Going Blind To See: The Psychoanalytic Treatment of Trauma, Regression and Psychosis

Introduction

Using the case of Schreber as an example, Freud (1911) explained that psychotic symptoms possess meaning, one of which is the attempt at reconstitution. However, he also (1933) believed that individuals with psychosis could not be analyzed, and that “one should carefully guard against failures by excluding such cases (p. 155).” This latter conviction was unfortunate as it set the stage for generations of analysts to shy away from treating severe mental states. Despite growing evidence connecting psychosis to trauma (Aas, et al., 2011; Larken & Morrison, 2006; Moskowitz, Schafer, and Dorahy, 2006; Read, et al., 2011), this tie continues to be overlooked or minimized in modern psychiatry, which frequently prefers to relieve symptoms with medication rather than explore their meaning with the patient. Other than studying the brain’s neurobiological functioning, few continue to study how the mind goes astray. Beginning in the 1960s, psychoanalysts turned over the care of individuals with psychosis to psychiatry and pharmacology, relinquishing unique methods of treatment and research. (Orna Ophir (2015) for explication of the reasons for this change).

Notwithstanding the overall trend, there have always existed analysts who insist that individuals with psychosis can be treated with psychoanalytic methods. Because of her emphasis on primitive psychic states (paranoid-schizoid position) and defenses (splitting, projection, projective identification, idealization), Melanie Klein (1975) and her followers did not shy away from the more disturbed patient. People like Winnicott (1954), Bion (1957), and Steiner (1993) have written on the dynamics and treatment of severe psychopathology. In the United States, Sullivan (1953), Fromm-Reichmann (1950), and Searles (1965) pioneered such treatment. Today, we have Eigen (1986), Ogden (1989), and Bollas (1995; 2013), who claim that psychoanalysis is the treatment of choice for individuals who have psychosis. Bertram Karon and Gary VandenBos (2004), too, take the position that psychodynamic psychotherapy is the optimal treatment for schizophrenia. All of these clinicians believe that psychosis is not beyond the scope of psychoanalysis, as it is often considered to be the result of environmental failure or trauma. Nonetheless, they have recommended some changes in the treatment parameters, and have warned about intense transference-countertransference dynamics. For example, Searles (1959) claimed that the person with schizophrenia tries to drive the analyst “crazy,” much as he or she was once driven “crazy.” Indeed, the intensity of the countertransference reactions (e.g., fear of confusion and boundary penetration, direct expressions of dependency, sexuality and aggression) to individuals with psychosis may help explain the collusion with psychiatry to embrace a hands-off policy to their treatment (See Karon & Vandenbos, 1981, and Hinshelwood, 2004 for more on countertransference with psychotic patients).

On the other hand, Michael Eigen, author of The Psychotic Core and many other books detailing therapy with serious psychopathology, has worked with individuals with psychosis for 50 years. He has said, “through contact with ‘madness’ I contacted myself in important ways” (Personal communication, June 30, 2011). Indeed, it behooves therapists to consider the ways we can grow by working with those experiencing extreme states of consciousness. Eigen also said, “This work enabled me to develop and use myself, grow in caring and resourcefulness.” Eigen’s comments remind me that Harold Searles (1979) wrote that the iller the patient, the more he becomes the therapist’s therapist. It is well known among those who treat psychotics that individuals with psychosis read our unconscious minds and that “reading” can benefit us by expanding our self-awareness. The use of projective identification also requires that we “stretch” ourselves from habitual ways of being to inhabit fantasies (Ogden, 1994). The International Society for Psychological and Social Approaches to Psychosis (ISPS) has kept the fire of psychotherapy for psychosis burning, and many members are creating innovations in the understanding and treatment of psychosis.

I view myself as following in the footsteps of those who believe psychosis is treatable by analytic methods. In this paper, I describe why at times I have found regression to be a necessary part of the healing process that leads to new possibilities for growth and development. Like Winnicott (1954), I consider regression as a psychic interruption or breech whose underlying purpose is to return the patient to a traumatic episode (or constellation of episodes) in which a reactionary, armored self developed. The defenses formed against such trauma prevent psychological growth and limit the self’s possibilities. The regressive return offers the opportunity for self-repair by working through the original trauma in a safe, holding environment. The system in which public psychiatry functions often offers little opportunity for regression or working through, since the focus of treatment for the severely ill patient often depends on medication or hospitalization. Without psychotherapy many individuals with psychosis become frozen into a lifetime of chronic illness. Winnicott’s treatment of Margaret Little, an analyst herself who experienced psychotic anxieties, is detailed in Winnicott’s paper on regression (1954) and in her book (Little, 1990).

Below, I describe the treatment of a man who experienced three regressive psychotic episodes. I will discuss the first two of these episodes, a briefly touch upon the third. In the case of Mr. C, I chose to work with him analytically so that we both could understand what vital communications lay embedded in his delusions, and what secret order hid within the chaos that was expressed in code. I have written elsewhere about the importance of working with symptoms in psychosis (Knafo & Selzer, 2015). I hope to demonstrate the ways this treatment affected both patient and analyst and resulted in new possibilities and growth.

Case Illustration

Mr. C began his therapy in a state of profound crisis, his voice shaking with emotion when he greeted me with the words: “You found me at the worst time of my life.” That he denied his own personal agency in asserting that I’d found him, conveyed his sense of helplessness. Mr. C felt an overwhelming sense of betrayal and rejection at having been forced to leave the home he had rented for 30 years because the landlord (whom he regarded as a father) was selling it.

I was quickly able to link Mr. C’s present state of crisis with an event from his early life. His relationship with his parents, especially his mother, had been highly disturbed, though he did not initially offer much detail. As a teen he wished to drop out of college, but his parents threatened withdrawal of financial support. Mr. C left school anyway and his parents stopped paying his way. Consequently, he did not speak to them for the next 37 years. He had an older sister from whom he was also estranged.

The withdrawal of financial support was the straw that broke the already overburdened back of the metaphorical camel. Mr. C harbored hatred and resentment his entire life because he had always felt unloved, unwanted, unworthy, and cruelly treated by a bloodless and icy mother and a weak and traumatized father. He saw life through the paradigm of victimization with dependency, abandonment, and betrayal playing starring roles. Mr. C’s intense hatred and externalizations made it clear that powerful paranoid dynamics were at play.

A few months after beginning treatment, Mr. C lost his relationship with Gena, his girlfriend of twenty years. Gena had been a powerful maternal figure to him, even supporting him financially during the previous year. She had discussed Mr. C’s plight with her analyst, and they decided it was best for her to leave him a sum of money and to give him a deadline in which to find work and begin supporting himself. He retorted that he was unable to do so, and felt intense anger at being forced to “grow up before his time.” (He was 56!) Though the parallel to the earlier parental situation leapt out with crystal clarity, it remained largely unacknowledged by Mr. C. He was losing his paternal landlord and his maternal girlfriend all at once.

Mr. C’s anxiety and depression increased, and he began contemplating suicide. His false parental substitutes had collapsed; Mr. C felt terrified and cast into the void. He confessed he had always felt like an imposter, afraid to be discovered as the person he truly felt himself to be: a helpless man-child with no secure sense of self and no grounding in the world. He linked his ghostly self with schizophrenia, saying, “I never felt part of the world… The world didn’t matter to me. Only my inner world mattered. It was scary, a fantasy world. I made up the rules. It was frightening. I didn’t feel I had a self. It was like a house of horrors in there. I was trapped. That’s why I have no idea who my sister, mother, or father were.” He said he felt good to be finally able to say this to someone. Analysis was clearly offering him a second chance at life, a chance to come alive as an authentic being.

Mr. C regularly spoke of his emotional states in terms of “body armor” and “body blocks.” The most common complaint was his “block behind the eyes.” This was the earliest emergence of the blindness theme, as he described the block as if it were a physical obstruction that possessed a concrete quality. On one level, I understood Mr. C’s focus on the body as part of his regression, like the infant who communicates through the body. Encouraging him to translate these conditions into affective communication, I found that, for the most part, he could not express his emotions, and when he did, could not differentiate them from one another. The only emotions he knew with certainty were fear and fury.

Mr. C utterly demonized his mother, deceased for many years, refusing to speak about her at first because he felt that if he did, he would be giving her “air time.” Still, she peeked in on our early sessions. He recalled her as a cold, unaffectionate, and critical woman who held Mr. C responsible for her misery. Mr. C tried desperately to please her, to garner some love and tenderness; he always failed because she “constantly changed the rules of the game.” Thus he grew more confused, helpless, and angry. In session Mr. C’s rage and fury were palpable. His face darkened dangerously whenever he spoke of his mother. Although I functioned as an idealized mother figure in the transference, I expected that one day I would be cast in the character of the demon mother. I hoped that by then Mr. C would have grown to entertain multiple viewpoints.

Mr. C pitied his father, whom he deemed weak and pathetic. He expressed sadness and anger that his Dad could neither save him from Mom’s wrath nor offer meaning to his experiences. Mr. C recalled his dread and confusion when he heard his father’s nightly screams as he awoke from World War II trauma nightmares.

Mr. C had an older sister with whom he had also severed ties. He had sexually abused her while she slept when they were adolescents. He initially felt entirely justified in his acts because it was a way to take revenge on his mother (“If I can’t have her, I’ll take the closest person to her.”). It took years before Mr. C could talk about the abuse and experience guilt for his actions.

Early on in treatment, Mr. C reported a dream in which he could walk, despite being in a wheelchair. This cautioned me to be alert to his feigning dependency or making himself appear to be more disturbed than he actually was.

I soon learned that his dependency needs were accompanied by rage-filled, angry demands that his mother, Gena, or I take care of him. Beneath his intense rage and panic was an unbearable longing for love and validation that had never been fulfilled, partly because he felt too vulnerable to express it.

During the first crisis, Mr. C wrote suicide notes daily, most of them addressed to Gena, enacting a revenge fantasy. I believe expressing his anger in this way kept him alive because it prevented him from internalizing it. Yet, while I was away for a few days he crashed into a truck and destroyed his car. A few days later he bought a gun. Now I was scared. I firmly insisted that if he wished to work with me he had to return the gun immediately and consult a psychiatrist for medications. Although I consider medication a last resort, I am open to the needs and desires of those with whom I work on this matter, and am fortunate to have psychiatric colleagues with whom I can talk to about dynamic issues as well as medical ones. This was one of those times when I did not wish to feel alone in the treatment of someone with serious violent urges. I have written elsewhere (with Selzer, in print) about the isolation and needs for safety in outpatient treatment of psychosis.

Mr. C cried and agreed to do as asked. We made a pact: He would not kill himself and I would not give up on him. We stayed in daily contact and he took the medications very briefly, hating the side effects. I did not insist after I saw the terrible side effects he suffered. Much later, Mr. C told me my faith in his ability to reconstitute without medication or hospitalization helped him trust me. My faith in him helped him believe in himself and his ability to survive.

Gradually Mr. C began building inner strength. I nurtured him as a mother would a young child, while not allowing him to exaggerate his weaknesses. Within six months, he sent out his resume and got a job. He took on a second job and then a third, increased his sessions, and we finally began an analysis. As his confidence grew, he reconnected with Gena.

After he stabilized in treatment, Mr. C began to express some negative feelings toward me, evoking the negative maternal transference, which opened the door for Mr. C’s awareness of his paranoid dynamics. One day he became enraged because I had pronounced Van Gogh with the “ch” sound after he’d pronounced it as Van “Go.” He was convinced I had intended to humiliate him.

The breakthrough came when something he said about his “head block” reminded me of a 1929 artwork by Man Ray called Anatomies. Although I didn’t ask him to, Mr. C looked up the work and read about the life of the artist; Mr. C became convinced that I intentionally wanted him to see the similarities between him and the artist, particularly the Jewish link. He started to think that I had sent him a secret message: he was “nothing more than a poor little Jewish kid who didn’t know who he was.” He worked himself into a fury, unleashing his anger at me, his mother, and even Man Ray. He hated his Jewishness and associated it with everything he despised about his upbringing: being weak like his father, set apart from others, and feeling left behind. In the throes of paranoia, he fumed at me for being sneaky and indirect. Why did I not say that I wanted him to address his Jewishness?

He was shocked to discover that I knew nothing about Man Ray’s personal history. For the very first time, Mr. C accepted that he had been paranoid. Mr. C also confessed that he had searched for me on Google and that he felt my accomplishments made me more inaccessible to him. His rage grew. I remarked that Mr. C felt castrated by me and he agreed. “Man Ray set me off,” he shouted, to which I responded, “Man, the name, and you’re not feeling enough of one.” “Bingo!” he replied.

Clearly, Mr. C’s mother failed to nurture him, resulting in his unmet needs that converted into rage. He easily experienced me, as mother substitute, as a persecutory object who wanted to harm him and destroy his self-esteem. In this case, he perceived me as trying to fill him up with Jewishness, the hated part of himself, and the part he associated with his hated parents. He projected his calculating destructiveness onto me, and I became the secret manipulator (recall his secretly abusing his sister in the dark), his sadism now residing in me. I was the bad mother/object, a paranoid persecutory object who was not to be trusted. The simultaneous awareness of me as a loving object and the encroachment of me as a persecutory object was terrifying to both of us.

Adding greater insight into his paranoia was the realization that he was reliving the sadomasochistic mother-son dynamic. He clearly saw that his paranoia was ever present, and a basic mode of functioning. Mr. C also realized that he used his paranoia to regulate his emotions, especially his anger. “By claiming I am being attacked, it provides me with a ‘hair-trigger’ excuse to give vent to a lifetime of repressed anger.” Ironically, Mr. C’s paranoia made him feel safe “because it gives me an excuse to regress to my ‘safe place.’” Mr. C’s “safe place” was one in which he was withdrawn; he hated the world, and he justified his desire to die “because no one will ever love me.” A cascade of insights followed. He said that when paranoid, he regressed to an early state in which the world revolved around his own needs and wishes. He also saw how paranoia and schizophrenia worked together. Whereas the schizophrenia cut him off from the world, paranoia kept him attached to it, albeit in a distorted manner. The paranoia helped keep people at an optimum distance. He put it this way: “If I let people get too close, I fear they will find out I am really a nobody, and will abandon me which is my worst nightmare. But if I keep them too much at a distance, I lose them and am still abandoned.”

Mr. C’s abundant insights about his paranoia and schizophrenia were very impressive to me. Yet, I wondered whether they were too intellectual and just how much Mr. C was able to feel them, not just think them. I knew that they needed to be lived and felt, repeated and enacted, worked through in our relationship and in his relationships outside of therapy. I knew, too, that we were on our way.

As our progress continued, our work gradually began to center around Oedipal issues. He continued to search for me on Google and expanded his snooping to all my family members to uncover more about me and to “get” what was denied him. I interpreted his actions as parallel to him having taken sex from his sister while she slept: a vengeful, violent act of transgression. Becoming aware of his enactments brought Mr. C sadness. He experienced two new emotions: guilt and concern for others.

He told me that he wished to bring his mother back to life so that he could strangle her. I wondered if his ability to feel safe in the analytic relationship allowed him to commit, verbally, the murder of his mother, which, in effect, would help him to grieve the lost opportunity of a murder never committed. The gap between his wish to bring his mother back to life and his wish to kill her was where much of our work began to focus. By bringing his mother back to life in the therapeutic space, and by using me as a surrogate mother, he could have a corrective experience and begin to repair his past enough to further liberate himself from its unhealthy restraint. I hoped, his second wish would fade.

“My rage covered up my longing for my mother,” he admitted. The following week, he described two dreams that took place in his mother’s bedroom. I was in them both in condensed form as both his mother and me. In one, I was dying and he watched me get old before his eyes. He drew on my face and bald head to bring me back to life. Mr. C realized that he wished to bring his mother back to life through me, so that she could see him as a grown man, so that he could finally get the love he longed for, take it in for the first time, so that he could offer her his love as he never had before, and so that he could finally make reparation for what had been done in order to truly begin again. While associating to the dream, Mr. C recalled visiting his mother, at her request, while she was on her deathbed. As in the dream, he had found her incredibly aged. “She wanted me to tell her I loved her before she died, but I wanted to punish her, to hurt her.” Mr. C replied by saying he would not tell her he loved her. With his dream, it was as if Mr. C returned to this scene with a wish to change it. Now, Mr. C wanted to say to his mother, “Look what I’ve become. I’m a man now. Now will you love me?”

I remarked on how he had reversed the situation in which he took advantage of his sister while she slept. Now he revived women from their sleep state, saving them from death and from him. He replied, “Yes, if they are awake, I can’t take advantage of them. That is how I am feeling now. I couldn’t be direct then. I didn’t have the power in me. Now that I feel empowered I can give. I wish I had felt that as a kid.”

Psychotic Regression

All seemed to be going quite well—Mr. C remained in analysis for six years and united fully with Gena—until I began to perceive certain danger signs that we were headed for a new set of troubles. I had mixed feelings about what I began to see as Mr. C’s inevitable regression. Part of me wished to do something to prevent it, and another part knew that it might be his only chance for achieving deep and lasting change.

Mr. C had a psychotic episode that lasted six months. I now saw that he had correctly assessed a fragile psychotic core at the heart of his being. Ironically, the better he got, the more he understood, and the stronger his ego became, the easier it was for him to regress to a psychotic state. He had developed sufficient ego strength and felt safe enough with me and in his relationship with Gena to give in to a regressive process and not have it cause permanent damage.

He quickly returned to a highly dependent position. It was as if he needed to relive his infancy and childhood and all that went wrong in it. He felt helpless though he continued to function (minimally) and work (hardly). He was in a constant state of panic. But when he saw me, he “let it all out”: his fears, his rage, his terror, his extreme dependency, his feelings of being emasculated, and his despair. I became the bad mother of his childhood on whom he would take out his rage and his needs. At times, he expressed murderous desires. But I was also the good mother, who was consistently there for him, who cared for him without fail, who believed in him, and who did not abandon him even when he expressed his fury.

There were three sets of circumstances that brought on Mr. C’s regressive psychosis. During the 2008 presidential election, Mr. C’s paranoia began to resurface, and he spent hours in analysis raging at the liberals and at Obama. He confessed that he was afraid “the blacks” would take over the country and that he would lose control. Mr. C began to fear something terrible would happen. When questioned about what that might be, he could only say that Obama would be assassinated. Only later did we realize he was predicting his own psychotic break.

The second event had to do with his girlfriend, Gena, with whom he had not had sex in twenty years. At least consciously, Mr. C feared that sexualizing his relationship with Gena would result in his losing the good mother she represented. Whenever he mentioned the subject or if I broached it, he became extremely anxious, defensive, and refused to go further. Gena, having worked through some issues of sexual abuse in her analysis and having found a lubricant for her vaginal dryness, announced she was ready to have sex with Mr. C, stressing that she would wait patiently until he was ready. Mr. C quickly regressed to the position of a dependent infant and began to experience physical symptoms and to believe he suffered from some fatal illness. He had always complained of sight problems, his vision blurring when things went poorly, but now he feared he was going blind. He focused exclusively on his body, losing the ability to think symbolically. Yet, I immediately suspected whatever blindness he suffered would symbolize the loss of insight; he was going blind to see. He spent hours on the Internet identifying with lists of symptoms and diseases and visiting doctors and taking medical tests.

Eventually, Mr. C arrived at a psychotic insight: he was going blind. He felt he was literally losing his sight, the block behind his eyes, an early complaint, was now becoming complete. He claimed the world was dim and dark, unclear and frightening. Mr. C’s “blindness” was a desymbolized concrete metaphor for what he was experiencing. Mr. C, a man who could readily reflect and associate, became obsessed with his blindness and was no longer able to link it to a broader network of associations. Melanie Klein (1945/75) wrote about hypochondriasis as a felt near presence of the persecutory object about to enter the damaged body. Was Mr. C’s blindness related to his mother’s felt presence overtaking his weakened sense of self? Was it the ultimate castration, à la Oedipus, signifying his growing lack of insight? Interestingly, De Masi (2009) has written that in psychosis the unconscious is blinded and prevented from coming into contact with the perceptual part of the self. Now, because of his blindness, Mr. C could regress to being completely dependent on Gena. He would not have to reconcile her maternal function with her sexual needs. This disparity was a sight he could not bear. He blinded himself to the heavy conflict between a desperate need to be taken care of and the terror associated with the intimacy of sex. Closeness meant castration; distance meant abandonment. There had been no in between for him. In his mind, there was no way out, no resolution, no bottom.

The destruction of his sight reflected his need to rid himself of perception and thought, the very organs that could recognize inner and outer reality (Bion, 1959). Mr. C’s “sickness” became the manifestation of his breakdown. Paranoia found a home in his body in the form of extreme hypochondria. The horror of the outside world became the horror of his inside world. Without sight, he became terrified, and was ridden with annihilation anxiety (Hurvich, 1989), the very symptom he had intended to manage. Within a short time, he complained of going deaf as well. By trying to avoid the terror-charged conflict between sexual intimacy and dependency, he created a far greater fear. He felt threatened by the system he had created defensively, and this process destroyed the very means that would have helped him work through his core conflict (De Masi, 2009).

I always felt that Mr. C’s life was driven by childhood trauma, mostly around the issue of his mother. When he spoke of her, I was reminded of Aulagnier’s (1975) theory regarding the origin of psychosis as the consequence of the primary violence of the mother’s mind on the child, which prevents autonomous development of his inner world. Mr. C’s mother could not, or would not, contain his anxiety, aggression and envy. Nor could she respond to his powerful longing for her. Thus, his unbearable anxiety was directed back at himself, and plummeted him into nameless terror. Mr. C recalled when he was a small boy his mother abandoned him in a crowded New York City street to teach him a lesson. He compared the panic and helplessness he was now feeling to the panic he had felt then. Mr. C learned to hate. He learned to construct an omnipotent, fragile self-system and a destructive superego that wanted to punish and kill both himself and others. He knew he carried within him a primal malfunction, which he called schizophrenia.

Because of his extreme reaction to Gena’s invitation to sex, I began to wonder if Mr. C had been sexually abused by his mother. If he hadn’t been overtly abused by her, he had clearly been crushed by the power she wielded over him. Interestingly, he compulsively attempted sex with Gena in the midst of his psychosis and “nearly died” from “abject terror.” The room was dark and he could hardly see but he told me “the presence of my mother haunted me throughout.” Naturally, he was unable to perform. “I thought of my mother. I had a baby dick. Too small. Not big enough. Not erect enough. It was futile.” He associated his childhood home in Brooklyn with “darkness, no direct sunshine, the blinds were usually drawn. It felt sinister, secretive.” He began to think that he had set up sex with Gena in order to replicate a scene from his childhood. When Gena touched his penis, it felt like a baby penis.

During this time, I saw my function as one of containing Mr. C’s rage, fear, and anxiety, naming his emotional states, and helping him own these without being destroyed by them. Meanwhile he saw doctor after doctor: five ophthalmologists, two neurologists, several otolaryngologists and two neuro-opthamologists. He had CAT scans and MRIs. He had acupuncture and Feldenkrais, a type of movement therapy used to promote flexibility. We considered medication under the care of two psychiatrists, and he tried antidepressants, anti-anxiety, sleep and even antipsychotic medications; he stopped them when he experienced severe adverse effects.

Mr. C had trouble falling asleep and, when he did sleep, he awoke in a sweaty, panic and couldn’t go back to sleep. Once he dreamt he buried his father alive in a pit resembling the one his father had hidden in during the war. Mr. C seemed to be repeating his father’s trauma by awakening every night at the same time his father had. Making this connection helped Mr. C “see” the intergenerational traumatic identification he had internalized with his father.

Mr. C began to look exhausted—dark rings under bloodshot eyes—and frightened, his face a presentation of grimaces as he shouted and stormed during treatment. He wrangled attention and support from everyone he knew until they reached the limits of patience. We both considered hospitalization but he begged me not to have him hospitalized, convinced that his life would be over once he became a psychiatric inpatient. I encouraged him to hang on and assured him that the episode would eventually break. I knew a part of him heard me, though he was unable to do any psychic work. I am certain I was trying to convince myself as well.

Mr. C exhibited what Pao (1979) called “organismic panic.” He had seen and felt too much, so that he created a delusional world of blindness in his attempt at restitution. Again, Mr. C became hyper-anxious, sleepless, and suicidal. I held onto Winnicott’s (1954) idea that an individual, being unable to defend the self against failure, would freeze an untenable situation in the unconscious with the hope of thawing and repairing it at a later time in a safe environment. I remained alert for what Podvoll (2003) called “islands of sanity”—areas in which ego functioning and ego integrity still exist, and also Podvoll’s call for compassionate action. Amazingly, Mr. C continued his treatment four times a week and still worked two of his three jobs. He also kept all his friends. Here were three beautiful islands of sanity.

His dependence on Gena increased, and I saw the two of them several times, as I needed to know what support he had on the outside. I was relieved to see that she was on board. I suggested that she not encourage his dependency, and that she speak to the highest functioning part of Mr. C. Gena’s loyalty, patience, and love played a central role in Mr. C’s eventual recovery. Of course, Mr. C began to split between Gena and me. She was the “good mommy” and I was the “bad mommy.” Part of what Mr. C needed to experience in his regressive psychosis was the rage at his mother, and I became her substitute. Gena reminded Mr. C of the positive role I had played in his life, and this helped to counter his paranoia. He felt guilty because of the intense rage he experienced toward me, and I felt overextended and unappreciated during the hours of his sustained abuse.

The third event contributing to Mr. C’s psychosis had to do with a breakthrough he had. He had always felt a serious disconnect between his mind and his body, often complaining about tightness in the back of his head. A few weeks before the onset of his psychosis, he claimed to have had a “breakthrough in consciousness.” Stating that for the first time his body and mind were in sync, he was thrilled to feel a unity he had hoped and waited for all his life. Unfortunately, this breakthrough came at a time that his girlfriend was offering him sex. He now saw clearly what lay before him: his fear of performing as a man, his limitations, and most of all his mortality. Though Mr. C was 63 at the time, he was very physically fit and athletic and always claimed he felt as if he were 20 years old and that there was nothing he couldn’t do if he wanted to. All at once, he needed to face his limitations, which included his stage of life. “Suddenly, I thought, Oh my God! I am a living thing. That means I can die! I’m afraid of life. I am flesh and bones!” He realized that he had lived in a haze, disavowing his mortal, animal body, ignoring time as flesh. Though he had a partner, a career, and many friends, he carried within him a basic sense of alienation and disconnection that flared up when he became ill. At those times, he was overtaken by existential and annihilation anxiety. In his psychosis he could not forget his animal fate, the fact that he would die, its terrifying inevitability and finality (see Becker, 1973, for more on the denial of death). He said, “I have to go through everything again, but with my eyes open, not from a remote contact-less state.”

One day, after an emergency forced me to cancel an appointment with Mr. C, a blood vessel burst in his eye. He panicked, convinced that, indeed, he was going blind and had trouble connecting to me: “I don’t know you. You became a blank. . . . When I feel people don’t care, I crawl up in a ball and want to blow my brains out.” Still he continued treatment.

He was terrified of being alone. He’d cry, “I want my mommy,” and “I’m watching myself disintegrate.” At times, he felt that what was happening to him was a punishment. His dreams were filled with menacing black people, death threats, bombs, killing, and castration. He was unable to associate to their contents. He felt he had to defecate all the time and because of it developed a fear of going out. Incapable of containing the feelings exploding from him, he wanted “to shit on the world!” His thoughts and emotions had become concrete objects to be expelled rather than expressed.

Meanwhile his fury toward me increased. He suspected that I did not think it likely he was physically ill and each time a test returned negative he appeared disappointed; he’d then catch himself and say he was relieved. It was as if he felt I was unwilling to acknowledge that his persecutory objects were multiplying in his body and that he was desperately under siege, his body castle about to crumble. In the meantime, I believed that the annihilating work of the persecutory objects created Mr. C’s “blindness.” He saved the harshest criticism for the doctors I recommended. “You’re not supposed to smile at someone who hates you,” he said to me one day when I smiled at seeing him enter the office. He attacked every connection that sustained him (Bion, 1959): his connection with me, with the progress he had made over six years, his friends, even the link with Gena. Every session began as if no work had preceded it. The links between days, sessions, events, and even thoughts, dissolved in the storm, as he disassembled before my eyes. I continued to speak to what was most integrated and functional in him. I remained a reliable presence that could withstand his rage, dependency, and anxiety while attempting to hold his regression and psychosis.

Rage, spite, and vengefulness characterized Mr. C’s relationship with his mother. He became a failure in school to spite her. Nothing could top the rewards of revenge. His mother could not be dead enough. In one fantasy, he imagined strangling her, throwing her out a window, stabbing her with a knife, spitting on her, defecating on her, and stomping on her head. After he recounted the fantasy with no affect, he suddenly panicked: “Oh my God! I killed the one person I’m most dependent upon. What have I done?”

I knew that Mr. C was speaking not only of his relationship with mother, but also of that with me. Indeed, he wrote his checks removing the “Dr.” stating proudly, “I demoted you.” I had failed him as the perfect mother. When I asked him what a perfect mother would look like, he answered, “someone who would keep me a baby.” “Then that’s the mother you had,” I replied, to which he answered, “I need you to help me see this red thread in a way that doesn’t destroy me.” Indeed, this red thread was the tightrope we walked, Mr. C and I, as we attempted to enable him to see just what he could tolerate, without deteriorating and without going totally blind. At a moment of insight, he said, “I spent my whole life hating my mother any way I can, even when I was not connected to her, even in her death. And you represent that.”

It was difficult for me to watch this 63-year-old, very large man reduced to a weeping blob crying for his mommy. I had to remind myself of the work we had done together for six years. At times, I wondered about my own sense of reality. Had he ever been better? Was he really physically sick? Had I missed important aspects of his character? Was he driving me crazy as he had been driven crazy by his family (Searles, 1959)? And, was this a failed treatment rather than the success story I had thought?

Yet he sometimes came to session announcing, “I want to work.” In one such session he tried to convey his primal terror: “I feel so helpless, as if I was literally just born and someone is saying: Run this company for me.” Once, after running to the emergency room with a false emergency, he was calmed by being seated in a wheelchair. He felt the wheelchair was luring him and he had to fight its temptation. Naturally, I reminded him of the dream he had reported early in treatment in which he sat in a wheelchair even though he was able to walk. The seduction of his psychotic solution—his “blindness”—was in constant conflict with what I could offer him.

I taught Mr. C breathing exercises to calm himself. I showed him the secondary gain he was receiving from his behavior. He loved the attention he was getting from all of his friends who called him daily from worry. I solicited the scientist in him and invited him to be curious about the symbolic meanings of his blindness. Little by little, we began to see “psychosis-free intervals” (De Masi, 2009), during which he started to do some psychic work aimed at understanding and “seeing” the meaning of his psychotic construction. Often when we had a good session, characterized by an appearance by Mr. C’s curiosity and willingness to engage with me in trying to understand and gain control of his predicament, his vision would “miraculously,” though temporarily, improve. At times, he’d say, “The real Mr. C made an appearance today,” or “Today I feel almost normal,” illustrating the ups and downs of his condition.

I tried to help Mr. C monitor his affect states to develop a sense of control over them, so that he would know when to resort to anti-anxiety medication and when not to. Mr. C’s occasional insights, his motivation to live and to work, his desire to transcend his past, his connection with Gena and his friends and me, his ability to work: all of these still existed, even in minimal forms, and I spoke to them, enlisted them as my co-analysts, and they eventually got us over the hump.

I was less afraid of Mr. C’s regression than I was of his despair. I still recall seeing Mr. C, a large man now melting away, with a desolate and despondent far-away look in his eyes. He could barely sit still, his entire body shaking. Concentrating was too much to ask of him. I feared he would take his life, and we spoke of it constantly. I knew many professionals would have had him hospitalized. I was fortunate to have worked with two psychiatrists who also encouraged Mr. C to try to get better without hospitalization. Yet, despite his appearance, Mr. C continued coming to treatment, believing it was his only hope. Gradually he began to entertain the possibility that his blindness was psychogenic in nature. He began to take risks and venture out in the world.

The biggest turning point took place after my August vacation, during which I maintained contact with him by email and phone sessions. Providing continuity was, I believe, essential while I was away. In particular, it helped Mr. C feel and “see” my dedication and care about him. In short, while he was demonizing me, I remained fully committed to our relationship, even extending the treatment parameters. It was only a matter of time before he would internalize that truth.

At first, he did not realize he was improving. For example, he came in one Monday and told me he had been blind all weekend. Later in the session he mentioned that he had played tennis twice and went shopping. When I pointed out that he could not have been that blind to do what he had done, he became angry with me; later, he agreed with my obvious inference. He reported a dream in which he gave oxygen to a father figure. I interpreted that Mr. C was attempting to revive his father from death and, by association, himself from a death-like state. Indeed, Mr. C began to show signs of life as he slowly began dropping his antagonistic behavior. His neurotic defenses reappeared, replacing the psychotic structure. He was gradually recovering his vitality and feeling much better.

Indeed, Mr. C began to speak psychologically again. “My mother was blinding me, he said, “She gave me no affection, love, or security. And I am blinding myself for the sake of pleasing her, even though I say I don’t want to be attached to her.” For Mr. C, the blindness was “what she wants” and also “how I get back at her.” I ventured to sum up, “We have been reliving your childhood, your neediness and lack of love from your mother, your hatred of her, and, of course, the stalemate you found yourself in with her, your terror of the world and feelings of unpreparedness. You are saying to me and to her, ‘Don’t you see? I cannot do this without something coming before!’” Within his break, Mr. C made us both blind to recapture the disconnect between mother and son. “She rendered me impotent, sexually and emotionally. She made me a slave. I couldn’t break away.” Mr. C had a dream in which he reconnected to his sexuality. In it, he was attracted to several voluptuous women, women shaped like Gena, something that would have put him off in the past.

We began to do the work of separating Mr. C’s childhood from his adulthood. “My childhood was one big emergency. I couldn’t get out of it. I could only hide.” Whereas he had previously demoted me by taking away the Dr. from my name, now he decided to give me a raise and began paying me more. “I’m sleeping better. I’m feeling better. I feel I am coming out of this. I’ve been hiding out. I can give now. I feel what you did for me.” He had a dream in which his arm was cut and the flap of skin opened. “I am getting rid of my emotional cancer,” he interpreted. One day he brought me a bag of light bulbs for my office and a dream in which he sought a better view.

“I just couldn’t accept that reality was real,” he said. “And now that I am through avoiding, let’s talk about sex and death.” Interestingly at the end of this writing, I am reflecting on a recent session with Mr. C. in which he admitted that needing sex from a woman, especially one he loves, gives her power over him and subjugates him since his need may be greater than hers. She stands above him, her body a desirable object to which he must join himself, forced by dint of his desire to perform for her. This could be a beautiful dance for him except that he feels he would lose himself within it, disappear, be absorbed and enslaved by her, die in darkness again. He loves her and wants her; he is terrified by his desire and the possibility of being dominated through it; he fears the loss of what ego resource he has built; he hates her for this conundrum. At last he sees this clearly.

Concluding Remarks

Winnicott (1954) claimed that it takes courage to regress, and Nass (1984) maintained that the capacity to experience and tolerate early modes of functioning requires a strong ego rather than a regressed one. Again, one could reason that a strong ego is, in fact, one that is partly defined by the flexibility of its various functions, one of which is the capacity to tolerate and to return from regression (Kris, 1952). Mr. C was able to survive psychotic regression because he found receptive containment in me for his toxic impulses and because he had enough ego strength to get him through it.

Regression is especially important for individuals who have experienced trauma. Mr. C returned to the site of his environmental failures (hateful, punitive mother and traumatized father), and the holding environment I consistently offered facilitated his getting in touch with his primitive rage and fear. Thus he was able to regress and to examine his trauma within the safety and stability of our relationship. Although he fought me and the treatment, he never left. Instead he used me and the setting to act out his trauma without the threat of censure and retaliation. In the simplest terms Mr. C had to go from being a person who had developed in reaction to and defense against what happened to him into a person who saw and knew what happened to him. To truly understand what has happened to one does not mean to come upon some invariant, objective truth. It means to deeply and insightfully decide on the meaning of one’s experience in a way that such meaning saves one.

Mr. C has regained most of his ego capacities and his symbolic function. “I am still Mr. C,” he said after emerging from his psychosis, “but now I’m Mr. C hooked up.” We worked for more than a year at making meaning of the psychotic regression he experienced, after which he pronounced, “It sounds crazy but I’ve never felt stronger. For me to move forward, I can’t imagine not going through this. I had to split to protect my life. I had to face what happened to me. The trauma had to be released. I faced my terror and death. I am calming down now. I am emerging.”

Mr. C’s case brings up questions about outpatient treatment with psychosis. Elsewhere, I (Knafo & Selzer, in print) have written about conditions for successful outpatient psychodynamic work with psychosis. In that chapter, Selzer and I discuss the pros and cons of inpatient versus outpatient therapy, what it takes for each participant to engage in outpatient therapy, and the necessity of thinking about treatment as occurring in a system fluid and flexible enough to adapt to the needs of both patient and therapist. We advise that moving between inpatient and outpatient therapy should not be considered in terms of success or failure but, rather, that different mental states require different treatment conditions.

The role of regression is a key factor in the “where” and “when” decision. In the hospital, the patient is informed through word and deed that he has been placed in a situation that encourages or, at the very least, tolerates, regression. He is given a hospital gown rather than permitted to dress in clothing he chooses; he is told when to eat and sleep. He lives in a confined space with strangers who may be in worse shape than he is. The patient is controlled by hospital rules and regulations that take over decision making for him in exchange for the guarantee of safety.

Outpatient treatment works in the opposite direction. The process is collaborative, which means that more is expected of the patient. Resources are limited, indicating that no matter what gets stirred up in a session, the patient leaves and the therapist is unaware of what transpires within him until she sees him again.

What, then, is the consequence of regression on the questions of when and where? The therapist’s inability to tolerate the uncertainty of the patient’s fate between communications (referring not only to sessions, but also to calls, emails, and other patient contacts) would be an indication for hospitalization. When is the reverse the case? When is it all right to tolerate regression? Mr. C experienced three psychotic regressions, two of which are described in this paper, during a decade-long analysis. He had a strong support system (several close friends and a 30-year relationship with a woman) and he was able to hold on to his jobs despite being quite delusional and paranoid. Although he regressed in sessions with me, he was able to mobilize just enough ego strength to perform his daily professional duties, though in a minimal way. Because his employers valued his work, they tolerated Mr. C’s eccentric behavior and offered emotional support. He did not miss a session during his psychotic episodes. Due to these islands of sanity (Podvoll, 2003), as well as Mr. C’s earnest desire to stay out of the hospital, I worked with him on a nearly daily basis during his psychotic regressions, each of which lasted approximately six months. After Mr. C emerged from his psychotic episodes, he and I spent months, sometimes even years, analyzing what brought them on and ways to fortify himself in the face of future regressions.

The case of Mr. C illustrates several key elements in the treatment of psychosis. It shows, most importantly, that psychosis can be treated with analytic means. It also demonstrates that regression is sometimes a necessary and healing component of the treatment. In addition, making meaning of the psychotic symptoms is an integral part of the treatment. When dealing with psychosis, Bollas (Personal communication, December 11, 2011) attempts to understand the patients’ reasoning, and then communicates that meaning to them, emphasizing how it is reasonable for them to behave and think the way they do given the specific historical and psychic circumstances. In the midst of his psychotic episode, Mr. C was convinced that he was going blind. Indeed, it is often the case that the body is enlisted to express a person’s psychotic delusions. These somatic convictions (e.g., blindness, disease, bizarre sensations) need to be understood and interpreted. Mr. C’s “blindness” was profoundly symbolic (i.e., he was indeed blind to many aspects of his experience) as it represented his desire and need to regress to a state of dependence.

Treating psychosis is often like entering someone else’s nightmare or trying to disarm a bomb. It is no wonder many shy away from such work. On the other hand, daring to visit the limits of experience (where almost anything is possible) can be exciting and creative because it always takes place on the threshold of the unknown. Having faith in the resilience and natural healing potential of people, no matter how bizarrely they present, offers them containment and acceptance which can turn into increased possibilities for growth.

Interestingly, Mr. C says his eyesight has been restored and he can see clearly again. This gain has (unsurprisingly) been accompanied by improvement in insight as well. He is again open to disseminating the idiom of his psyche, in listening to and articulating the “messages” from his inner world. For my part the work with Mr. C. has deepened my belief in the importance of the relationship in the therapeutic process. The relationship is the transparent vehicle in which all the content of therapy arises and the literal crucible in which transformation takes place. When I shared this chapter with him, Mr. C cried and said, “You told my story.” I responded, “I told my story too.”

Postscript

Years after I wrote this paper, Hurricane Sandy hit New York and Mr. C was forced to leave his home. Once again, he felt rejected, abandoned, and homeless (though he lived temporarily with Gena). He regressed for a third time into a psychosis that was the most virulent of them all. Once again, he began to believe that he was suffering from a life-threatening illness. Most concerning, however, was the powerful negative therapeutic reaction that emerged. The maternal rage I had glimpsed at the beginning of treatment now took full possession of him, and Mr. C seemed determined to destroy me, himself, and the treatment. He was like a suicide bomber who didn’t care who or what he destroyed as long as he had his pound of flesh, which meant revenge for not getting what he needed from his mother. To be honest, this regression was the most trying because his unrelenting rage was directed unswervingly at me.

The pleasure Mr. C took in describing his death-dealing fantasies was disconcerting. In the countertransference, I felt that he was de-skilling me and, in fact, killing me. I also felt it was important to him, and of course to me, that I survive his death threat. Struggling to regain my bearings, I asserted my boundaries and communicated firm limits. I declared that I would not allow him to destroy me although I could not prevent him from destroying himself. He reacted with enormous rage; however, after that point, he rapidly emerged from the psychosis. One year later, he told me that his strategy for killing me had not worked and he had to try something else. That something else was analysis—for him to finally realize how much pleasure he derived from sadistically bringing me down and merging with me (as the demon mother) in my weakened and dead state. “I wanted to kill the thing I love the most,” he said, knowing now that I represented his icy mother against whom he wished to venge himself with the heat of his fury: “You freeze me, I’ll burn you!” We continue to work on this dynamic. Having survived his destructive yearnings, we now exist as two separate beings. Mr. C can now use me à la Winnicott (1971), as well as express care, remorse, and guilt toward me. Owning his rage and its deadly consequences, and beginning to mourn what he never received from his mother, have become central preoccupations in the analysis.