The Psychotic Wall
1. Hate In the Countertransference
Many New Yorkers have had the experience of getting on the less-crowded subway car only to find that it is less-crowded because there is a homeless person sleeping on the bench and the human smell in the car is overpowering. The doors shut and you are stuck there. Next stop people rush off, only to have new persons rush on, followed by disgusted realization once the smell hits them.
This is an example of what Winnicott refers to as Hate in the Countertransference (Winnicott 1975), or likewise known as objective countertransference. While Freud viewed a certain kind of countertransference as unconscious feelings arising in the analyst, this objective countertransference is entirely conscious to an overpowering degree. “The analysis of a psychotic is irksome as compared with that of a neurotic and inherently so” (Winnicott, 1975, p. 194)
If a new patient comes into the consulting room smelling strongly of piss, any analyst who can smell is going to react; it is an objective reaction. In Winnicott’s formulation it is necessary for the analyst to acknowledge the hate that may be produced by this reaction: “analysis of psychotics becomes impossible unless the analyst's own hate is extremely well sorted-out and conscious” (ibid). And yet it is equally important that the analyst make no visible reaction to it. We can see in this hypothetical “piss” situation how the basic Freudian techniques of both neutrality and abstinence can become useful: It is counterproductive to the treatment to tell the filthy patient to take a bath (neutrality). Neither should the analyst indulge the patient’s gross-out symptom by a negative reaction (abstinence).
It may be the case that the patient refuses to bathe as a means of ultimate defense from the social link; one of the more formidable castle redoubts of the schizoid position. “His unlikeableness has been an active symptom unconsciously determined” (Winnicott, 1975, p. 196). Yet it may also be that the unwashed person is awaiting contact; searching for that rare somebody who can tolerate their abject presence enough to listen to them.
2. The Asylum
Madness in Michel Foucault’s Madness & Civilization is placed within, and grows out of, the wider context of the early modern hysteria for enclosure. At this time of initial capitalist takeoff in the 17th and 18th centuries, whole classes of persons have been divested of the use of communal lands that are now turned private property. Walls, in this era, are going up everywhere.
Madness, at the very beginning of our modern age, was defined by its uselessness. Where a new value was assigned to productivity, labor and employment, a new malevolence was assigned to the mad person, because they could not work.
“The asylum was substituted for the lazar house (leper colony), in the geography of haunted places as in the landscape of the moral universe. The old rites of excommunication were revived, but in the world of production and commerce. It was in these places of doomed and despised idleness, in this space invented by a society which had derived an ethical transcendence from the law of work, that madness would appear and soon expand until it had annexed them… This community acquired an ethical power of segregation, which permitted it to eject and, as into another world, all forms of social uselessness. It was in this other world, encircled by the sacred powers of labor, that madness assumed the status we now attribute to it” (Foucault, 1988, p. 57-8)
What is implied here is that as physical brick and mortar walls go up throughout society, psychical walls are also being erected. Whereas an earlier, more superstitious age would tolerate and care for the town mad-person, in the age of reason madness itself must now be enclosed as if it were a pathology no less contagious than the once feared leprosy; a contagion of unreason and of uselessness. The enclosure of madness inside the asylum walls compounds madness itself. One becomes not so much afraid of being psychotic, but rather of having to be locked away with psychotic people. Or even yet: one seeks sanctuary from the demand of the world, in madness behind these walls, set apart from a cruel and terrifying reality that makes you work. The physical/psychical walls of the asylum create a separation between psychiatry and madness, between madness and the “sane” world, and between what we might call the non-psychotic core of the patient from their own madness: insanity is confined at last within mental illness.
These confines can be found in the doctor/patient relationship itself. According to Foucault, it is Freud who finally points this out and isolates it. The alienation of the asylum becomes disalienating in the psychoanalyst because of their subjectivity (Foucault, 1988, 278). And yet the ghostly walls of the asylum remain, determining the power dynamic between analyst and analysand.
3. Freud’s Glimpse Beyond the Wall
While Freud’s inability in treating the psychotic is mentioned often and loudly, it is rarely mentioned that later in life he found that certain kinds of psychotic transferences could be developed. “The analytic study of the psychoses is impracticable owing to its lack of therapeutic results. Mental patients are as a rule without the capacity for forming a positive transference, so that the principal instrument of analytic technique is inapplicable to them. There are nevertheless a number of methods of approach to be found. Transference is often not so completely absent but that it can be used to a certain extent; and analysis has achieved undoubted successes with cyclical depressions, light paranoic modifications, and partial schizophrenias” (Freud, 1925, p 60.) Furthermore it is the concept of narcissism that has allowed the psychoanalyst, “to get a glimpse beyond the wall” (p. 61).
Spotnitz follows this path. “The general attitude that schizophrenia is incurable is almost invariably an expression of narcissistic countertransference resistance. The patient feels incurable and he induces that feeling in the analyst. If the analyst accepts that feeling as his own, and acts on it, the therapy fails. If, on the other hand, he recognizes the source of the feeling and also becomes aware of his affective responses to it, the constructive use of these counter feelings dramatically brightens the prognosis for the patient” (Spotnitz, 1979, p. 558).
4. Chestnut Lodge
One famous walled sanatorium was Chestnut Lodge, operating in Rockville Maryland, close aside Washington DC. An asylum in high boutique style, there the mentally ill could check themselves in and receive rather more humane treatment than other psychiatric institutes, in part because of the psychoanalytic theory and method that laid the foundations for this treatment; lead by analysts Frida Fromm Reichmann and Harold Searles, et al. There were no shock treatments, no insulin injections and no mandatory drugs administered. The therapy was talk. And yet such an humane environment came at a high cost to the patients: in the 1950’s residence at the lodge would cost $850 per month; at that time, three times the monthly median income. This was an asylum only for those who could afford it.
5. Searles’s Intuitive Empathy
It is in this charmed atmosphere of the Lodge that Harold Searles begins an investigation into psychotic transference. Together with the efforts of Frieda Fromm-Reichmann a means of developing this transference was established. In two papers, Transference Problems in Schizophrenics (Fromm-Reichmann, 1939) and Transference psychosis in the psychotherapy of schizophrenia (Searles, 1996) the methods by which contact is made are detailed. What is peculiar is that while both papers describe the hard separation between patient and analyst, only Searles examines his own feeling states. It is probably the case, although I do not know, that Fromm-Reichmann’s avoidance of her own feelings in this process, is due to the old Freudian disavowal of the countertransference as subjective noise. Was she incredulous that she could even have a countertransference with these primitive, highly regressed psychotics? Searles, for his part, while he does not mention countertransference by name, he speaks of his reaction to his patients with an acute sensitivity, and intuitive empathy, as Ferenczi might have said. Searles would later go on to write a book on countertransference so it is no wonder he may have been curious of the phenomena.
In any case, through the use of Searles descriptions of his affective response to working with the psychotic patient, we can see that he is feeling out this hard boundary, this wall interposed by the psychosis. He says that “the therapist may find the patient reacting to him as being an inanimate object, an animal, a corpse, an idea, or something else.” (Searles, 1996, p. 670). This misidentification happening day after day proved to be alienating, so that “I found the lack of confirmation of myself, as I know myself, to be almost intolerable.”
The patients would mistake him for other figures from early life. “One paranoid woman, for example, used to shriek at me the anguished accusation that I had cut off my hands and grafted there the hands of her long dead grandmother” (p 660).
The patient will project their insanity on to the doctor (p. 674). The Doctor will become fearful of going insane (p. 657). “Just sit there until you catch yourself!” one furious patient yelled at Searles, before confessing, “I’m playing possum with myself, trying to catch myself” (p. 662).
Searles claims that he “found solid reason to feel appalled and helpless in the face of the havoc… of chronic schizophrenia” (p.655). This harkens back to Foucault who writes at length about how the mad are using logic. What is disturbing to us is that their madness can seem at times, so reasonable. “The marvelous logic of the mad which seems to mock that of the logicians because it resembles it so exactly, or rather because it is exactly the same, and because at the secret heart of madness, at the core of so many gestures without consequence, we discover, finally, the hidden perfection of a language” (Foucault, 1988, p. 95)
The strange uncannyness of these interactions reveal a profound truth about the analyst’s ability to enter the psychosis. If, as Michael Eigen has argued, that we all have a psychotic core, does not the analyst come to understand this in the most terrifying way? In some sense joining the patient on the other side of the wall inside of the psychosis.
As Searles explains “the deep and chronic symptoms of schizophrenia are to be looked on not simply as the tragic human debris left behind by the awesome holocaust… but can be found to have… an aspect which is both rich in meaning and alive… with unquenched and unquenchable energy” (p.654).
While it appears that Modern Psychoanalysis does not know this yet—nor perhaps, do its critics—the effort to communicate with the psychotic patient by the means of transference itself is an attempt at breaking into the asylum. Foucault perhaps, could not have envisioned such a break in. What is profound regarding Searles’s discoveries with his patients, is that psychosis crosses the wires of reality itself. The analyst finds himself, cast through the looking glass, on the other side of history.
It remains to be seen what side of history the schizophrenic belongs to.
Works Cited
Foucault, M (1988) Madness & Civilization. (trans Howard, R.) Vintage Books
Freud, S. (1914) On Narcissism: An Introduction. The Standard Edition of the Complete Psychological Works of Sigmund Freud 14:67-102
Freud, S. (1925) An Autobiographical Study. The Standard Edition of the Complete Psychological Works of Sigmund Freud 20:1-74
Fromm-Reichmann, F. (1939) Transference Problems in Schizophrenics. Psychoanalytic Quarterly 8:412-426
Searles, H. (1996). Transference psychosis in the psychotherapy of schizophrenia (1963). In Collected papers on schizophrenia and related subjects (pp. 654-716). International Universities Press.
Spotnitz, H. (1979) Narcissistic Countertransference. Contemporary Psychoanalysis 15:545-559
Winnicott, D. W. (1975) Chapter XV. Hate in the Countertransference [1947]. Through Paediatrics to Psycho-Analysis 100:194-203
