Modern Psychoanalysis of the Schizophrenic Patient

Transcription

1 Modern Psychoanalysis of the Schizophrenic Patient Theory of the Technique 2004 Second Edition Hyman Spotnitz, M.D., Med.Sc.D. YBK Publishers New York

2 CONTENTS Preface to the Softcover Edition of 1999 Preface to the Second Edition, 1985 Preface to the First Edition Chapter 1. Introduction 1 Chapter 2. Conceptualization of the Illness 19 Chapter 3. Amplification of the Basic Theory of Technique 41 Chapter 4. A Neurobiological Approach to Communication 47 Chapter 5. From Rudimentary to Cooperative Relationship 73 Chapter 6. Recognition and Understanding of Resistance 95 Chapter 7. Management and Mastery of Resistance 111 Chapter 8. Narcissistic Transference 129 Chapter 9. Countertransference: Resistance and Therapeutic Leverage 153 Chapter 10. Interventions: Range and Sequence 177 v vii ix References 207 Suggested Reading 219 Name Index 225 Subject Index 229

3 68 MODERN PSYCHOANALYSIS OF THE SCHIZOPHRENIC PATIENT In general, the higher the developmental level at which the patient enters treatment, the broader the range of therapeutic communication that he can tolerate and the less urgent it is for the analyst to operate strictly within that range. Silence does not mobilize much explosive force in a patient whose problems are oedipal in nature because the capacity for verbalizing emotional energy is well developed. The patient can discharge those high states of central excitation associated with sensory deprivation rather readily in speech. There is relatively little danger that the patient will release efferent impulses into undesirable forms of motor activity. A wider range of communication is therapeutic as well as tolerable. Because of a relatively long course of wholesome development, varying degrees of verbal contact create situations which favor the resolution of in the case. The immediate release of efferent impulses into motor activity acting out is characteristic of the most primitive mode of functioning. Patients entering treatment for preoedipal problems have a limited capacity to engage in precise verbal release; they tend to discharge their impulses into indiscriminate forms of motor activity rather than speech. This tendency and the attendant dangers create anxiety, and inhibitory tensions are mobilized. In order not to stimulate the operation of the more primitive action patterns, one therefore refrains from exposing these patients to extreme degrees of sensory input or sensory deprivation in terms of verbal contact. To control the mobilization of aggressive impulses by the patient and secure their release in language, the analyst adheres rather strictly to a narrow range of communication. This militates against the threat of iatrogenic regression. Schizophrenic patients often appear to tolerate the absence of verbal contact for prolonged periods far better than less disturbed persons. They do not verbalize their aggressive reactions to such deprivation as readily as, for example, the psychoneurotic patient. Some of them go on talking for many sessions without soliciting any communication from the analyst. However, the misdirecting influence of frustration-aggression is implicit in such behavior. Not being in command of their aggressive reactions, these patients can only conceal them the schizophrenic reaction. Their tendency to store up aggressive impulses reflects an extreme need to inhibit their discharge. To prevent a potentially explosive situation from developing, and to deal therapeutically with these defensive reactions, the analyst restricts his gratification of the patient in terms, that is, of verbal contact. Rather than the moderate dosages at varying intervals to which the psychoneurotic patient responds, the psychologically healthful diet for the schizophrenic patient early in treatment is usually minimal dosages of communication at relatively long intervals. During the first twenty minutes of the session, in particular, interventions are, in principle, as few and as widely spaced as the situation permits. Toward the end of the session, more communication from the therapist may be needed to facilitate the patient s leaving the office.

4 A NEUROBIOLOGICAL APPROACH TO COMMUNICATION 69 What is the actual difference between moderate and minimum dosages of communication? Since firm measurements are impossible, the term units of communication is introduced to suggest the difference. One unit of communication, viewed as a verbal feeding, would be the equivalent, say, of a mouthful of milk. It is the briefest of interventions, such as a single question or very short statement. These communications may be ego-syntonic or egodystonic. The units stipulated below represent an estimate, on a long-range basis, of the amount of time the analyst spends in talking to the patient. Quantified roughly, the analyst s communications to a patient being treated for oedipal problems range from 10 to 100 units; the range indicated to deal with the characteristic defenses of the schizophrenic patient is from 2 to 5 units. The difference between these two types of verbal feeding is comparable to that between the normal dietary needs of the adult and those of a child who has been conditioned to underfeeding. In general, in the formative stage of the relationship, verbal contact with a schizophrenic patient is rarely in order. It is desirable that the analyst remain under the specified five units until the narcissistic transference has been resolved. Between the regular brief feedings at relatively long intervals, two additional units are occasionally provided when demanded. Whatever the patient develops to a transference object experienced as being like oneself, or even a part of oneself, yields temporarily to a few appropriate words, preferably spoken when a communication is solicited. The intensity of the can be more easily influenced when the analyst limits and times communications in the manner suggested above. The development of the case when one tries to deal with through larger dosages of communication at shorter intervals the customary procedure in other cases is indicated in the following diagram: The situation delineated above is especially undesirable in the outpatient treatment of schizophrenia; indeed, it was probably a contributing factor in

5 70 MODERN PSYCHOANALYSIS OF THE SCHIZOPHRENIC PATIENT many failures that have been reported in such treatment. The danger of precipitating iatrogenic regression in persons being treated on an ambulatory basis usually mounts when they are exposed to overfeeding. Too much communication creates more excitation, primarily exogenous, than the patient can discharge appropriately. That situation is averted by respecting the patient s need to develop and work through the narcissistic transference in a state of mild frustration-tension controlled by minimal gratification. That, indeed, is my prescription for the psychotherapy of the schizophrenic patient. Analytic therapists who equate the classical approach with passivity and have been educated to the idea that this is unsuitable for the schizophrenic patient are more apt to exceed the range of two to five units of communication than to operate below it. Nevertheless, it is possible to veer toward the other extreme; failures that appear to be associated with verbal starvation, one of the factors contributing to emotional drought, are occasionally encountered: Too little communication is as deleterious as too much and for the same reason: the relative inadequacy of motor output. Resistance originating in the narcissistic defense can be resolved without undue difficulty when the analyst consistently limits himself to small dosages of communication at long intervals. After the narcissistic transference evolves and the patient begins to relate more characteristically to the analyst as a separate object, he is more capable of verbalizing feelings. During the transitional stage, the communication dosages are gradually increased and the intervals between them are shortened. The patient develops an increased tolerance for more communication, and finds it pleasurable. The development of object transference usually signifies that the reorganization and reintegration of the patient s energy system have reached the point where he can respond appropriately to larger verbal feedings. When exposure to from 10 to 100 units of communication reactivates the old pat-

6 SUBJECT INDEX Acting in, 147, 180 Acting out, 68, 147 Action impulses, 36, 61, 119 Action patterns, 68, 127, 148 Aggression (aggressive drive, impulses, urges), 23 27, 39 40, 52 54, 115, 138, 191, 192 against the self, 24 25, 29, 30, 31 aim of aggressive drive, 24, bottling up of. See sub Frustration-aggression catharsis, 142 in clinical situation, 33 34, 42 46, 66 constructive and destructive, current views on, defense against, 25, mobilization of at trauma level, 17, 31 33, potential for, 39, 52 role of, in schizophrenia, 31, 34, 39 40, 102. See also Rage; Schizophrenia, nuclear problem in Aggressive endowment, 52 Aggressively determined images, 138 Aggressivization of infant, 52 Alive (feelings), 28, 50, 51 Ambulatory treatment, 13, 17, 19, 70, baseline requirements for, American Psychiatric Association, 3, 10, 155 Analyst as separate object, 5, 70, 104, 105,145, 198 Analyst s shortcomings, 186, 206 Analytic cure, 6, 8, 17, 62, 185. See also Cure Analyzability, 20n, 37, 43 Anger, 29, 52, 90, 102, 106, 150n, 204 Anxiety, 23, 25, 68, 100, 141, 142, , 170 couch as a haven from, 81 level, 121 retaliation, 26 Aversion, 167, 170 Baby sitting, 84 Behavioral change, 62, 115, , 199, 205 from rage-withdrawal to rage-combat pattern, neural events implicated in, 62 63, 65 Body-ego, 21 Body language, 103 Body self, early sense of, 50 Borderline patient(s), 15 16, 37, clinical functioning of, Boredom, 167 British Psycho-Analytical Society, 154 Cancellation of sessions, Catatonic disorder (states), 11, 22, 24, 74, 77 Cathartic approach, 150n Causal therapy, 5, 41 Cerebral hemispheres, 64 Character problems, 174 Chemotherapy. See Drug therapy Clarification, 112 Communications of analyst, 41 42, 48, 67 71, 84, , 121, 126, 183 in initial interview, maturational, 66, 180 neurobiological formulation on, quantification of, three-fold task pursued in, 71 to patient s family, 80n, See also Nonverbal communication; Interventions; Verbal feedings Communications of patient, 66 67, 102, , 124, 126, 166, 196 progressive, 113, 115, 120, 126, 168, 185, 194, 205 repetitive, 119, 184 symbolic, 103 topics covered in, 124. See also Resistance; Transference ; Treatment-destructive Conflict-defense model of schizophrenia, 39 Confrontation(s), See sub Interventions Conjoint (combined) treatment, 199. See also Group psychotherapy Constipated rage, 34, 35. See also Rage Construct(s), , 164. See also Reconstruction Constructive aggression, 24, 44 Contact functioning, 116, 126, 143, 183, 204. See also Interventions.

7 230 SUBJECT INDEX Contract, analytic, 79 82, 93 breach of, 79 third-party participation in, 82 violations of, 122 Controlling patient s behavior, 17, Cooperative functioning, 15, 80, 81, 94, 102, 114, 124 Couch, 4, 80 81, 90, 101, 103, 113, 115, 119, 153, 168, , 189, 196, 197, 198 arising from early, 122, , 196, 197 posture on, 81, 168 Counterforce to communication, 84, 112, 125 Countertransference, 3, 7, 15, 16, 37, 42, 45, 46, 113, 130, 148, 153, 175, 190, 204 anaclitic (nurturing) type of, 166, 167, 168, 171 analysis of, 155, , 164 and analyst s personality difficulties, 132, 155 Breuer s in case of Anna O., definition and scope of, Freud s views on, 153, narcissistic. See Narcissistic countertransference negative, 45, objective, , , See also Induced feelings and reconstruction, 233 as, 163. See also Countertransference and specific transference states, subjective, , 164, 165. See also Countertransference Countertransference, 7, 42, , , 160, 164, clues to, narcissistic. See Narcissistic countertransference negative, 45, 169. See also sub Narcissistic countertransference positive, 169 sources of, 163, Crying, 181, 184, 195 Cure(s), 3, 6, 8, 13 15, 17, 29, 62, 74, 77, 79, 124, 185 patient s theories of, 185 process of, in neurobiological terms, 49. See also Analytic cure; Psychological reversibility; Recovery Decisions, major, during treatment, 90, 97 De-egotization of the object, Defense(s), 19, 25, 26 28, 29, 31, 33, 34 35, 37, 39, 46, 70, 73, 95, 104, , 118, 174, 190 against release of mobilized aggression, 25 earliest modes of, 26, emotional neutrality of analyst as, 163 in latent cases, mechanisms in psychotic conditions, 19, paranoia as a defense psychosis, 19. See also Narcissistic defense Deficiency states, 54 Deficit model of schizophrenia, 39 Delusions, 28, 29, 44 45, 51, 73, , 176 Dementia praecox, 2, 3, 5n, 21, 22, 130, 131 Dental care, 78 Dependency cravings, 49, 87, 99, 122 Depersonalization, 22, 25 Depression, 16 17, 31, 37, 99, 131, 142 Deprivation, irrational, 187, 204 Destructive aggression, 23, 24, 130, 135, 181 Devaluating the object, 190 Diagnosis. See sub Schizophrenia Diagnostic and Statistical Manual of Mental Disorders DSM-I, 3, 10; DSM-II, 10; DSM-III, 11 Differentiation, emotional, 27, 46n, 107 Dopamine receptors, 59 Dozing off, 167 Dreams, 56, 60, 81, 102, 107, 117 approach to, and dream state, 81, 107 and object-ego fields, Drives, instinctual. See Instinctual drives Drug therapy, 12, 13 Drugs, antipsychotic, 2, 12, 13 administration of, 13 toxicity of, 12, 14, 17 Dynamics of personality development, neurobiological approach to, Early ego states, 6, 21, 34, 134 Early maternal environment, 30

8 SUBJECT INDEX 231 Echoing the ego, 189, 191 Echopraxia, 189 Eerie feelings, 101 Ego boundaries, 24, 27 28, 31, 35, 101, 102, 143 between ego-object fields, 44 45, Ego deficits in schizophrenia, 39, 194 Ego-dystonic impulses, 99 Ego feeling, 27, 142, 149 pre-ego feelings, 164 Ego field and object field, 31, 44 45, , , 151, 204 evolving from first object field, in narcissistic transference state, 108. See also De-Egotization of the object; Objectification of the ego Ego formation, 21, 24, 27 30, 106, 145, See also Ego field and object field Ego nuclei, 166 Ego passage, 108n Ego sacrifice, 29, 31 Ego-syntonic object, 6, 114, 143, 150 Ego weakness, 96 Egotization of the object (introjection), 108. See also Ego field and object field Egotizing feelings, 184 Emotional communication(s). See sub Interventions, types of Emotional induction, 155. See also Induced feelings Emotional maturity, 6, 17, 49 50, 64 65, 151, 206. See also Personality maturation Emotional neutrality, as a defense, 163 Emotional responsiveness, 163, Emotional sacrifice of analyst, 17 Emotional stress, patient s vulnerability to, 39, 51, 92 Environmental circumstances, 4, 92 93, See also Resistance, external Erratic behavior, 82, 94 Errors, 89, 90, 160, , 175 theoretical, 1 2, 4 Etiology. See sub Schizophrenia Experience of satisfaction, 32, 118 Explosive situation, prevention of, 68 Expressive psychotherapy, 8 External circumstances, 17. See also Resistance, external; Environmental circumstances. External. See sub Resistance Extra sessions, 83, 85 Failure(s) in treatment, 9, 17, 75, 98, 163, Freud s views on, 96 Falling apart, 104, 105, 120, 144, 188 Family, analyst s contact with patient s, 76 77, 82, 86 87, 92 94, 98 Fantasies, 22, 32, 102, 106, 108, 124, 142, 146, 147, 148, 180, 193, 204 Fees and financial transactions. See sub Treatment relationship First International Psychoanalytic Congress, 20 Free association, 5, 63, 99, 113, 114, 181 reformulation of fundamental rule of, 65, 80, 101, 113, 116, 121, 181. See also Saying everything Frequency of sessions, Freud s psychology for neurologists, incorrectness of some theories in, Frustration, 26 30, 39, 66 68, 103 and ego formation, Frustration-aggression (tension), 32, 39, 66, 103, 106, 140 bottling up of, 34, 35, 67, 103, 123, 151 facilitating release of, 44, 120, 127 managing level of, 112, 115, 126 misdirecting influence of, 68 and, , See also Aggression Frustration-tolerance, 22, 29, 84 Functional disorders, spectrum of, 51 Goals of treatment, 3, 6, 9, 65 initial, of patient, 73, 83, 95 Going crazy, 100 Gratification needs, 50n Grilling for evidence, Group for the Advancement of Psychiatry, 155 Group psychotherapy, analytic, 65, 92, 103, 195, 199 Guilt (feelings), 83, 93, 99, 135, 146, 153, 175, 189n, 195 Hallucinations, 10, 11, 43, 74, 99, 102, 136 Hate, hatred, 21, 24, 25 26, 150, 159, 202, 203 expression of, to patient, , 170

9 232 SUBJECT INDEX Freud s views on and hypersensitivity to, 23, 42, in patient s psyche, 29, 42, 99, 100, 151, 191, 192 of self, 33, 146, 195 as therapeutic force, 43 verbalization of, for transference object, , 170 Health hazards for analyst, 173 Helping the ego, 194 Here and now, 46, 98, 138 elaboration of negative transference in, 138 Homicidal maniac, 33, 93 Hopelessness (feelings), 3, 15, 16, 99, 100, 142, 167, 172, 198 Hostility, 21, 26, 42, 44 45, 101, 108, 119, , 196 Hypocritical stage, 199 Iatrogenic regression, 43, 68, 69, 70 Identification(s), 28, 37, 42, , 127, 134, 162, 193, 196 and character problems, 174 complementary and concordant, 154, 166 Immunization, 9, 11, 125, 200. See also Toxoid response Impulses, aggressive. See Aggression Impulses, discharge of into motor action, 68, 101 Incurability, feelings of, 1, 15, 99, 104, 146, 170, 173 Indifference, 20, 132, 167 Indirect method, 47 49, 51, 54, 179, Induced feelings (emotions), 3, 45, 108, 163, , 170, communication of, 125, 163, nature of, 3, 16, 45, 164, 170, 174 use of in reconstruction, 108, 148, 165. See also Countertransference, objective; Narcissistic countertransference Inhibiting action, 32 33, , 141, 143 Initial interview, Insight, 7, , 180 Instinctual drives (impulses), 23 25, 33, aim of, 23 erotic, defensive role of, 24. See also Aggression; Libidinal factors Instruction to talk, See Free association Insulation against action impulses, 36, 112 Interneuronal communication, 55 Interpretation(s), 16, 26, , , , 179, 197 of dreams, Freud on, 5 7, 111 maturational, 180, 181, , 199 of oedipal problems, 45, 46 on request, 180, 195 sequence in, 179 silent, 65n, 114, Interruptions in treatment, 91 92, 125 Interventions (general), 68 69, , 143, , , 183, 187, in opening phase, 114, 116, parsimony in, 63, 65, 112, 177 range of, 7, 15 16, 17, 179, sequence of in transference states, , specificity in, 16 17, , 182 Interventions, types of commands (orders), 179, , 196 confrontations, 93, , 125, , emotional communications, 16 17, 39, 125, , 164, 172 explanations, 126, 180, , 199 joining, 44, 46, , , 182, , 198, 200 maturational communication(s), 66, mirroring, 120, 134, 181, , , 192, 196 psychological reflection, 44 45, 125, 126, 127, 149, 195, 202. See also Communications of analyst; Interpretation; Joining techniques; Toxoid response Introjection, 106, 108, 143, 145 Irma s dream, 158n Irrational deprivation, 187, 204 Irresolvable conflict, 36, 140 Joining techniques, , 198 ego-dystonic, 180, ego-syntonic, 181, , 196 Laboratory, patient s body as, 71 Language and preverbal impressions, Letter writing, 91

10 SUBJECT INDEX 233 Libidinal factors, 20 21, 22 23, 29, 41. See also Instinctual drives Libido theory, 23, 27 Life history, patient s interest in, 125, 199 Life situation of patient, 17, 80, 83, 90, 127 Loss of control (fear of), 119, 133 Maladaptations, 28, 52, 54, 65 Maryland Psychiatric Research Center, 12 Masturbation, guilt about, 195 Maturational agent(s), 50, 54, 203 Maturational communication(s), 66 67, 180 Maturational failure, spectrum of reactions to, 51, 140 Maturational interpretation(s), 180, 181, 194, 199 Maturational need(s), 39, 50, 51, 52, indirect meeting of by analyst, 54, 164 Mature aggression, 31 Mature personality, 107, 205. See also Personality maturation; Recovery Medical/dental care, 78, 89, 98 Meeting threats with threats, 189 Memory(ies), 32, 59, 95, 99, 106, 107, 116, 118, 187 of preverbal object relations, 113 verbalization of, 99. See also Reconstruction Mental energy, 50, 60 62, 64, 65 Mind-body relationships, 56, Modeling new behavior, Modern indirect psychotherapy, 7 Modern psychoanalysis (operational theory), 7 9, 14 15, 16 17, 39, 64 adherence to classical framework in, 6, 8 9 amplification of basic theory of technique in, 16, application in preoedipal disorders, 39, 75, 178 choice of name for, 7 8 supervision in, 164, training in, 15. See also Psychoanalysis Modified psychoanalysis, 8 Monologues, ruminative, 141 Mother-child relationship (preverbal), 25, 27 34, 35 36, 39 40, 50 54, 103, 166 Mothering urge toward patient, 166 Motor output (motility), 32 33, 44, 66, 68, 70 Murderous feelings, 43, 100, 170, Narcissism, 21 22, 30 31, 35, 158 Narcissistic armor, 132 Narcissistic countertransference, 37, 45, 113, 162, equivalent terms for, 162 objective type of, 148, subjective type of, 161, 162, 163. See also Countertransference; Induced feelings; Narcissistic countertransference Narcissistic countertransference, 109, 113, 160, 163, 164, analysis of, 164 clues to, negative, , 172, 198. See also Countertransference ; Resistance; Transference, narcissistic Narcissistic defense, 70, 71, 102, , 113, 190, 205 Narcissistic injury, 77 78, 102, , Narcissistic needs, 137 Narcissistic neuroses, 5, 21, 132, 134 Narcissistic object, analyst as, 105, 135 Narcissistic personality disorders, 15 16, 37, 51, 158 Narcissistic transference, 6, 37, 69, 70, 108, , 161, 186 clinical characteristics of, evolution of in treatment, implications of, for technique, related terms, 6, function of, , 156 states of: negative, 105, 115; positive, 135, 136 therapeutic management of, 68, 69, 70 71, 129, 132. See also Transference; Transference, narcissistic Needs, inner, 118 Negative catharsis, 124 Negative judgment, 121 Negative therapeutic reaction, 99, , 121 Neophobia, 123

11 234 SUBJECT INDEX Neuron(s) and interneurons as integrating unit of nervous system, 58 Neuron reserve, 60, 61, 62, 63 Neuronal pathways, activation and deactivation of, 49, Neuronic inertia, theory of, 57 Neuroscience(s), 49, 57 clues from, to biodynamics of schizophrenia, 49 Neuroscientific formulation on curative process, Neurotransmitters, 59, 65 Neutralization, theory of, 26, 35 New York State Psychiatric Institute, 4, 77 Nonanalyzability. See Analyzability Nonverbal communication, 7, 63, 92, 103, 174, 180 Normality, 1, 14, 59 Nuclear conflict in schizophrenia, 31 Nuisance, patient as, 20, 15, 167, 203 Object attachment(s), 22, 27, 82, 132 Object field, , 140, 149, 151. See also Ego field and object field Object impressions (imagos). See Object representations Object protection, 31, 33, 40, 43, 102, 109, 140 Object relations, 23, 24, 28, 113, 135, 140, 151 Object representations (imagos, impressions), 24, 34, 39, 44, 108, 138, 140, 145 Object (oedipal-type) transference. See sub Transference Objectification of the ego, 108, Oceanic feeling, Office practice, 10, 13, 17. See also Ambulatory treatment Outcrazying the patient, 191 Outpatient treatment. See Ambulatory treatment Overevaluating the object, 189 Overstaying time, 122 Paradoxical intention, 180, 181 Paranoia, 20 Part-objects, 137, 147 Patienticide, 157n, Patient s expectations, Penalizing of patient, 89 Perceptual identity, 37 Personality development, neurodynamics of, Personality maturation, 17, 35, 55, 94, 96, 97, 109, 124, 147, 158 Pharmacotherapy. See Drug therapy Physical contact, 99, 122 Pre-feelings (pre-ego, undifferentiated), 6, 99, 106, 142, 145, 164 Preoedipal disorders, 16, 41, 51, 68, 94, 102, 103, , 117, 136, 140, , 163, 177, 180, 187 Primary defense, 119 Primary wishful attraction, 119 Primordial hate, 26 Prognosis. See sub Schizophrenia Progressive language discharge, 104, 105. See also Communications of patient, progressive Projection(s), 20, 27, 106, 108 Projective identification, 143, 144, 163, 200 Promises of successful outcome, 79 Psychic energy. See Mental energy Psychoanalysis (method), 1, 7, 8, 14 5, 16 17, 25 28, 39 40, 41, 48 49, 64, 75, 96, 113, 153, 162, 177, 206 application in schizophrenia, 1 17, 42 definition of (Freud s), 8 goals of, 1. See also Analytic cure; Personality maturation influence of on central nervous system functioning, 49 modern. See Modern psychoanalysis and physical science, resemblances, Psychoanalysis with parameters, 8 Psychoanalytically oriented psychotherapy, 8 Psychogenic illness, 8, 51, 109 Psychological medicine, words as, 49 Psychological murder, 34 Psychological reflection. See sub Interventions, types of Psychological reversibility, 9, 11, 17, 19, 28, 29, 37, 49, 51, 109. See also Cure; Recovery Psychological tests (testing), 77 78, 205 Psychoneurosis, 5, 19 20, 41 42, 51, 131, 141 Psychoneurotic patient, 36, 42, 45, 68, 112, 149 Psychosis (psychotic disorder) 10 11, 14, 19, 24, 26, 27, 28, 29, 30, 33, 37,

12 SUBJECT INDEX , 60 62, 64, 102, 107, 109, 114, 116, 132, 156 basic function of, 30 defense mechanisms in, See also Narcissistic defense Psychosomatic (psychobiological) conditions, 8, 17, 51, 109, 173 Quantitative approach to communication, Questions, 77, 78, 91, 93, 116, 117, 120, 121, 122, 124, 148, 150, 170, 179, 183, 186, 188, 194, 196, 197, 199, countering questions, 195 about delusional ideas, , 197 ego oriented, factual, 183, 188 object-oriented, 103, 120, 143, 184, 201. See also Contact functioning Rage, 24, 28, 29, 30, 32, 34, 36, 37, 39, 45, 102, 106, 133, 144, 147, 148, 151, 167, 195, 204 constipated, 34, 35 narcissistic, 23, 30 31, 43 44, 168 removing obstacles to discharge of, 36 Reaction-formation, 177 Reconstruction, 108, 117, 144, , 164, 165, 203, 204 Recovery, 2, 11, 13, 15, 17, 35, 45 46, 64, 79, 151, See also Cure; Personality maturation Referrals, 78, 92 Regression, 10 11, 15 16, 19, 21, 26, 34, 35, 37, , 133, 196 control of, 102, 116 defensive, 28, , 116, 143. See also Narcissistic defense iatrogenic, 43, 68, 70 Repetition compulsion, 99, 130 Repression, 19 20, 21, 41, 52, 99 Resistance, 5 7, 8, 45, 62, 66 71, 87 88, 92, , , 153, 156, arousal of, 115, 119, 125, 182 classification of by Freud, communication function of, controlling intensity of, 67, 69, 125 and counterforce to communication, 67, 84, 112, , 125 counter-. See Countertransference dealing with, 75 76, 95, , , 187 and defense, 70, 95, 104, 112, 126, 190 definitions of, early patterns of, 80 92, , 120, 141 of ego (repression), 99, 101, 115 external, of id (repetition compulsion), , 115 of idealization, 135 influencing one pattern of, inner (internal), interpretation of. See Interpretation negative judgment pattern of, 121 in neurophysiology, 66 personality fragmentation, patterns of, 102, 116, 120, 125, 127 in physical science, 48 preanalytic, 73, 76, preoedipal, 103, 182, , 195 priorities in dealing with, in psychoneurotic patient, 41 42, 112, 113 quantitative approach to, 112 recodification of permissible responses to, 7 recognition and understanding of, , 125 and regression, , 112, 116 of repression, 99 resolution of (steps in), 66, 70 71, , , 165, 205 secondary gain, 99 of silence, 119, 121 special manifestations of, in schizophrenia, status quo (inertia), 117, superego, 99, 115, 150 stonewall, 180 symptoms as, 101, 113 to termination, 42, 46, 117, transference. See Transference treatment-destructive patterns of. See Treatmentdestructive to use of couch, 101 working through of, 42, , , Resistance analysis, 8 Restitutio ad integrum, 2 Restitutio quo ante, treatment oriented to, 14 Restitutional symptoms, 22, 36 Retaliation anxiety, 26

13 236 SUBJECT INDEX Revulsion, analyst s feeling of, 167 Right to resist, 111 Rudimentary phase of relationship. See Treatment relationship Safeguards against explosive behavior, 43 45, 81 Saturating with suggestions, Saying everything, 57, 113, 115, 197 Saying the wrong thing to patient, 171 Schizophrenia, 1 4, 19 23, 31, 34, 36, 37, 40, 49, 59, 95, 99, 101, 164 amplification of psychoanalytic technique in treatment of, analytic task in treatment of, 36 analyzability of (early views on), 1 2, 5 chemotherapy in, 12 13, 17 contemporary models of, and defense. See Narcissistic defense diagnosis of, 9 12, 17, etiology of, 1 2, 13 14, 27 30, 31, 39, 52 nuclear problem in (working hypothesis), 19, prognosis in, 2 3, 12 15, 17, 17 psychological reversibility of. See Psychological reversibility recovery from (essence of), 13, See also Treatment relationship Schizophrenic associations, 116 Schizophrenic reaction(s), 3, 9 10, 33, 34, 65, 108, 115, 131, 139, 147, 200, 204. See also Schizophrenia Schizophreniform and schizoaffective disorders, 11 Self-analysis, 75, 112, 161, 164, 165, 199 Self-attacking attitudes, 33 34, 44, 105, 167, 189 Self-command, Self-love, 24, 26, 35 Self-neglect, Selfobject(s), 21, 44 45, 46n, 137, 147, Selfobject transference, 6, 138 Self-propelled discharge, 65 Self-torture pattern, 102, Sensations, 27 28, 51, 60, 63 64, 101, 105, 108, 129, 142, 144 Sense of danger, 168 Sense of satisfaction, 60, 167 Sense of self, 51, 54, 137 Sensory deprivation, 39 40, 60, 66, 68 Separate object, analyst as, 5, 70, 104, 105, 145, 149, 202 Separation-individuation, 6, 27, 46n, Sessions, frequency of, Sexual impulses and feelings, 19 20, 26, 41, 99, 101, 106, 136, 146, 149, 150, 156 Silence, 67, 177, 178 of analyst, 65, 68, 121, 177, 178 of patient, 66, 84, 120, 121, 141, 182 Silent analysis, 46, 65n, 114, 115, 117 Silent interpretation, 65n, 114 Smoking, 33, 90, 141 Speech, (speech apparatus), 36, 63, 114, 177 Spite, 15, 132 Strategic dictator, analyst as, 81 Stress-diathesis model, Stress, patient s vulnerability to, 39, 60, 92, 115, 125, 200 Student analyst, problems of, 98, , 204. See also Countertransference ; Induced feelings Suicidal urges and thoughts, 33, 34, 93, 97, 106, 145, 151, 167, Supervision, major concerns in, 160, 164, , 197 Supportive psychotherapy, 8, 39, 54 Symbiotic relatedness, 162 Symbolic communication, 16, 92, 103 Symbolic destruction of object, 36 Symbolic gratification, 54, 120 Symposium on Infant Psychiatry, 50 Symptomatology, 10 11, 12, 15, 19, 22, 37, 51, 74, 77, 156 Synaptic activity, 59 Talion principle, 151 Talking out, 105, 106, , 185 Tardiness, 81, 101, 115, 122 Technique, amplification of theory of, Telephone calls, 91, 92, 122 Telephone therapy, 92 Termination, 42, 80, 117, Therapeutic alliance, 16, 74, 131. See also Working alliance

14 SUBJECT INDEX 237 Therapeutic leverage, 37, 45, 154, 163, 165, 170 Therapeutic negativism, 2 Therapeutic strategy, patient s interest in, 90, 199 Toxoid response, See also Immunization Training, in modern psychoanalysis, 14 15, Transference, 5 6, 20 21, 30, 37, 67, 78, 86, 95, , anaclitic, behavior in neurodynamic terms, capacity for, 5 6, 141 charging of defenses with, 66 continuum of transference states, 140 convincing patient of, 131 delusional, 137 dissolution of, 151, 187 externalizing, 136 Freud s views on, hatred, , 157, 171. See also Transference, negative levels of, 136 love, 41, 157. See also Transference, positive management of, 131, 132, narcissistic. See Narcissistic transference negative, 42, 43 44, , , 133, 138, 149 object (oedipal), 5 6, 43, 45 46, 70, , 108, 126, 134, , , 198, 199, 203 oscillating states of, 16, , , 186, , positive, 43, 45, 114, 123, 11, 133, 157 primitive/primordial, 136 prototype of, 156 psychosis, 37, 135, 137, 140 restitutive function of, special problems in, tempo of development of, 44, , 160. See also Narcissistic transference; Transference Transference cure, 62 Transference neuroses, 5, 134, Transference object, 43, 69, 109, 114, 124, 136, 139, 140, , 149, , 163, 187 ego-syntonic, 6, 135, 150 Transference psychosis. See sub Transference Transference, 41 42, 100, 101, , 115, 117, 120, 126, 127, 131, 147, 151, 160, 181, 194 narcissistic, 44 46, , 141, , , object, 41 42, 46, , See also Narcissistic transference; Transference Traumatic psychosis, 28 Treatment contract. See Treatment relationship; Contract Treatment-destructive, 83, 87 88, 115, , 119, 123, 141 clues to, controlling intensity of, , 115, 125 disappearance of, 127 Treatment relationship (alliance), 17, 51, 54, analyst s responsibility for formation of, attitudes of analyst in, , changing goals of patient in, concept of cooperative functioning in, 15, 81, 94, 124 contact with patient s family, in, 80n, contract for, 79 82, 83, 88, 94, 122, 124 duration of, 79, 86 fees and financial transactions in, 83, frequency of sessions in, general attitude toward rules in, initial interview for, 76 79, 84 interruptions in, 91 92, 125 optimal intensity of, 86 and patient s behavior outside office, 90, 197 session cancellations and extra sessions in, 85, special demands on analyst in, 41, 44, 46, 84 trial period in, 79 vacation periods, 91 92, 125 Undifferentiated feelings, 6, 31, 106, 145, 148. See also Pre-feelings Unlearning, 7 Vacation periods, 91 92, 125 Verbal feedings, 65, 66, 69, 70, 104, 105, 179, 196 on self-demand, 69, , 183. See also Contact functioning Verbal starvation of, Verbalization, 66, 103, 105, , 115, 118

15 238 SUBJECT INDEX of negative feelings, 45, 102, 112, 122, 123, 124, 126, 130, 141, 196, 197 of preoedipal state, 108, 109, 142, Vienna Psychoanalytic Society, 23 Vulnerability to emotional stress, 38, 39, 92 Warm acquiescence, 193 We-self (transference), 137 Wishes, negative and positive, 118, 120, 121, 154, 185, 193 Withdrawal, 21 22, 24, 25, 28 Words as tools for behavioral change, 49 Working alliance, 74, 76, 94 Working hypothesis, 7, 19, 38. See also Schizophrenia, nuclear problem in Working through, 112, 125, Writing letters, 91