Herbert Rosenfeld (19673, 1964, 1987) Rosenfeld (1963) observed that manic-depressive patients form intense transferences, initially positive and idealized, and when frustrated perceive the analyst as persecutory, which if left unchecked may lead to acting-out or suicidal attempts. Rosenfeld believed that the manic-depressive patient’s primary anxiety “concerns his conscious or unconscious awareness of the intensity of his destructive impulses which threaten to injure or destroy the object on whom he depends, originally the mother” (Jackson, 1993, p. 122). The more severely depressed patient believes he has killed and lost his love object and that all attempts of reparation are useless. As therapy proceeds, the patient may begin to have hope, and through projective identification may stimulate in the therapist his anxieties about his destructive impulses and his despair. This can be understood as an unconscious attempt on the part of the patient to test out whether the analyst can stand those feelings which he himself cannot bear and therefore to help him to understand and begin to emotionally deal with them. When manic, perhaps as a defense against his deep feelings of inadequacy and dependency, the patient no longer seeks understanding, but rather to assume a triumphant and contemptuous attitude of omnipotence and superiority.
The term “narcissistic object relations” was introduced by Rosenfeld (1964) to emphasize that “much confusion would be avoided, if we were to recognize that the many clinically observable conditions which resemble Freud’s descriptions of primary narcissism are in fact primitive object relations” (p. ), i.e., narcissism is not an objectless state. Rosenfeld (1987) termed the form of relatedness between the psychotic part of the personality and objects “narcissistic omnipotent object relations”, and it refers to the way psychotic patients use others as containers into which they omnipotently project those parts of themselves which are felt to cause psychic pain and anxiety. Through introjective and projective processes the patient begins to feel symbiotically identified with the object. Narcissistic omnipotent object relations defend against the recognition of separateness between self and others. When in analysis the patient begins to make progress and his narcissistic self-idealization diminishes, he becomes more painfully aware of his need and dependency on the analyst.
In destructive narcissism, Rosenfeld believed there is an idealization of the destructive omnipotent parts of the self. In these patients, libidinal object relations, including wishes to be dependent upon an other are attached and devalued. This might be the basis for certain negative therapeutic reactions. I am reminded here of the patients Betty Joseph (1989) describes in her paper, “Addiction to Near Death.” And as Jackson (1993) noted: “When the patient improves substantially, depression characteristic of the depressive position, with constructive guilt, remorse, and reparative wishes appears, for brief moments at first. A further form of depression may occur when a manic phase subsides, when the patient may experience despair and disappointmentat the discovery that what is believed to be abundant good health was in fact severe pathology” (p. 123).
LEON GRINBERG (1997) noted that Melanie Klein’s (1952) concept of the existence of interval objects offered a new explanation of the function of the transference, our analytic cross to bear. In Klein’s view, anxiety arising from the conflicts with these interval objects, drives the subject towards the external object. The analyst, through projective identification, is equated with aspects of the patient’s self and/or internalized objects. Grinberg believed that patient’s attempt to induce the analyst to act “by attracting him towards their defensive system” (p.3). These induced experiences are detectable through the analyst’s countertransference: Grinberg suggested that “Klein’s theoretical and technical methods have made it possible to reach the deepest layers of the psyche and to analyze the most regressive personalities – namely, psychotic, borderline, narcissistic, psychopathic, perverse and other subjects” (p. 3).
In considering the role of genetics and biology in manic-depressive illness, Henri Rey (1994), a post-Kleinian psychiatrist-psychoanalyst, remarked: “When more is known about genetics [and the genes] we may understand better their specific roles. We can accept that the splitting processes, the projective identification, the excitation, the mood of depression and many other manifestations might have a genetic background. However, to take an example of a child learning to speak; it is not genetics that decides if he or she speaks English, French, Chinese, Arabic or anything else. The genes make it possible to learn to speak through its mechanisms are inherited, but the role of the environment remains crucial. This applies to every other aspect of our mental behavior. That which is deficient, not there, abnormally present, can be compensated by an adequate environment that helps to achieve at least in part, what the genes could not do. Furthermore, without a correct environment the genes cannot develop, for reasons such as lack of proteins at a moment of maturation. For example, the development of certain aspects of sight is grossly interfered with if the brain cells do not receive light stimuli. Furthermore, a certain specific movement or period for development necessary for growth to take place, which is genetically determined, may not happen because of interference by the environment in the one way or another...Therefore, to treat a patient only with drugs, even if they are helpful, is very wrong, because the part played by genes and other physiological factors cannot be assessed to the full extent. My early work on the complex relationship between hormonal activity and schizophrenic mental states has left me in no doubt that genetics, biochemical and psychodynamic factors must all be considered in the assessment and treatment of psychotic patients. Current research supports my motion that a combination of drug treatment and psychotherapy is more effective than either of the two treatments on their own. For this reason the question remains: why deprive a patient of a treatment that could become helpful?” (pp.134-135)
Murray Jackson (19930 another post-Kleinian psychiatrist-psychoanalyst, who has worked extensively with psychotic patients including manic-depressive patients, at the Maudsley Hospital in London, had this to say of the role of psychodynamic psychiatry: “A great deal of inspiring and hopeful psychoanalytic work with manic-depressive patients has been done in the past, but this seems to have had little or no impact on clinical psychiatry, which remains firmly on a neurobiological theoretical base in respect of their patients. Nonetheless, it is in the cooperative working of the hospital psychiatrist with the psychoanalytic psychotherapist and with the integration of neurobiological and psychoanalytical theoretical perspectives that the future lies for greater understanding and better treatment for the severely ill manic-depressive patient...Psychodynamic knowledge is also needed to recognize the powerful destructive efforts that psychotic processes can have on the hospital staff, however mature and well-intentioned they may be” (p. 130)
Gabbard (1992) in a plea to retain psychic meaning and psychodynamic knowledge in the “Decade of the Brain” expressed his concerns as follows: “To lose the psychodynamic perspective is to lose the complexity and richness of human functioning in the quicksand of neurotransmitters and molecular genetics. Meaning must be preserved. It is instrumental to the induction of neurobiological changes associated with psychopathology. That which is crucial to etiology and pathogenesis will be also be crucial to informed treatment planning” (p. ). Jackson (personal communication) in a soon to be published book noted: “Psychoanalytic concepts offer important contributions to the understanding of psychotic illness, and help to make sense of the apparently meaningless or bizarre thinking and behavior commonly associated with psychotic or delusional states of mind. In this way they can provide a guide for workers with different skills and perspectives an contribute to the formulation of treatment plans appropriate to the patient’s needs, psychological disabilities and assets at any particular time. The integration of a psychoanalytic perspective with other treatment modes is a matter of urgency at the present time when the dazzling achievements of biomedicine and emphasis on brief methods of therapy are bringing the risk that the psychological understanding of the individual will be progressively reflected. At the worst is the prospect that psychiatrists’ skills in psychological understanding and treatment will eventually atrophy.”
The latter point has been underscored by Peter Fonagy (1997) in his expressed concerns that our current lack of an “immersion” experience previously built into our long-term psychotherapeutic work with more seriously disturbed patients will be lost in our current ethos of medication only and infrequent case management visits, thereby resulting in a serious deficit in our knowledge base which we need to have in order to teach future generations of mental health clinicians.
Jackson pointed out that a psychoanalytic perspective can help clinicians decide which type of psychological treatment might be most helpful to a particular patient, and when long term individual psychoanalytic psychotherapy may be indicated. In regard to his own theoretical approach, Jackson noted: “Exploration of the formation and significance of the strange, confusing, and often bizarre elements of thought that are the ingredients of the phenomena of psychosis has been greatly helped by the development of the conceptual tools of object-relation and past object psychology. These concepts sprang from the original works of Freud, Jung and Abraham, which have been developed and expanded in a unique way by Melanie Klein.” On a more directly clinical level, Jackson suggested: “Contact with psychotic patients can be emotionally disturbing, even for experienced professionals, and this is one reason why psychosis’ treatment is usually best conducted as work within a multi-treater’ team of mental health professionals. Individual psychotherapy with such mentally disturbed patients requires a degree of personal maturity and a special interest, and is therefore, not for everyone. Those who choose it will find that a sufficiently long period of personal psychoanalytically based psychotherapy will help them to understand their less disturbed patients and their own primitive levels of functioning, an experience that can be of great benefit to themselves and their work.”
Jackson, based on his extensive clinical experience, expressed a belief that even the most seriously ill patients and those deprived of comprehensive treatment for long periods of time can often benefit from psychotherapy provided that the necessary conditions of an experienced and well-trained psychotherapist and a continuing setting of psychodynamically-informed psychiatric facility is available.
Brian Koehler PhD -- New York University
July 4, 2004 A series of recent research results from various labs around the world is suggesting that my theory is correct, that to a very large extent the neuroscience of schizophrenia is the neuroscience of separation, social isolation, neglect and maltreatment, chronic and profound stress/anxiety (with implications for such socio-cultural factors as poverty, urban living, migration, racism, fragmentation in the family and wider culture, significantly preoccupied caregivers, etc.) This has encouraged me to further explore the research on neurogenesis in the human brain (eg,hippocampal dentate gyrus). In so doing, I came across a study by Czeh et al (2001) “Stress-induced changes in cerebral metabolites, hippocampal volume, and cell proliferation are prevented by antidepressant treatment with tianeptine” reported in Proc Natl Acad Sci USA 98: 12796-12801, which isolated several factors impeding hippocampal neurogenesis: stress, inflammation, CRF & glucocorticoids (cortisol), glutamate & NMDA receptor agonists, as well as opiates. Factors that were demonstrated to stimulate and enhance neurogenesis included: electoconvulsive shock (this seems to go against the findings of memory loss), lithium & anticonvulsants, antidepressants and 5-HT1A (serotonin) receptor agonists, and brain-derived neurotrophic factor (BDNF). The results were quite surprising to me. Most probably, psychotropics have both positive and negative effects (the art & science of our field is in considering the wishes of the patient foremost and then the cost/benefit ratio of using these agents). There is so much we do not know about mental illness and its most effective therapies. We have to tolerate a good deal of uncertainty and frustration in trying to arrive at the most humane and helpful approaches to human suffering. Brian Koehler I would like to recommend to interested members of our ISPS community an article which attempts to outline the difficulties involved with, as well as potential benefits in the emerging dialogue between psychoanalysts and neuroscientists: “The emerging dialogue between psychoanalysis and neuroscience: neuroimaging perspectives”: by Manfred Beutel, Emily Stern & David Silbersweig (the latter two are from the Functional Neuroimaging Lab at Cornell University) published in the Journal of the American Psychoanalytic Association (51/3: pp 773-801). The authors review various studies involving neuroimaging which have demonstrated the beneficial effects of psychotherapy on neural chemistry and function. The authors are currently involved with promising research comparing psychodynamic psychotherapy with dialectical behavior therapy for borderline patients. A single case study of a borderline patient in one year of psychodynamic psychotherapy revealed normalization of serotonergic activity in the prefrontal cortex and thalamus. In summary, there are two avenues in which these results are understood by Beutel et al: prefrontal activation and influence on limbic over-arousal (e.g., self-reflection, insight, etc.) and relational reworking (transferential/countertransferential processing of implicit, unconscious memory-what the Sandlers and Fonagy have termed the present unconscious) of traumatic and pathogenic adverse early childhood experiences. They noted: “Thus, the curative factor is seen not primarily in the somewhat ambiguous historical reconstruction by removal of repression, but rather in the elaboration of preconscious and unconscious relationship representations in the transference. According to this view, psychoanalysis thus deals with the present unconscious shaped by childhood experiences that it does not represent directly” (p. 791).
Beutel et al comment on the artificial distinction between mind & brain: “Based on the studies reviewed here and in the context of an emerging view of brain plasticity, the distinction between somatic therapies that impact on the brain and psychological therapies with elusive, purely subjective effects is no longer tenable. It must rather be assumed that psychotherapies that successfully ameliorate symptoms and complaints (or more profoundly change object relationship patterns, affect regulation apacities, and the like) are likely to have a measurable impact on the brain, even though we know little about the [processes] involved” (p.794). A new volume on the neurobiology of fear and anxiety, “Fear & Anxiety: The Benefits of Translational Research” edited by Jack Gorman in 2004 for the American Psychiatric Publishing, Inc., demonstrates the widespread effects of these affects on CNS structure and function. The word “translational” refers to an integration of basic neuroscience research with clinical practice. There are chapters on direct effects of stress on the brain by Bruce McEwen & Ana Maria Magarinos (McEwen is a neuroendocrinologist at The Rockefeller University in NYC specializing in the study of stress. In a talk with him, he seemed favorable to my theory suggesting the large overlap between the neuroscience of schizophrenia and the neuroscience of separation/isolation, profound and chronic stress/anxiety), developmental adversity and later anxiety, effects of terrorism and disasters. Also there is an excellent article by Michael De Bellis on the neurotoxic effects of childhood maltreatment and trauma, the scientific basis of psychological therapies in anxiety disorders by David Barlow & Laura Allen, LeDoux on the amygdala in fear conditioning, Amaral on the amygdale and social behavior, etc. Jack Gorman and Justine Kent in their chapter “New molecular targets for anti-anxiety interventions” have this to say about psychotherapy: “These findings also suggest that interventions aimed at increasing prefrontal governance over limbic activity might be successful in reducing anxiety and fear in humans. Psychotherapy is presently the best candidate for such an intervention... [also] several studies suggest that response to cognitive-behavioral therapy is more durable than response to medication” (p. 205). See also Fisher, S. & Greenberg, R. P. (Eds.) (1989). The Limits of Biological Treatments for Psychological Distress: Comparisons with Psychotherapy and Placebo. Hillsdale, NJ: Lawrence Erlbaum Associates (Bert Karon has an excellent article on schizophrenia in this volume).
Brian Koehler - New York University
Ruth: Starting from Karl Abraham, who reported his experiences with persons diagnosed with manic-depression, psychoanalysts have sought to understand and help these individuals (Abraham's work inspired Freud to write his excellent gem of a paper, "Mourning and Melancholia"). Abraham, as others described in my various postings, did report successful psychotherapeutic experiences with such persons. Melanie Klein, as well as such analysts as Donald Winnicott, Lacan,Tustin, Bion, Eigen, etc., pointed out that 'extreme states of mind' were part and integral to the human condition. In terms of my own experience, it was primarily at the state hospital where I learned a great deal about the 'internal world' (which as Buber and many others have pointed out, is always in the in-between, on the boundary between internal and external) of such individuals. I learned that mania and anxiety and, at times, fear of one's destructiveness, are intimately connected. When the patient's anxieties decreased, often did the manic symptomatology. In my practice, I have seen persons with bipolar disorder recover with or without medication. Some prefer to stay on their mood stabilizers (one young man whom I am seeing becomes very rageful at his parents and has broken furniture in the family home-perhaps unconsciously trying to break through his parents impermeability and schizoid-like isolation from meaningful emotional contact as well as arising from a deep sense of powerlessness and impotence in his life-and he, at the moment prefers to be on his Depakote out of fear of doing someone harm, including himself).
In speaking once with Harold Searles, he thought that Kay Redfield Jamison's book, "Unquiet Mind" (which he liked very much and I assign to my grad students at NYU), points to the importance of psychotherapy and understanding in her recovery. My view is that Jamison may minimize certain experiential and historical factors from her own life as contributory to her illness: her father's alcoholism, her family's frequent moves during her childhood so that she probably experienced disruptions in important interpersonal relationships as well as perturbations in her sense of self as cohesive and continuous, peer ridicule at school for her formal way of relating to others (her father was in the armed forces and prone to drinking and dark moods), social isolation, etc.
Brian Koehler New York
I would like to re-visit the unfortunate term “schizophrenogenic mother” and relate it to current neuroscience research which entails transgenerational transmission of trauma. I will not go into any detailed historical exposition of the use of the term in psychoanalysis and the complexities of the issues surrounding it. Rather, I will quote Harold Searles’ views on the topic and then describe current neuroscience research with non-human primates and a variable foraging demand paradigm, which, I believe, may hold some insight into the early initiation of later schizoid and schizophrenic difficulties in personal and social living. Harold Searles (1986) noted: “Much has been written, by many writers--including myself, years ago-- concerning the Bad Mothers of schizophrenic or borderline patients. I have gradually learned that such villanizing of these mothers underestimates (1) the importance of the patient’s identifications with the Bad-Mother components of his mother; (2) his own holding himself primarily responsible for her emerging as a Bad Mother, with his guilt and grief (as well as rage) about this being unconsciously defended against, in him, by his identification with those Bad-Mother components in her which he has been unable to cure; and (3) the simplistic villanizing of these mothers glosses over the analyst’s own ever-alive Bad-Mother components. As I have come to see these things more clearly, there has come about a profound shift in my once-held, relatively static view of the schizophrenic, or borderline, patient as tending to be more or less crippled by traumatic events which occurred many years ago, in his infancy or childhood. There is some truth in that, I still believe. But as I have found over and over, with borderline patients for example, how able the patient is to reproduce--largely unconsciously, of course--his early mother-child relatedness with me in the transference, as well as with persons round about in his adult living, and evoke the most lively Bad-Mother responses from me, or small-child feeling-reactions in me to the Bad-Mother components in him, I get a livelier sense than I once had as to the extent to which this adult patient’s illness is continually being fed and maintained through the unconscious complicity of the persons, including the analyst, round about him in his current living” (pp. 291-292).
The richness of the above dynamics could never be captured in research with non-human primates, however, we share a great deal of our genome and neurophysiology and neurobiology with other mammals. Therefore, I will summarize some current primate research in my attempt to get a clearer view of the effects of early care-giving on later adolescent and adult psychopathology in humans. Coplan, Paunica & Rosenblum (2004) in their “Neuropsychobiology of the variable foraging demand paradigm in nonhuman primates,”( in “Fear & Anxiety: The Benefits of Translational Research” edited by Jack Gorman in 2004 for the American Psychiatric Publishing, Inc.) noted that early stress is increasingly recognized as an etiological factor in such conditions as: obesity, hypertension, type II diabetes, short physical stature (reduced growth hormone response to GH secretagogues), delayed neurocognitive development, atherosclerosis, fibromyalgia, irritable bowel syndrome, migraines, various psychiatric conditions, etc etc.
Coplan et al (2004) used a variable foraging demand paradigm (VFD) in their primate lab to assess the effects of unpredictability in maternal securing food supplies on the developing offspring. They noted: “The repeated shifting of foraging demand appears to overwhelm maternal coping capacities and, to varying degrees to induce a form of functional emotional separation [I believe this is a key point] between mother and infant. As a consequence, we have hypothesized that the affected mother becomes psychologically unavailable toward her infant. Even when maternal response to the infant’s initiation for bodily contact and comfort is present, a qualitative disruption of focus and execution of maternal interactive repertoire occurs and the critical process of affective reciprocity between mother and infant is hampered. The VFD mothers appear unable to respond contingently to their infants’ attempts to elicit affection, huddling, and ventral contact. Additionally, VFD mothers fail to engage in the intense compensatory patterns toward their infants typically seen in control conditions following normal acute disturbances of the dyadic relationship.” (pp. 48-49) These factors significantly impact on the developing CNS of the offspring.
Matthew et al (2004), in another study ( in “Fear & Anxiety: The Benefits of Translational Research” edited by Jack Gorman in 2004 for the American Psychiatric Publishing, Inc.) of the effects of early stressful experiences, imposed on maternal nonhuman primates with a VFD paradigm, on the later development of offspring (transgenerational transmission of trauma?), reported: “In summary, highly significant...differences between VFD and control primates were observed in two brain regions deemed important in regulating emotional experiences, approximately 10 years after the initial adverse rearing stressor. These preliminary neuroimaging findings add to the growing evidence of traitlike neurobiological and behavioral abnormalities in VFD-reared primates” (p. 144).
The neurobiological consequences of such adverse early experience does match what we see in neuroscience research in schizophrenia. On the human level, as pointed out long ago by Martti Siirala (Siirala, M. (1983). From Transfer to Transference: Seven Essays on the Human Predicament. Helsinki University Press), the wider culture has ‘schizophrenogenic’ components (emerging from collective splitting processes) in which families and individuals can become ‘caught.’ However, the human being can be quite resilient, e.g., in the Tienari et al research, 85% of the high risk adoptees (defined as being born to a mother diagnosed with schizophrenia) raised in dysfunctional adoptive settings did not develop a schizophrenia spectrum disorder.
Brian Koehler -- New York University