went over
the bridge looked like the factory had forgotten to finish them: doors
and hoods were missing, and even the upholstery had been removed
to allow fewer places to hide contraband items. Israeli customs offic-
ers would spend hours taking vehicles apart and putting them back
together to assure that nothing was smuggled in from Jordan. In
another precaution, the Israelis routinely swept a dirt road that ran
parallel to the border in order to detect the footprints of people try-
ing to cross it. It should be noted that the border was amply sup-
plied with sophisticated electronic surveillance devices, minefields
and the natural barrier of the Jordan River. Even if there was some
justification for the extra precaution, it is most likely that the idea
of a psychological border was intertwined with the physical bor-
der at this location, resulting in rituals that created a psychological
gap between the two countries that went beyond realistic military
activities.
After September 11, 2001 every traveller who is paying attention
to large-group psychology, must be aware of how legal or tradi-
tional physical borders also symbolize the large-group identity that
provides a huge umbrella protecting the people belonging to it. In
Europe immigrants from the Middle East, Africa and Eastern Euro-
pean countries inflame the affected large groups’ border psychology.
When clear physical demarcations are perceived as ambiguous or
indistinct, psychological borders are weakened as well, and shared
anxiety can develop.
These two principles—maintaining non-sameness and psycho-
logical borders—influence international relationships, especially at
negotiation tables. I have observed that one of the dangerous times
during which diplomatic negotiations quickly may collapse is when
the opposing parties, usually with the help of a third “neutral” party,
come close to making a major agreement. This “coming close,” for

both parties, unconsciously threatens the two principles mentioned
above. Anxiety about injury to large-group identity increases and
this may lead to the collapse of negotiations, paradoxically after
hard work and after coming very close to making an agreement.
Psychoanalysts analyzing individuals like Joseph know about the
appearance of anxiety and other troublesome feelings when a per-
son with borderline organization comes to a crucial juncture experi-
ence. If psychoanalysts are participants in a conflict resolution team
dealing with large groups they, emotionally and intellectually, will
be more prepared to respond to similar emotions when they surface
at a time the opposing groups make efforts for a rapprochement.
Knowing about the two principles described above will help the
psychoanalytically informed “neutral” third party in negotiations to
introduce strategies that will inform the opposing parties in the fol-
lowing way: “Making an agreement and signing a document does
not mean that you will lose the border separating your large-group
identity from the identity of your enemy’s large group or that you
will face the possibility of becoming the same as your enemy. When
a mutual formal agreement on a difficult issue is reached, both sides
will still keep their own identities.”
Just as individuals with a borderline personality organization
imagine losing “good” self- and object images, enemy negotiators
that attempt to shrink the psychological gap between “good” and
“bad” large-group identities when coming together for negotiations
for a peaceful co-existence face a similar phenomenon. Negotiators
become anxious about contaminating their large-group identity
with the one that is invested, in their mind and often in reality, with
terrible aggression. The possibility that their “good” large-group
identity will become “bad” if an agreement is reached is a psy-
chologically threatening event. The facilitating team that includes
psychoanalysts should be aware of this. Furthermore, anxiety over
closing the gap between the enemy representatives due to “mixing”
large-group identities is complicated due to the fact that even before
negotiations take place, large groups in the conflict, outside of their
awareness, become alike.
While it is very threatening for a large group to lose its psycho-
logical border and contaminate its own large-group identity with
the one belonging to the enemy, in situations where conflict between
two large groups becomes hot, deadly or chronic, paradoxically,

enemies become alike to a certain degree. This process, on a con-
scious level is denied vehemently. At the foundation of this paradox
lies the fact that large-group enemies are both real and fantasized
(Stein, 1990). They are real if they are humiliating, shooting and kill-
ing people in the other large group in the name of identity. They are
also fantasized because they are reservoirs of the first large group’s
externalized unwanted parts, a result of a shared process that began
in childhood when suitable reservoirs of externalization were estab-
lished, and as a result of large-group regression in which adult mem-
bers do the same thing children would do: create suitable targets of
externalization.
In hot, deadly or chronic international conflicts, suitable reser-
voirs do not remain permanent, effective and distant reservoirs “out
there.” The externalizations and projections a large group puts in
these reservoirs overflow and come back to contaminate itself. Thus,
psychologically speaking, both large groups, to a certain degree,
become the same. Al Qaeda divided the world into two categories.
After September 11, the United States did the same. “You are either
on my side or else,” became a political doctrine. Ideas such as the
“clash of civilizations” or in this case “clash of religions,” directly or
indirectly was supported within both large groups. Dissenters exist,
of course, but they do not change the essential shared sentiments
within the large group unless they recruit a huge number of follow-
ers who become a political force.
When speaking of enemies becoming alike, I refer to shared
psychological movements, not to the actual methods used by each
group involved in wars or war-like situations. One may kill through
terrorism and the other may kill in “legal” and so-called “civilized”
ways. Many factors, such as historical circumstances, reactivation
of past victimizations, the existing political system, military power,
technology, economy, and most importantly, the degree of large-
group regression and the personality organization of the political
leader can make a large group dehumanize the “other” and exercise
terrible cruelty in both “barbaric” and “civilized” ways.
Elsewhere (Volkan, 2004, 2009) I describe how a political leader’s
personality organization plays a crucial role in inflaming or tam-
ing the process of one large group becoming like the enemy group.
If the leader is able to explain to the followers where the reality of
the enemy ends and where the fantasy about the enemy begins, this
tames the process of becoming like the enemy. If the leader does
not provide good reality testing that includes an understanding of
the enemy large group’s “psychic reality” and does not make some
attempt to respond to it in humane non-destructive ways, dangers
become magnified and regression is maintained.
Members of one group in conflict may attempt to define their
large-group identity through externalizing unwanted parts of them-
selves onto the enemy, projecting their unwanted thoughts, affects,
perceptions, and wishes just as patients with primitive personality
organizations typically do. For example, it is not we who are trou-
blemakers, but they. Often externalizations and projections into the
opposing large group reflect a clear “us” and “them” dichotomy of
rigid positions: we are “good,” they are “bad.” Such mechanisms
can also involve a more complex relationship between representa-
tives of the two opposing groups in a pattern similar to the mecha-
nism of projective identification (Klein, 1946) that psychoanalysts
see in individual patients, and typically in patients with borderline
personality organization. While having a dialogue, representatives
of one large group may externalize self- and object images and
project onto the other their own wishes for how the opposing side
should think, feel, or behave. The first team then identifies with the
other that houses their externalizations and projections—this other
is perceived as actually acting in accordance with the expectations
of the former. In effect, one team becomes the “spokesperson” for
the other team, and since this process takes place unconsciously, the
first team actually believes their remarks about the enemy. However,
the resulting “relationship” is not real since it is based on the proc-
esses of only one party. The psychoanalytically informed facilitat-
ing team interprets or interferes with the development of projective
identification, since once it develops, the reality of perceptions is
compromised.
During negotiations the facilitators should find non-controversial
methods to examine openly the concept of a large group becoming
like its enemy in order to conceptualize and realize opportunities
for different responses, above and beyond destructive ones. The
facilitators, instead of suggesting or “forcing” the enemy negotia-
tors to ignore the threats to their large-group identities, should try
to shrink the gap between the enemy groups, but not to remove it.
After some empathic communication begins, the opposing teams

often experience a rapprochement. But, this closeness is then fol-
lowed by a sudden withdrawal from one another and then again
by closeness. This pattern repeats numerous times. I liken this to
the playing of an accordion—squeezing together and then pulling
apart (Volkan, 1988, 2006a). Initial distancing is a defensive manoeu-
vre to keep aggressive attitudes and feelings in check, since, if the
opponents were to come together, they might harm one another—at
least in fantasy—or in turn become targets of retaliation. When the
negotiators of opposing large groups are confined together in one
room sharing conscious efforts for peace, sometimes they must deny
their aggressive feelings as they draw together in a kind of illusory
union. When this becomes oppressive, it feels dangerous, and dis-
tancing occurs again. The most realistic discussions take place after
the facilitating team has allowed the accordion to play for a while,
until the squeezing and distancing become less extreme.
Practitioners of international “conflict resolution” may in fact
do harm if they force the removal of identity differences between
opposing large groups as swiftly as possible or focus on seeking
“apologies” and encouraging “forgiveness” too hastily when deal-
ing with coexistence. Concepts such as “apology” and “forgiveness”
are only descriptive, and they should not, before adaptive solutions
can be found, mask a need for shared psychological processes that
respect the principles of large-group interactions and for resolutions
of shared resistances (Volkan, 2006b). Even after the unification of
Germany, where the aim was not to develop a co-existence between
East and West Germans, but to evolve an absorption between them,
the political and social strategies built to accomplish this were only
successful through step-by-step adaptation. Forgiveness and apol-
ogy can take place after shared feelings of remorse, guilt, and depres-
sion evolve in a shared mourning process.
I will now examine how we can apply what a psychoanalyst
learns from observing and handling the mending process of a bor-
derline patient accompanied by guilt, depression or mourning to
bringing together enemy large groups. Large groups are made of
individuals; therefore, large-group processes reflect individual
psychology. But a large group is not a living organism that has one
brain. Therefore, once members of a large group start utilizing the
same mental mechanism, it establishes a life of its own and appears
as a societal, and often a political, process. In this chapter I already

referred a few times to “regression” of large groups. I borrow the
word “regression” from individual psychology since I have not yet
found a good term that describes a large group’s “going back” to
the earlier levels of its psychic development in defence of the shared
anxiety caused by threats to large-group identity. First of all, it is
difficult to imagine that large groups have their own psychic devel-
opments. The closest thing to the concept of a large group having
a psychic development is the large group’s usually mythologized
history and the story of how the large group was “born.” In fact,
when large groups regress, they reactivate certain, sometimes cen-
turies-old, shared historical mental representations, which I named
“chosen glories” and “chosen traumas” (Volkan, 1999a, 2004, 2006a).
They are linked to large-groups’ difficulty in mourning, shared guilt
feelings and depression and they become activated when represent-
atives of enemy large groups become involved in negotiations.
Large groups celebrate independence days or have ritualistic
recollections of events and heroes whose mental representations
include a shared feeling of success and triumph among large-group
members. Such events and heroic persons attached to them are heavily
mythologized over time. These mental representations become large-
group amplifiers called chosen glories. Chosen glories are passed on
to succeeding generations in parent/teacher-child interactions and
through participation in ritualistic ceremonies recalling past suc-
cessful events. Chosen glories link children of a large group with
each other and with their large group, and the children experience
increased self-esteem by being associated with such glories. It is not
difficult to understand why parents and other important adults pass
the mental representation of chosen glories to their children; this is
a pleasurable activity. Past victories in battle and great accomplish-
ments of a religious or political ideological nature frequently appear
as chosen glories. In stressful situations political leaders reactivate
the mental representation of chosen glories and heroes associated
with them to bolster their large-group identity. A leader’s reference
to chosen glories excites followers simply by stimulating an
already existing shared large-group amplifier. During the first Gulf
War Saddam Hussein made many references to Sultan Saladin’s
victories over the Crusaders even though Saladin was not an Arab,
but a Kurd.
While no complicated psychological processes are involved when

chosen glories increase collective self-esteem, the role of chosen
traumas, in supporting large-group identity and its cohesiveness, is
more complex. It is for this reason that a chosen trauma is a much
stronger large-group amplifier than a chosen glory. A chosen trauma
is the shared mental representation of an event in a large group’s
history in which the group suffered catastrophic loss, humiliation,
and helplessness at the hands of its enemies. When members of a
victim group are unable to mourn such losses, tame their depres-
sive feelings and reverse their humiliation and helplessness, they
pass on to their offspring the images of their injured selves and the
psychological tasks that need to be completed, such as reversing
humiliation and helplessness and completing the work of mourn-
ing. This process is known as the “transgenerational transmission
of trauma.” (For a review of the concept of transgenerational trans-
mission and adults “depositing” their traumatized self- and object
images into the developing self-representations of children, see:
Volkan, Ast, and Greer, 2001.) All such images and tasks contain ref-
erences to the same historical event, and as decades pass, the mental
representation of this event links all the individuals in the large
group. Thus, the mental representation of the event emerges as a
most significant large-group identity marker, a large-group ampli-
fier. Chosen traumas should be differentiated from shared traumas,
like the Holocaust, which is still very “hot,” or acute traumas like
those that are happening at the present time in Iraq and the Republic
of Georgia for various large groups. The reactivation of chosen trau-
mas can be used by the political leadership to promote new mas-
sive large-group movements, some of them deadly and malignant.
In one prime example of this, I have documented the story of how
Slobodan MiloševiĆ allowed and supported the reappearance of the
Serbian chosen trauma—the mental representation of the June 28,
1389 Battle of Kosovo (Volkan, 1997).
The reactivation of chosen traumas fuels “entitlement ideologies.”
Entitlement ideologies are also connected with the large group’s
difficulty mourning losses, people, land, or prestige at the hands
of an enemy in the name of large-group identity. Mourning is an
obligatory human psychobiological response to a meaningful loss.
When a loved one dies, the mourner has to go through predictable
and definable phases. The individual mourning processes can be
“infected” due to various causes (Volkan, 1981b, Volkan and Zintl,

1993) just as “infected” large-group mourning for losses caused by
the actions of another large group will appear on societal/political
levels. For example, a political ideology of “irredentism”—a shared
sense of entitlement to recover what has been lost—may slowly
emerge that reflects a complication in large-group mourning and an
attempt both to deny losses and to recover them. What Greeks call
the “Megali Idea” (“Great Idea”) is such a political ideology. Politi-
cal ideologies of this kind may last for centuries and may disappear
and reappear when historical circumstances change thereby influ-
encing international relations. Diplomatic efforts then become very
difficult to handle, because the reactivation of a chosen trauma with
its accompanying entitlement ideology and associated affects, fan-
tasies, wishes and defences causes “time collapse.” This magnifies
the image of the current enemies and current conflicts (Volkan and
Itzkowitz, 1994).
When enemy representatives come together for a series of dialogues
the facilitators will notice that eventually chosen glories, chosen trau-
mas with their associated feeling states, entitlement ideologies and
time collapse will contaminate negotiations. The representatives will
compete and try to illustrate whose chosen trauma—usually associ-
ated with glories—is worse than the other’s. The facilitator cannot
order the negotiators to forget the past and focus on the present.
Affects and ideas do not disappear because someone tells someone
else to forget them. In a psychoanalytically informed negotiation
process, the facilitators use strategies for absorbing feelings linked
to reactivated chosen traumas and define how chosen traumas and
glories are most significant markers of large-group identities. They
become models for identification for emphatic understanding of the
“other’s” difficulty in mourning. This leads to the appearance of
“normal” mourning among the representatives of opposing groups
for their losses—people, land, prestige—during the current conflict,
the separation of past realistic and fantasized grievances from the
current issues, and more realistic negotiations.
Diplomacy and psychoanalytic insights

International relations primarily refer to interactions between politi-
cal leaders such as presidents, ministers of foreign affairs or diplomats
belonging to different nation states as they negotiate and decide upon,

draft and sign, agreements between each other involving diplomatic,
legal, economic, or even sports matters. The negotiating parties will
be perceived as allies or enemies according to existing “formal” agree-
ments. Their relationships will also conform, if controversies do not
develop, to “international rules and regulations” accepted by organi-
zations such as the United Nations or the European Union. In today’s
changing world, however, the term “international relations” includes
much more. When there are wars or war-like situations or alliances
between ethnic, religious or political ideological groups within one
nation state or in different nation states, which are not accepted as
legitimate entities, often legal international bodies are involved in
their diplomatic negotiations. In today’s world there are world-wide
terrorist groups whose activities, at least in the public mind, are cat-
egorized as an aspect of international relations.
The modern version of the concept of “globalization” has expanded
what people in the street think about what international relations
means. Globalization has become the buzzword in political as well as
academic circles that, especially with the help of modern communi-
cation technologies, personifies a wish for prosperity and well-being
of societies by standardizing economic and political elements and by
bringing democratic freedom everywhere in the world. The tragedy of
September 11, 2001 and the Western World’s—especially the United
States’—response to it, the wars in Iraq and Afghanistan, war-like
conditions in Africa and elsewhere and—as I write this chapter—the
September 2008 economic crisis in the Unites States that influenced
the financial markets worldwide, make an idealized version of globali-
zation an illusion. Globalization that includes prejudice, racism and
an indifference to large-group differences (Kinnvall, 2004, Liu and
Mills, 2006, Morton, 2005, Ratliff, 2004) never brings about the well-
being of the affected societies.
We can also consider non-governmental organizations (NGOs),
giant business corporations, the media and electronic communica-
tions as players in international relations. However one defines the
concept of international relations and whatever one includes under
this term, it always involves interactions between national, ethnic,
religious or political ideological large groups composed of tens or hun-
dreds of thousands or millions of persons. In the twenty-first century
once more we are witnessing the amazing ability of the human mind
to create incredible technological achievements, while the aggressive

aspect of human nature remains the same and always complicates
international relations.
When I think of official diplomacy, I remember W. Nathaniel How-

ell, the United States ambassador in Kuwait when Saddam Hus-
sein’s forces invaded that country, and the Resident-Diplomat at
CSMHI. A tall man who played basketball in his youth, he com-
pares good official diplomatic negotiation to playing basketball.
The opposing teams rush from one side of the basketball court to
the other using rules and regulations and try to score points. In the
end, one team wins, but the other team also scores and achieves
some degree of self-esteem for being a good competitor. According
to Ambassador Howell (2000), being involved in a well-managed
and fair official diplomatic activity is as pleasurable as watching a
well-played basketball game.
If an international conflict becomes “hot” or chronic, a large
group’s psychological identity issues contaminate all the real-world
problems such as the economy or legal issues, as well as the offi-
cial diplomatic efforts for resolving them. Expanding Ambassador
Howell’s metaphor, let us imagine that someone spills a large amount
of olive oil on the basketball court. Now the game becomes chaotic.
The first thing required is to wipe off the oil spill and clean the floor.
In an international relationship the oil spill that makes a routine play
impossible primarily centres around large-group identity, its protec-
tion and maintenance. When large-group identity issues become
inflamed and problematic, conducting international relations only
through “typical” diplomatic efforts becomes very difficult and
sometimes impossible. Utilizing psychoanalytically informed large-
group psychology can be compared to cleaning up olive oil on a
basketball court.
In order to understand this cleaning process, once more let us
return to the concept of “therapeutic space” the maintenance of
which, as described earlier, is required during the analysis of an
individual. The Tree Model aims to create a therapeutic space in
unofficial diplomacy. Diplomats attempt to create it in official diplo-
macy usually without the benefit of psychoanalytically informed
large-group psychology. There is no definite technique for creating
a therapeutic space in official diplomacy between warring enemy
large groups where they can “play” a serious and deadly game
while always killing the effigies rather than one another. It would
be, of course, very difficult and perhaps impossible to establish such
a place if enemy groups constantly invaded it with real bullets, mis-
siles, torture, and live bombs—like suicide bombers. As Shapiro and
Carr (2006) state, attempts to understand large groups are daunt-
ing. They may be “a defence against the experience of despair about
the world, a grandiose effort to manage the unmanageable” (p. 256).
Furthermore, many obstacles have hindered collaboration between
psychoanalysts and authorities dealing with international relations.
Elsewhere I tried to examine in some detail these obstacles that come
from both the diplomatic world and psychoanalysis itself (Volkan,
1999b, 2005).
In spite of the difficulties mentioned above I hope that psycho-
analysts and psychoanalytically oriented clinicians will become
involved in interdisciplinary initiatives, make efforts for large
groups’ psychological well-being and provide information to the
diplomats about large-group psychology. In this chapter I suggested
that the insights learned from individual psychology and psychoan-
alytic techniques for helping individuals with borderline personality
organization to mend their opposing self- and object images should
not be blindly applied to large-group psychology, which must be
studied in its own right.
Summary
When the representatives of large-group enemies are brought
together in unofficial or official diplomacy with a “neutral” facili-
tating team for finding peaceful co-existence, these representatives’
ability to hold on to their respective large-group identities may be
threatened. This, in turn, may create severe large-group identity
problems, complicate negotiations, and create stubborn resistances
against making peace. The aim therefore, is not to mend, but only
to narrow the psychological gap between the enemy large-group
identities and to strengthen opposing representatives’ hold on their
large-group identities so they can make more realistic agreements.
Psychoanalysts and psychoanalytically oriented clinicians are best
equipped to notice conscious and, more importantly, unconscious
elements in large-group conflicts to which official diplomacy
may not pay attention. Such efforts include the development of a

large-group psychology in its own right so that the meaning and
influence of the abstract concept, large-group identity, can be bet-
ter understood and so that we will have a theoretical foundation to
suggest psychoanalytically informed strategies for finding peaceful
answers for international conflicts.
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PLENARY DISCUSSION
A
Plenary discussion took place in which all presenters were
invited to address key questions raised in the conference.
Paul Williams took questions from the audience, read them
out to the presenters and invited them to reply.
PW: I’ll read three versions of this question. What can be done to promote
or enable psychoanalytic input into the psychiatric treatment of psy-
chosis? Most Psychiatrist teams and services do not engage in any
kind of psychoanalytic thinking.
Another version—Most of the resources for people with severe men-
tal disorders go to mainstream psychiatric services. What words and
concepts used in the last two days can best build bridges with main-
stream psychiatric services, what are the psychoanalytic ideas that
can help build bridges.
A slightly different question—The Scottish Government is currently
investing a great deal of money in suicide prevention. How would
the panel suggest that analytic insights could be used within the
psychiatric system successfully to help this situation?
223
224 P L E N A RY D I S C U S S I O N
Any thoughts?
1) Franco De Masi: In the paper which I read this morning I tried
to convey my thoughts on the nature and analytic treatment of
psychosis; thoughts that have taken shape over the many years of
my clinical practice. At the start of my career, when I worked in
psychiatric institutions, I thought that treating psychosis by means
of psychopharmacological therapy and therapeutic interviews was
possible, but full of uncertainty. It would sometimes happen that
I could not explain why a certain patient had recovered from a
psychotic crisis, or I would be forced to accept that the same patient
who had apparently been “cured” could suddenly be re-admitted
due to an inexplicable relapse. A new attack could also take place
after pharmacological therapy had been suspended, although the
dosage was so small as to appear to have almost no effect on the
patient. Yet the suspension of pharmacological treatment, which was
evidently effective at warding off the attacks, prompted a new crisis.
When I left the psychiatric service twenty-five years ago to devote
myself entirely to the profession of psychoanalyst, it was a long time
before I took on a patient who suffered from psychosis or who had
had episodes of it in the past. Despite my experience at university
and in hospitals, the study of psychoanalytic works and attendance
at conferences, I felt rather helpless in the consulting room. I therefore
decided with great caution to undertake the analytic treatment of a
psychotic patient. I still believe that it is inadvisable to have more
than one psychotic patient in treatment at a time. My present aim is to
make a contribution to our understanding of the specific difficulties
we encounter in the analytic treatment of psychosis. I hope that
by showing the strong points and limitations of our therapeutic
abilities, we may go some way to explaining the complex nature
of the disease and provide new thoughts on this mysterious field
of study. At the present I am continuously engaged in supervising
and discussing many cases of psychotic patients with psychiatrists,
psychotherapists and psychoanalysts of my country. I could only say
that I am learning a lot and at the same time I am giving them some
hope for a better outcome of the therapy of this kind of patients.
2) Caroline Garland: I had the experience of working at the

Maudsley for about fifteen years and the thing that struck me was
a stand-off between the psychotherapy unit and the rest of the
P L E N A RY D I S C U S S I O N 225
psychiatric hospital and I agree entirely with what the previous

two speakers have said but I also think that if we could address
the mutual content and hostility and actually develop an attitude
of mutual respect we might do rather better. After all, not all
psychoanalysts have psychiatric knowledge and not all psychiatrists
have psychoanalytic knowledge and it seems to me that that might
be when we are talking about building bridges at conferences such
as this and perhaps others might help.
3) Don Campbell: I spent thirty years working in the NHS

Portman Clinic where we see two types of patients on an outpatient
basis, patients who are delinquent or violent and those who are
suffering from a perversion. When I arrived there thirty years ago
it was a rather isolated unit that was struggling for survival. The
prevailing impression was that mainstream psychiatry and forensic
psychiatrists were not interested in psychoanalytic thinking about
our patient population. Then Margaret Thatcher closed down what
were the asylums in the UK and in their place instituted what
was euphemistically called care in the community. Some of you
may remember this. Many psychiatrists, and I am speaking more
about those in the forensic field, were interviewing patients with
a view to assessing their dangerousness and the suitability of their
discharge into the community. They became very interested in what
makes problematic patients tick, why they do disturbing violent
or bizarre things. Over the last ten years there has been a growing
relationship between forensic psychiatrists and psychoanalysts
working at the Portman Clinic. For instance, the Portman Clinic
has been requested to consult with the staffs of secure and medium
secure units up and down the country, and is training people who
are working in these units. The Portman Clinic professionals are
not offering psychoanalysis as a treatment modality, which is only
appropriate to a narrow percentage of this population, but we are
bringing our interest in how the patient thinks, works and manages
their lives. By beginning with not having all the answers, but being
interested in understanding severely disturbed patients, a bridge
can be created between psychoanalytically oriented professionals
and psychiatrists.
4) Franco De Masi: I am repeating good advice but I still say

that it takes some kind of work from the one who has a stand in
psychoanalytic thinking when you are working in a psychiatric

hospital. You have first of all to believe in yourself, but not to
believe that you are better or that you have a better knowledge or
better opinion but you have to believe in yourself so you don’t feel
denigrated, expelled, subjected to the others, even though it is in the
room so you have to kind of have an attitude that you understand
that the other has a different attitude but you still have the ground to
stand on. And you also have to have some kind of stubbornness, you
have to go on day after day being there, listening to what the other
thinks and make your contributions. I think it is kind of troublesome,
you have to work for it really, but I think it is worth working for and
if we have the attitude that we know better and we don’t participate
in the others thinking then I think we are out of the play: and just a
reference to Glen’s book on Psychodynamic Psychiatry, the others
are in doubt with elements of Glen’s book and say well you can get
some ideas there also besides the ideas that you already have. So
believing in yourself is very important.
5) Stephen Sonnenberg: I want to just add a dimension to what

has already been said and it has to do with the love of teaching and
learning how to teach. I think that all psychoanalysts really have to
be dedicated to teaching about what we do and to teaching in a non-
authoritarian way and in a way that isn’t embedded in jargon, in a
way that really recognises that people really want to learn about what
we do and I am going to give you two very quick examples. I live in
a city of about one million in the United States; it’s an emerging city,
an intellectual centre, a government centre but it’s also a relatively
small city and I have in response to a need established a centre for
people, mental health professionals, psychiatrists, psychologists,
social workers and other counsellors to learn about psychoanalysis.
I meet with these people thirty times a year and the typical response
I get from somebody who recently graduated from a typical Ameri-
can psychiatric programme where she learned no psychotherapy
and a lot of pharmacology is—”I don’t know what I’m doing here.
I never thought I would be here, but this very important to me and
I am learning so much”. The other thing I would just mention is that
the American Psychoanalytic Association has undertaken a new ini-
tiative and that is to provide education about psychoanalysis to the
non mental health community per se; that is, education outside of
psychotherapy training and outside of psychoanalytic training and

actually the target audience begins with pre-kindergarten and ends at
the nursing college and we developed a series of committees that are
targeted to teach about psychoanalysis for example in the university
for undergraduates, for graduate students and I think the end result
of that is going to be reflected in what we might refer to as consumer
demand because the more people we teach about psychoanalysis and
the more people who know about it those people are going to demand
to be heard quite concretely, they will not put up with medical care
with health care in which they are not heard and once they demand to
be heard then psychoanalysis finds its central place in teaching other
health care providers how to listen, how to hear and how to respond.
PW: The next question is a more clinical question, please could we have
some discussion on how the conceptualisations of psychosis discussed
today apply to psychotic phenomena in borderline patients? For
example do these need different forms of understanding in treatment
and what do we make of people with major psychotic illnesses who
initially present with a borderline picture?
1) Otto Kernberg: First of all, we have to carry out a good diagnostic

evaluation of patients before treating them. Unfortunately, in
psychoanalytic tradition very often you have one or two initial
interviews, and then you see whether the patient fits on the couch
or not: in other words, there is not really a careful analysis, not only
of symptoms, but of the characterological structure. It is not too
difficult with a good knowledge of diagnostic psychiatric criteria
to make the diagnosis not only of borderline personality disorder,
but borderline personality organisation—in other words, the
structure that characterises severe personality disorders, and then
to determine the evaluation of each of the symptoms they present.
From that viewpoint, there are very few cases, which initially raise
the question, is this a patient with a borderline structure or is it an
atypical psychosis? We have developed in our institute a method of
“structural interviewing:” I don’t have time to talk about this now,
that permits a rather sharp differential diagnosis in patients where
that is not clear. That is my first point.
Then, in the course of the treatment, these patients may develop
micro psychotic episodes. The transference focused psychotherapy
has particular techniques to deal with such micro psychotic episodes.

I can’t go into detail, but just by way of demonstration, first of all,
we maintain strictly the frame of the treatment in order to protect the
patient, the relatives and, the therapist. Within that context, in the
psychotherapeutic situation, we explore what usually emerges as a
transference psychosis. The micro psychotic episodes, usually in the
middle of such treatment starts with the therapist. This is “bad” in the
sense that one has all the problems in the sessions, but it is also “good”
because we can diagnose and help the patient avoid the expanse of
psychotic functioning beyond the sessions. The methods that we have
developed for that particular circumstance is that of “incompatible
realities.” The patient has the conviction, for example, that the ther-
apist has been spreading rumours about him to other people; he is
convinced of it. We first check is he really convinced? And, if that is
so, we acknowledge that conviction by the patient and then we tell
him, “I acknowledge that you are convinced of that; I will not try to
convince you of any different things, so you should be aware that
I respect your conviction. Now, are you able to hear my conviction?
If the patient is not able to listen, we have to wait; but if the patient
is able to listen, we may tell him, I am convinced that that is totally
absurd. I am convinced that that is crazy. Now, there are two of us in
this room, we have no witness. It could be that I’m crazy and that you
are right, or that you are crazy and I am right, but what is clear is that
we are living in an incompatible reality”. Many patients at that point
try to soften this, as if I were not fully aware of what I am doing. I tell
the patient “I’m totally convinced that I am 100% aware of what I am
doing, as you are 100% convinced that I am spreading rumours about
you. We are in the situation of incompatible realities, but we can agree
on one thing: that there is madness in this room. If we can agree that
there is madness in this room, the only problem is to locate it either
in you or me. We can study the nature of this “madness,” what is the
content about, and thus we transform this into a primitive fantasy that
represents the psychotic nucleus of that patient. We can analyse the
implications, who is doing what to whom—self and object, who is
doing what and for what reason. As we explore that in depth, what
gradually emerges is a concrete, often historical issue in the patient’s
life. It’s an extremely effective technique. I am giving you only this one
example, there are other such situations, but a good understanding
of psychoanalytic technique, modified in our approach to borderline
patients permits the resolution of those psychotic elements. There

are other cases where such a psychotic development spills over into
external reality and I can’t go into all the details except to express
my conviction that this can be dealt with psychotherapeutically with
remarkable speed, once you are aware of and are able to manage these
technical approaches.
I would like to add something more general regarding the earlier
question, about how we can influence the psychotic field. I think
that one thing we have not stressed enough is that we have to learn
and integrate the input of knowledge from psychiatry. It is not only
that we teach psychiatrists what we do, but we have to really be able
to engage other fields with their own words, with their understand-
ings. Only then we will be trusted. That doesn’t take away anything
from what has been said; it is just an addition.
2) Glen Gabbard: I think that the issue of psychosis in borderlines

is complicated by the fact that things are much more messy than
the DSM IV or the standard diagnostic manuals indicate whereas
the psychotic episodes in borderline personality disorder are
supposed to be mini psychotic episodes, I can tell you from years
of working with borderline patients there is a sub group that are
always a little bit south of the border and they have a subtle thought
disorder that goes on chronically, not just situationally, they may
have acutely psychotic episodes of which the distortion of reality
is more striking but often there is a background disturbance in
reality testing, it is not schizophrenia, it is not schizoaffective, it
is not bipolar but one has to be tuned into the fact that many
of these patients have thinking that is very loose. Similarly there
is another category that doesn’t fit anything, it is an affectively
labile person who doesn’t meet the criteria for bipolar, who
doesn’t meet the criteria for schizophrenia is more psychotic than
what we would think about for a borderline patient and often
you have this group of patients that are very disturbed where you
have to borrow techniques both working with borderline patients
and working with psychotic patients and they find some kind
of amalgam that works for the individual. Back to the question
about what do we have to contribute to psychiatry, what we have
to contribute is that we value the unique, the idiosyncratic, the
complex about people. We don’t simply put a label on them and
say this is what this is and this is something we can always bring
to our colleagues.
3) Franco De Masi: I think you can accept a patient without saying

that he can or will develop a psychotic episode. In my book related
to psychosis I write on two patients, one borderline patient who
developed a psychotic crisis because I was not able to understand
a very important question and he developed a transference
psychosis. Another woman whom I saw as a depressed woman
developed an erotic delusion and erotic attachment to me. It is
not so uncommon to not see at first interview that treating the
patient psychoanalytically can produce a psychosis during the
treatment.
PW: This is another clinical question and it is about the aetiology

of borderline personality disorder. Very similar failures and
impingement by the mother in relation to the infant have been cited
as generating both BPD and psychotic functioning. Can more be said
by the panel about exactly what factors they think lead to borderline
personality disorder or to psychosis, or do we not know?
1) Peter Fonagy: Very similar factors lead to lots of different things

so for example smoking causes a range of problems, a lot of pleasure
I’m not trying to deny that but in addition to that you can get
heart disease, cancer all kinds of things, so a risk factor mustn’t be
confused with a cause. In particular when we are talking about early
mother infant relationship we are talking about something that sets
up a vulnerability in a person and the evidence is consistent with
what psychoanalysts have been suggesting over the last fifty or so
years, that the first year or eighteen months of life is formative in a
number of ways, notably in the way the brain gets itself organised.
But it doesn’t mean that everybody who has impingements in that
time will be vulnerable. Genetic factors have an enormous amount
to do with this so for example now we know,—many of you may
not know this—there is a gene, a serotonin transporter gene, 5HDT
that exists in two alleles forms, short alleles and the long alleles.
Sitting here 30% or 25% of you, depending on the ratio, would have
the short form. Most of you will have the long allele. It turns out
that people with the short allele are vulnerable to environmental
impingement so if you had the short allele then you are more
likely to be depressed in the following six years after adverse life
events. If you have the long allele it doesn’t matter how many life
events happen to you, you will be absolutely fine. You are like me! It
turns out—and this is really the important thing—is that in infancy
if you have, as we have also known, sensitive care giving you are
more likely to be securely attached but it turns out that if you have
the short allele of this gene you are environmentally vulnerable and
it matters a great deal how sensitive your care-giver is. If you had the
long allele it doesn’t matter at all, you can be neglected, and you’re
fine! It gives you a resilience, a robustness that is genetic. So what I
am getting at here is that these risks, events or risk factors interact
with each other, constitution interacts with early environment which
then creates in turn a vulnerability to later impingements which in
turn then might create a vulnerability for later provoking factors.
Developmental psychopathology is actually quite complicated.
Psychosis it turns out is probably a vulnerability. I think it is created
in the very first years of life. The evidence is coming together on that.
With borderline states I don’t think it’s that simple. I think it needs
a whole host of other things. Why am I saying that? It turns out that
the prevalence of borderline personality disorder is very different
depending on what country you live in. So in the United States—
lots of psychiatrists, lots of borderline personality disorder. Norway
lots of psychiatrists, very little borderline personality disorder, so
it’s probably not psychiatrists that cause borderline personality
disorder! But there are differences in the cultures between those two
countries and there have been those who suggested that the powerful
correlation between the strengths of religious organisations that
are valued by the community relates to some depth of underlying
social networking or structure, which correlates very highly with
the prevalence of borderline personality disorder. If people feel an
absence of Venus if I can borrow the term that we had heard in a
couple of presentations I think that probably is a major risk factor
for BPD. Given all kinds of historical influences, so I wouldn’t want
to over-emphasise its importance–its part always of a much larger
developmental picture.
2) Vamik Volkan: I have not spoken about clinical matters. What

we heard here is fascinating but there are also certain things that
we cannot measure as far as I am concerned. For example how can

you measure a mother’s unconscious fantasy that the child she gave
birth to should be dead. There are aspects of psychoanalysis that
makes psychoanalysis such a rich thing. Beside the thing that we
can measure and focus on in actual practice when we have a patient
we ask the question, what are we treating and the story comes out,
the story gets hot and needs to be worked through. Basically what
you find out if somebody going to develop borderline personality
disorder is that there is something besides the measurable things,
something in the environment that interferes with the normal
developmental splitting. Such things as, for example, if you are a
replacement child you are unconsciously given two identities; you
are a girl and you are also a replacement child for a male dead child
and you then have problem in integrating this. One problem in
America is that there are intensive one to one relationships and quick
individuation pushes in children, which makes more borderline
people. In multiple mothering, as in the Middle East, if one mother
is a good extension of the other mother then we have no problem
but if multiple mothers are not, they don’t fit each other then they
interfere with the child’s personality organisation. So there are many,
many stories that enrich our way of looking at borderline personality
organisation. The other thing that I briefly want to mention is that
there are so many such patients and so I much appreciate the
mentalization technique or what you call transference technique but
we should also not forget that there are more typical psychological
techniques for dealing with these problems. In America there are
two kinds of borderline treatment, one is most of what we heard
here, the other one is that you allow them to regress, the patient
comes and you knows they are going to regress through a psychotic
transferences and then move up. My beef if I can call it that is that
when we write about borderline treatment we should write from the
beginning to the end, we have to provide detailed case reports on
the whole process which I think is then very useful for teaching in
order to show the complexity of it.
PW: Nine analysts on the panel only one female analyst, Why?
Answer from one panel member: I think the answer to that is clear—
it is Paul’s fault!
PW: I can only tell you that it is the reverse of meetings in the British
Psychoanalytic Society where there are nine female analysts to one
male!
PW: A question for Prof. Fonagy—wait a second (another voice from the
audience)—isn’t it true that one woman really is smarter than nine
men! (applause)
This question is for Prof Fonagy but it is also open to others.
Peter, you said and wrote in the past that the most appropriate
treatment for borderline patients was psychoanalysis. In your
presentation psychoanalysis seemed to have no role but only
MBT as the panacea for borderline conditions. Can you clarify
whether in what role you see for psychoanalysis in the treatment
of borderlines?
1) Peter Fonagy: Thank you for that! It is indeed true that I did
write and I still believe that psychoanalysis has a place in the
treatment of severe disturbance by psychoanalysis. I now mean
that intensive psychoanalytically oriented therapy has a place in
the treatment of borderline personality disorder. I want to add two
qualifications: the first is that unmodified psychoanalysis I think is
possibly unhelpful and quite likely to be harmful for the individual
with borderline personality disorder because if the individual who
has no privileged access to their own internal state cannot read
off their mental state, there is nobody really judging what they
are being told and whether it is correct or not. Quite often this
literally creates a psychotic, certainly very regressed state, and
suicidality. I think I would need to see the empirical evidence for
thus way of doing things before I believed it. The second issue
is that it has to be modified and a modified psychoanalysis par
excellence is mentalization based treatment. It is a treatment that
focuses on exploring the patient’s mental state associated with
the analyst’s mental state. However it does require a firm basis
so I would see the role of psychoanalysis and the role of more
complex explorations of the patient’s mind to be a second phase
in, if you like, a two phase treatment–so you have to establish a
relatively robust capacity in the patient to mentalize and usually
this would be associated with a dramatic reduction in suicidality,
a reduction in self harm, a reduction is hospitalisation and also
most of the time improvement in adjustment in a number of other

areas, employment and so on. And then that person I think can
benefit from further more classical, traditional or holds unbarred
or at least less barred treatment.
PW: This is a question about art psychotherapy on behalf of a large number

of art therapists attending this conference from Great Britain/
Northern Ireland and beyond. I have been asked to tell you how
wonderful this conference has been. We feel that active engagement
in the arts therapies has a valuable contribution to make to these
client populations in terms of primary process understanding
mentalization, symbolising and containment. The conference has
opened up some complex principles in a non reductive way, we would
welcome any views of the panel on the role of the arts therapies in the
treatment of severe disturbance.
1) Stephen Sonnenberg: I just have a real quick anecdote. A highly

skilled very brilliant mental health professional who I have just
completed analysing just two weeks ago after twelve year analysis,
a person who was an addict in recovery, took up an art form during
the last couple of years of his analysis, I am not going to say what
that form is. I am not going to give any more information about the
person but I can tell you that the person has become an accomplished
artist and that experience has been very therapeutic for him.
2) Bent Rosenbaum: For me the question comes a few months too early
because there is a Danish PhD thesis, which will be evaluated during
September and October on these matters. What I have experienced
myself from different parts of psychiatry—I have always been
interested in the art form. I think it cannot be underestimated. I think
it is underestimated but it shouldn’t be really. To engage patients in
music, dance, theatre, painting not the least, I have my wife sitting in
the back who has been in the treatment centre for severely psychotic,
she had a workshop with paintings. In the beginning nobody went
into the room. She was just sitting there and painted herself, then
came one patient, and another patient and then there were twenty
patients. They made exhibitions. When she stopped six years after
I have never seen so many touching letters from patients thanking
her for just being in that room, demanding nothing but putting up
some kind of possibilities for them to do something with the skills
they have. I think it is underestimated and if I had the? I would have
both music and painting and theatre also.
3) Otto Kernberg: Art forms can also be very diagnostic—you have

a real typical borderline patient and goes through occupational
therapy and makes painting and you look at it, my god there is
splitting, they make a rug there is a line in the middle, so the patient
gets better even his/her art form changes, they start integrating, so
those of you who work with borderline patients please go and look
at their paintings. You will be surprised to find out how much the
internal world gets reflected in their art form.
4) Paul Williams: I would like to support those comments in my

own work in the Centre for Psychotherapy, the clinic we have here in
Northern Ireland. We are doing work with very severely disturbed
patients who undertake art therapy and music therapy and it’s
remarkable how the inner worlds of these patients emerge quite
quickly. I’m not an art therapist or a music therapist but I sit and talk
with these therapists. I talk about psychoanalysis, they talk about
music and we try to come together in creating a sense of meaning
around these communications and often the patients move on to
individual work or group work.
PW: This is a question directed principally to Bent Rosenbaum, I am

working with a client who had a diagnosis of paranoid schizophrenia
had intrusive persecutory delusions, hears voices, the delusions
he believes are real, people really are poisoning his food whereas
the voices he started to accept are a creation of his own mind. As
a result he has been able to make some connections in the way he
feels when the voices persecute him to how he felt persecuted in
various situations when he was a child. Despite a gradual increase
in his understanding of the aetiology of these voices they remain
unremitting. He can ignore them more but they are still present
just as much. Have any techniques or understanding you have used
actually alleviated auditory hallucinations, not necessarily with the
simultaneous medication changes.
Bent Rosenbaum: We know that there are different techniques to try

to alleviate the voices. I think this patient has come quite far actually
getting the patient to acknowledge the hallucinations, getting the
patient to acknowledge the idea that these hallucinations or the
meaning of them, they are coming from somewhere. I would also
like the patient to understand that the past is not something behind
him but in front of him, something that he will meet. It is not only
they are coming from somewhere but the past is something that
you meet and then limit your ability to think about the future. But
the specific techniques, its true that psychoanalysis as such doesn’t
come up with specific technique for symptoms but why shouldn’t
you be able to explore within the clarification concept these voices,
how do they sound like, are they different, what are they aiming
at, who are the persons who have the voices, how are they dressed,
what do they look like. So in the perceptual field explore with
the patient these kind of voices in order for him to give them, I
mean he has got them already in his mind, but try to neutralise
the anonymity of the voices. Because the anonymous voices are
difficult to cope with. If you get persons, if you get ideas, if you
get meaning, that’s one of the techniques to do it. I don’t guarantee
anything, nobody can do that, but that is really a way forwards.
And then comes the idea whether the voices are really going to
tell you and me. I mean the voices say something but what are
they really going to tell me, can they tell other stories. You have to
look at this from the outside perspective. I think also the delusions
in this man go together with the voices, so as long as you go into
the voices you might also get to the delusions in the same round.
I think you have to find your techniques if you are going to deal
with symptoms within the psychoanalytic framework but there are
ways to do it.
PW: In Brazil children as young as 8 are paid in crack cocaine so become

addicted and then live a life of poverty. Crack cocaine dealers are
targeting mental health units in the United Kingdom in similar
ways. How can we compete as a therapist for the drug that gives
a high that we can never possibly offer patients particularly when
their life for example if they are diagnosed with a schizophrenic
illness hold so much daily distress. This is directed principally at
Steve.
Stephen Sonnenberg: That’s obviously a very complicated

question. I have seen the Favelas in Brazil and I have worked with
chronic mentally ill patients. It’s very clear that addiction must
be appreciated within a bio-psycho-social framework and that its
societal framework, its societal context is very important. Now I think
it is important to remember that the notion of the bio-psycho-social,
and Glen Gabbard has written a wonderful paper on that, pointing
out how it’s a slippery slope to think that way, but nevertheless
it has some utility and that is a psychoanalytic notion. So I think
that as psychoanalysts approaching this problem we should be
very comfortable with the idea that drug addiction does take place
within a social framework and it can only be addressed within
that framework. If we are dealing with the kinds of patients whom
I was talking about yesterday there can still be a great deal that
might necessarily be done within a social framework which is
why for example I advocate communication outside the analysis,
I mean families that enable addiction need to be dealt with just as
the kinds of problems in this question. Now I don’t want to avoid
the question, it’s a very daunting question and it is a very serious
problem. I think that we have to keep in mind that a brain/mind
slowed to develop agency, power, capacities for reflection, capacities
for human intimacy, opportunities to grow through interactions,
through education, I think we have to keep in mind that that is a
better alternative to drug addiction whether we are dealing with a
child in a Brazilian Favela or a chronic mentally ill patient and I really
believe that’s true. If you come at the problem from that perspective
I think recognising that we do have something to offer is extremely
important. Now in order to offer what we potentially can we also
have to be socially active, we have to remember that for example
interdiction of the drug trade is a law enforcement problem and we
do need to make sure that we are heard by our governments and
that they do deal with criminals who are selling drugs to chronic
mentally ill patients and to kids in slums. We have to recognise that
our social context, that our societies leave much to be desired and so
as psychoanalysts we should be very active advocates for creating
a better society, a better world and you heard of course from two
analysts today who are very committed to doing that and to doing
a great deal of that in the realm of international relations and I think
we all have to do it within our countries and our communities.
PW: I can see some tiredness coming over one or two faces. Would you
like me to continue with the questions or should we draw it to a close
in a little while.
1) Caroline Garland: If I might interrupt the powerful but
remorseless male logic of question/answer, I would like to go back
to the statement that came from the art therapists. It is not just ‘art
therapy’ that is therapeutic, it’s art. If you look at great works of
art you are put back in touch with your good internal objects: great
works can make you feel better about life even when they are about
terrible events. One of the things that has interested me very much
recently has been a series of etchings by Goya called Los Caprichos.
Goya had a near fatal illness when he was in his late 40’s and as a
result of this he became stone deaf, he could no longer hear a voice,
could hear nothing—and as you know this is closely associated with
an increase in paranoid ideation. Yet Goya as a great artist could take
some of the absolutely horrific fantasies and images and demons
that he then felt himself to be locked up with, transform them and
put them down on paper in a way that speaks to us universally.
There is nobody who looks at those works who doesn’t know what
he is talking about; we feel better for having our monsters pinned
down on paper. So I would like to advocate therapy-via-great-art as
well as art therapy.
2) Don Campbell: I just wanted to go back to a question that we

didn’t get a chance to address. Perhaps other panellists would like
to chip in. It is a question about the application of psychoanalytic
ideas, particularly within the area of suicide prevention. Earlier Peter
Fonagy reminded us that identifying risk factors is not necessarily
identifying a cause, but it does flag up vulnerability. There are
many demographic studies of attempted suicides, suicides by age
range, socioeconomic factors, family structures, and so forth, all of
which will flag up at risk individuals. I think any approach to the
prevention of suicide needs to take those risk factors into account.
I also think that it needs to follow, from a very early age, children
who could be identified as at risk. That doesn’t mean that they
are necessarily going to end up attacking their body or the body of
another. In fact, psychoanalysts are not very good at predictability;
they are much better at looking backwards in retrospect and learning
from that perspective. However, taking a developmental approach
to these vulnerable children, and following them as they grow

up could enable social services and schools to know when a child
becomes struck in their development, or when there is a slow down
in development. Some of the most at risk children are those who get
lost sitting in the back of the classroom. They don’t act out, but are
quietly depressed and breaking down alone and isolated, while they
are largely ignored because they do not create a nuisance. Now these
kids may be at risk of suicide or assaults on others in adolescence. Of
course adolescence is the time that is absolutely critical because the
child’s body takes the centre of its psychic stage. Vulnerable children
whose breakdowns went undetected before adolescence are often
ill equipped mentally to deal with the conflicts and anxieties about
their bodies and the development of their sexuality and their gender
identity that are triggered by puberty. Adolescent development is,
by definition, going to be disruptive and anxiety provoking for the
adolescent and the adults around them. In fact, it is appropriate to
be concerned about those adolescents who appear to be untroubled
by what they are going through. Psychoanalysts can help other
professionals identify children and adolescent who are at risk of
killing themselves or others.
3) Otto Kernberg: I appreciate you coming back to the subject of

suicide prevention. I thought it might be of interest to mention the
criteria for risk and the triage for treatment that we have developed
at our outpatient clinic for personality disorder. We get suicidal
patients either from the crisis line in our local area or patients
whose rapid triage has to be made by the person on call. We have
a general outline, and I don’t want to say that it is rigid, but I have
to summarise it a little: It has been very helpful and over a number
of years we really have been able to prevent most cases of suicide
in those who came to our attention. The criteria are relatively
simple. If a patient is acutely suicidal, we try to assess whether he is
depressed or not depressed. If the patient is depressed, whether it’s
a major depression, or a dysthymic reaction or a characterological
depression or a neurotic depression—whatever you want to call
it. Of course there are cases that are uncertain. In general, patients
with major depression and suicidal tendencies we hospitalise
immediately. It is just too high a risk. If it is a characterological
depression, we consider the possibility of treating these patients
psychotherapeutically in the outpatient setting with the combination

of anti-depressant medication and this is assessed from case to
case. The basic criterion is, is the patient able to establish an object
relationship quickly? Can he tolerate an intensive psychotherapy
that can “hold” him while the outpatient treatment proceeds?
That depends on the type of character pathology: it’s better for the
dependent, histrionic, and depressive personality, worse for the
schizoid, schizotypal, paranoid,—how strong is the impulsivity
of this patient? Is there a history of antisocial behaviour, drugs
or alcohol abuse or dependency, and, of course, the general risk
factors that have already been alluded to in terms of age, social
environment, support etc? A combination of criteria give a sense
as to whether it is safe to treat the patient on an outpatient basis,
or whether he or she should go into the hospital. If the patient has
carried out a suicidal attempt and is really not depressed, then we
have a typically characterological suicidality, what we call “suicide
as a way of life,” and here we really have the severe personality
disorders—a few of them are depressive-masochistic personalities.
Their indication is clearly for psychotherapeutic or psychoanalytic
treatment. These are cases for psychoanalysis. Most others are at
a borderline level, particularly those with narcissistic personality
structure, infantile, histrionic and borderline personality disorder
and a few bi-polars. For bi-polar patients, mood stabilisers are
very important. For those where characterological pathology
predominates, we try to decide whether they would benefit from
psychoanalytic psychotherapy—particularly transference focus
psychotherapy, or from supportive psychotherapy based on
psychoanalytic principles, or dialectic behaviour therapy—if there
is a specific, circumscribed, suicidal or para-suicidal syndrome.
So we use specialized psychotherapies in these areas. That’s our
practical approach, and it requires a good collaboration between
the members of the team. We have managed it so that cognitive
behaviour therapists and psychoanalysts don’t see each other as
enemies! But in our “research atmosphere,” we try to learn what
are the indications and contra-indications.
4) Glen Gabbard: I know we have to end but I think that this has
been an extraordinary conference and we owe a debt of gratitude to
John and Cathal and the College and especially to Paul Williams and
I suggest we give them a round of applause.
Dr. Cassidy
The honour falls to me to make a few remarks. I am Cathal Cassidy,
Chairman of the Royal College of Psychiatrist in Northern Ireland
and I am the one who was persecuting you to get you in on time
during the course of the two days. I would like to thank some
people. I would like to thank our inspiring speakers. I hope you
were inspired by the content of their talks and inspired also by
hearing it from them in person. I would like to thank our efficient
chairs, who ran things so well during the course of the two days. It
is important that we thank the sponsors of the conference including
those who supported it financially. It is very important that I thank
Nora McNairney who is a very important lady in this conference. She
is manager of the Royal College of Psychiatrists Northern Ireland
office. Nora has done an incredible job of organising 440 delegates
in this conference over two days.
I think we have to thank two people for vision and leadership for
this conference: Professor Paul Williams and Lord Alderdice.
INDEX
A scandal in Bohemia 131 Attachment-mentalization

A Study in Scarlet 131 reciprocity, implications 40–41
Adrenocorticotropic hormone Belsky’s evolutionary model 41
(ACTH) 12 Anwar el-Sadat (Egyptian
Akhtar, Salman 192 President) 188
Al Qaeda 208 Apprey, Maurice 188
Alcoholics Anonymous 128 Arab-Israeli conflict 188
Alcoholism 105 Arnsten’s Dual Arousal
Alderdice, John 188 Systems Model 54
Allegiance effect 4 Attachment system 39
American Psychiatric disorganized 50
Association 107, 226 Autoerotism 161
American psychoanalytic
literature 164 Bateman, Anthony 35
Amygdalar-based negative Belfast Conference 137
feelings 14 Bethesda Naval Hospital 113
Anterior cingulated Bion
cortex (ACC) 14 alpha-elements 157
dysfunction 14 beta-elements 157
Anterior hypothalamus concept of attacks
(MPOA) 38 on linking 159
243
244 INDEX
conceptualisation 157 Campbell, Donald 171, 225,

Elements of Psychoanalysis 52 238–239
notion of role of mother’s Capozzi, Paola 141
capacity 43 Card-carrying analysts 119
psychotic and non-psychotic, Caregiver-infant relationship 37
difference 84 Caregiver’s
symbol-formation 157 behaviour 42
Bio-psycho-social framework 237 empathic mirroring 42
Black action 108 facial/vocal mirroring 42
Blank analytic screen 56 Center for the Study of Mind and
Blos, Peter 192 Human Interaction
Body barrier 174 (CSMHI) 215
Borderline mechanisms method 188
of functioning 82 University of Virginia’s 188
Borderline organisations Central phobic position 31
of personality 81, 227 Child abuse 115
Borderline patients 58 Child’s
international initial preoccupation 42
negotiations 185–217 superego 192
Borderline personality disorder Child-caregiver relationship 41
(BPD) 1–15, 36, 64, 103 Children’s care giving
current mental states 62 environments 41
dynamic psychotherapy Chosen glories 211
of 9–10 Chosen traumas 211
emotional dysregulations in 14 Clash of civilizations 208
mentalization based approach Coherent causal-temporal
to psychotherapy 35 organisation 46
mentalization 55 Colonizing action 140
negative transference in 12 Combined dexamethasone tests 12
neurobiological factors 11–15 Communicative attention-directing
Norwegian study 5 behaviours 52
patients 7, 14 Conflict resolution 210
problematic family Contemporary analytic therapists 2
interactions 8 Contingency detection
psychoanalytic mechanism 42
psychotherapy of 8 Contingent mirroring,
self-pathology in 35 model of 41–44
splitting mechanism 8 Control mechanisms 37
therapeutic action 5 Corticoptropin-releasing
Borderline personality organization hormone (CRH)
23, 187–188, 198, 200, 207 challenge 12
Butler, Thomas 205 tests 12
INDEX 245
Cortisol 12 Elimination
Countertransference 27, 166 fantasy 174–176
developments 31 psychosis 177
utilization 24, 30 Emotional encoding 38
Countertransferential split 154 Emotion-related
Cross-trained therapists 4 imagery 39
Cultural amplifiers 193 material 39
Current mental states 62 Emotive and dynamic
Cypriot Greek farmers 205 unconscious 139–140
Episodic memories 38
Danish National Schizophrenia Erikson, Erik 187
project 164 definition 191
Davis, H. Montgomery 132 Erotisation in completed
Declarative memory systems 15 suicide 175–177
Delinquency and sexual Extra transference material 29
deviancy 177
Delusional disposition 146 False-belief task 46–47
Delusional power 140, 145–147 False-self, Winnicott’s notion of 43
seductive quality 141 Fifth Northumberland Fusiliers 131
Diagnostic and statistical manual of Fonagy, Peter 35, 230, 233
mental disorders, Fourth edition Freeman, Thomas 138
(DSM) 107 Freud, Sigmund 205
Diagnostic syndromes 81 individual identity 190–193
Dialectical behaviour therapy on suicide 171–172
(DBT) 5–6
Dicing with death fantasy Gabbard, Glen O. 1, 229, 237, 240
174–175, 177 Garlan, Caroline 81
Dorsolateral prefrontal cortex Garland, Caroline 224, 238
(DPC) 14 George Bernard Shaw 132
Doyle, Arthur Conan 132 Ghetto mental health patients 108
Dream-delusion 140–141 Global Assessment of Functioning
Dream-thought 141 Scale (GAF) 66, 107
Dyadic primitive sado-masochistic Globalization 214
struggle 180 Grandiose delusion 147
Dynamic psychotherapy 4, 6 Greenberg 3
long-term 10 Group-as-a-whole functions 163
Dynamic unconscious 139–140 Group treatment 86–89
borderlines in groups 88–89
Edwards, James, case 107 general principles 86–88
Ego
identity 187 Hallucinatory transformation 143
psychological psychoanalysis 30 Hippocampal learning 15
246 INDEX
Hippocampus 14 Lacan, symbolformation 158

Homosexuality 161 Large-group
structure of 162 identities 193–197, 203, 206
Horowitz, Donald 205 psychology 204, 206, 215–216
Howell, W. Nathaniel 215 Learning-from-the-patient 163
Hyperreactive London Parent-Child Project 43
amygdala responses 11
hypothalamic-pituitary-adrenal Mack, John 193
(HPA) axis 12 cultural amplifiers 193
Hypervigilant anxiety 12 Masi, Franco de 137, 224–226, 230
Masturbation 105
Identity diffusion 23 Megali Idea 213
Individual Meltzer, Donald 159
group identities 185–212 Mending splitting
growth-curve analysis 5 in individuals 197–202
identity 190–193 Menninger Foundation
International Journal Psychotherapy Research
of Psychoanalysis 138 Project 1, 10, 21
International Mental closeness, retaining 61
Psychoanalytical Association, Mentalization
41st Congress 137 biology of being frazzled 54
Interpersonal interpretive capacity for 40, 58
function (IIF) 37 child’s capacity for 49–50
Irish Psycho-Analytical child’s experience 49
Association 188 childhood maltreatment 51
Irredentism 213 collapse of 52
Islamic-Western world split 203 disorganized 50
Israeli Knesset 188 emergence of 48
experience to 48
Jones, Maxwell, ideas fixation points 44
of “therapeutic society” 151 impact of attachment
Jordan River 206 trauma on 53–56
inhibition of 54
Kernberg, Otto F. 21, 199, normal acquisition of 46
227, 235, 239 patient’s 58
Kleinian practice 41
paranoid-schizoid position 83 quality of 35–36
technique 30 reciprocal relationship of 40
Klein, Melanie 198 relationship influences on
Kraepelin’s dementia praecox 161 acquisition of 46–48
Krystal, maternal mistreatment stages of acquiring 44–46
and trauma 125 subjectivity before 48–50
INDEX 247
subjectivity stripped of 53 Mother-child unit 179

temporary collapse of 51 Mourning and melancholia 171
theory of mind 44–46
Mentalization-based therapy Narcissism 87, 161
(MBT) 3–4, 36, 56, 64–65 structure of 162
evidence Neurobiology of attachment 38–40
for the effectiveness 63–67 Neurotic personality
for borderline personality organization 186
disorder 63–67 Newtonian Mechanics 139
interpersonal context in 57 Non mental health community 226
interpersonal interpretive Non-governmental organizations
function 36–38 (NGOs) 214
model 59 Nonhippocampal learning 15
neurobiology Non-shaming therapist 122
of attachment 38–40 Non-substance abuse 105
retaining mental closeness 61 Northern Ireland peace process 188
therapist 7 Northern Ireland’s cross-community
treatment 64 Alliance Party 203
versus transference-based
therapy 7–9 Oedipal impulses 180
Mentalization based treatment Oedipus complex 192
in partial hospital (MBT-PH) Olinick, Stanley 187
63–64, 67 Orange Irish ancestral roots 132
intervention 67 Orbitofrontal cortex (OFC) 14
Mentalizing 35 Out-patient group mentalizing
emergence of function 44 treatment (MBT-OP) 64–65
enhancing 56–58 Over-optimism 85
in child 48
Mental mechanism 210 Paranoid personality 190
Mentalizing capacity 6 Paranoid-schizoid forms of
Merging fantasy 174–175, 178 thinking 52
Mesocorticolimbic dopaminergic Pathological mother/child
reward circuit 38 relationship 179
Metacognitive monitoring Penguin Man 186
procedures 52 Personality disorder 21
Meyer, Nicholas 132 borderline 1–15
Military medical school 113 Personality Disorders Institute 21
Mirroring Personality organization 190
markedness 43 Political ideologies 213
reasonable congruency of 43 Portman Clinic 225
Mitchelson, Austin 132 Posterior cingulate cortex 38
Morbid awareness 156 Pre-oedipal parents 179
248 INDEX
Pre-suicide states of mind 171–182 Psychoanalytic treatment,

body barrier 174 of addictions 103
case study 175–178 case of James Edwards 107–112
father in 179–181 case of stuart holcombe 112–119
Freud on suicide 171–172 literature for Joseph 119–123
nature and function of suicide scope of the problem 104–107
fantasy 172–173 technique to Joseph 126–130
self-preservative aggression Psychodynamic
and sadistic aggression psychotherapy 165
173–174 therapeutic technique,
types 174–175 consequences for 55
working with 181–182 therapy interventions 11
Pretend therapy 63 Psychological method 195
Profession-related identities 191 Psychopathic transferences 33
Psychic Psychopathology
equivalence 48 developmental 231
reality 209 nature of patients 82
self-defence 174 Psychopharmacological
Psychoanalysis 1, 28, 105, 156, 227 therapy 224
Psychoanalytic group therapy with Psychosis 137, 231
severely disturbed Psychotherapeutic interventions,
patients 81–101 types 11
clinical material 89–91 Psychotherapy
containment 85–86 therapeutic action of 2
Psychoanalytic transference focused 227
conceptualization, Psychotherapy researcher 3
considerations 137–148 Psychotic
insights, diplomacy 213–216 break-down 145
model 22 disorders treatment,
process 107 considerations 137–148
therapist 2 mechanisms of functioning 81
treatment, therapeutic mind 167
action of 3 personality 165
Psychoanalytic psychotherapy, transformation 143
borderline personality disorder
1–15, 29 Rado, Sandor 156
conventional wisdom 4 Reading the Mind
Høglend study 4–5 in the Eyes test 41
mentalization based approach Reasonable congruency of
35–67 mirroring 43
plenary discussion 220 Reductionism 11
therapeutic action in 1–15 Response-contingent stimulation 42
INDEX 249
Revenge fantasy 174–175 Splitting mechanisms 23

Rey, Henri 85 Stress-vulnerability model 160
Rosenbaum, Bent 151–168, 234, 236 Stuart Holcombe, case 112–119
behavior 116
Saddam Hussein, Gulf War 211 concurrent transference
Sadism 171 experience 130
Sadistic aggression 173–174 hypnosis in Austria 128
Sado-masochistic journalistic contrivance 117
interaction 181 profound aloneness 114
struggle 180–181 treatment 124
Saladin, Sultan victories 211 Subjectivity
Scandinavian psychoanalytic before mentalization 48–50
Review 161 post-traumatic experience 52
Schema-focused therapy (SFT) 3, 6 Substance abuse 105
Schizophrenia 229 Suicide fantasy
developmental nature and function 172–173
psychopathology 160–163 types of 174–175
psychotic states of 163 Super-ego
treatment of 103 and hallucinations 138
Schizophrenic modes 152 position–punitive 153
Segal, Hanna 52 Supportivepsychotherapy 3
Self-disclosure 9 Supportive therapy (SP) 5, 22
Self-organisation 35 Surviving self 177
Self-pathology in 35 Symbolformation 152
Self-preservative Symbolisation theory 157
aggression 173–174 Syndrome of identity diffusion 23
Self-punishment fantasy 174–175
erotisation in completed Target, Mary 35
suicide 175–177 Technical-ethical
Self-reinforcing system 119 considerations 119
Sexual deviancy 177 Thatcher, Margaret 225
Sexualization 161 The New York Hospital 21
Sherlock Holmes 132 The Sign of Four 132
Single mechanism theories 2 Therapeutic alliance, roles 9–11
Social acquisition of social Therapeutic
cognition 41–44 influence 1
Social biofeedback 42 lifers 11
Social-cognitive capacities 35 space 202
Sonnenberg, Stephen M. 103, 226, ToM acquisition 47
234, 237 Tourette’s patients 14
Split-off object relations 24 Transference
Splitting mechanism 188 analysis 29
250 INDEX
cure 11 techniques 28–32

development 27 to dialectic behavior therapy 22
distortion 60 versus mentalization-based
dominant 29 therapy 7–9
nature of 27 Transference interpretation
psychosis 200 empirical research on 3–5
reaction 109 moderate level of 4
upward-evolving 200 Transgenerational transmission
use 59–61 of trauma 212
Transference-countertransference Treatment as usual (TAU) 63–64, 67
encounter 107 Tree Model 188–189, 215
processes 164
vicissitudes 3 Uniformed Services University
Transference-focused of the Health Sciences
psychotherapy (TFP) 3, 5–6, (USUHS) 113
21–33, 59 United States government
borderline personality employee 107
organization 23, 32 Unmentalized (alien) self 50
Fenichel’s (1941) technical
recommendations 27 Volkan, Vamik D. 185, 231
for individual patients 22
group psychotherapy 22 Wallerstein 1, 10
indications and Watson, John 131
contraindications 32–33 Weill Cornell Medical College 21
overview of 22 Williams, Paul 148, 223, 227, 230,
psychoanalytic group 234–235, 241
psychotherapy 22 Winnicott, Donald 197
psychotherapy 33 notion of ‘false-self’ 43
strategies 23–26 sense 10
tactics 26–28
technical neutrality 30 ZAN-BPD 65–67

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THE PSYCHOANALYTIC THERAPY

Other titles in the Psychoanalytic ideas Series:

Autism in Childhood and Autistic Features in Adults:

Child Analysis Today

Psychoanalytic Ideas and Shakespeare

Shame and Jealousy: The Hidden Turmoils

Spilt Milk: Perinatal Loss and Breakdown

Symbolization: Representation and Communication

The Organic and the Inner World

Time and Memory

“You Ought To!”—A Psychoanalytic Study of the Superego

Edited by Paul Williams

Copyright © 2010 by Paul Williams

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

British Library Cataloguing in Publication Data

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

Typeset by Vikatan Publishing Solutions (P) Ltd., Chennai, India

Printed in Great Britain

PLENARY DISCUSSION 223

In early 2007 colleagues at the Belfast Centre for Psychotherapy,

subject engaged to speak. When we announced the Conference

Cathal e Cassidy M.B. FRCPsych.

A great deal of work went into mounting the conference on the

My name is John Alderdice. I’m a Psychiatrist and Psychotherapist

in the World, this would be a tremendous encouragement to those

working together. Finally, The British Psychoanalytical Society in

Professor Sheila Hollins

down of psychotherapy. The idea is that a reasonably large injection

Mr A: “I’m upset, very upset. It happened last night. I wet myself.

Valerie: “And Mr C hasn’t got a Mum to see. He hasn’t seen her

The therapeutic action in psychoanalytic

There is no single path to therapeutic change. Single mechanism

improvement in terms that shed favourable light on how they

Empirical research on transference interpretation

Two of these empirically validated treatments are psychodynamic

61% of those subjects were diagnosable with personality disorders on

Therapeutic action and borderline personality disorder

assault. Both TFP and DBT—therapies that specifically target sui-

psychotherapy developed by Kernberg, Clarkin, and the other

MBT vs. TFP

chaos of the borderline patient. Patients with BPD characteristically are

in directive interventions that are designed to address the patient’s

The role of the therapeutic alliance

pretation may be misplaced. Timing may be of much greater impor-

the time, most would now be diagnosed as BPD. Wallerstein found

reactive to relatively benign emotional expressions. This misreading

Ms. A, a 27-year-old patient with BPD, was ending a session with

In this vignette, I challenged the patient’s emotional certainty—

Both TFP and MBT encourage reflection by the patient on

Abend, S.M. (2001). Expanding psychological possibilities. Psychoanal Q

Clarkin, J.R., Levy, K.N, Lenzenweger M.F. et al (2007). Evaluating three

Gunderson, J.G. & Bateman, A., Kernberg, O (2007). Alternative per-

Pine, F. (1998). Diversity and direction in psychoanalytic technique. New

characteristics mentioned above. We tested the possibility of training

Overview of TFP for individual patients

involved in. The interpretation of these split-off object relations is

are activated remain typically split-off from each other in different

experiences is expressed in the tendency to replace such emotional

eliminate the secondary gain of treatment, and second that, in a

simultaneously on the transference and on developments in these