Psychoanalysis with persons diagnosed with a severe mental illness is at best considered to be irrelevant by many clinicians and researchers in the field, and at worst, to be harmful, fostering regression, increasing anxiety and disorganization leading to further impairment of 'reality testing.' It is a widely held belief among clinicians that speaking with a person about her or his delusions and hallucinations only leads to further entrenchment 'in psychosis.' I have found the history and contemporary evolution of psychoanalytic therapy to be a useful and helpful map, opening to the place in which the person struggles with such issues as identity formation. Such therapy creates a viable and valued sense of self. The patient masters destructive processes such as shame, annihilation anxiety, persecutory and depressive guilt, etc., which undermine his or her sense of self. The capacity to engage in relationships with minimal threat to self-esteem and autonomy increases along with a basic sense of acceptability as a person. The work of Gaetano Benedetti has been of particular help to me. It is unfortunate that his profound contributions to our field are relatively unknown or poorly understood.

I have had the good fortune to study with and be supervised by some of the architects of the relational school of psychoanalysis, including infant researcher Beatrice Beebe, Stephen Mitchell, Philip Bromberg, Emmanuel Ghent, Adrienne Harris, Doris Silverman, Esther Menaker, as well as contemporary Freudians such as Anni Bergman and Marvin Hurvich who have a strong interest in and have made profound contributions to the therapy and understanding of severely mentally ill individuals. These individuals, along with many of my ISPS colleagues (too numerous to mention by name), in particular Ann-Louise Silver, Bert Karon and Gaetano Benedetti, have added considerably to my sense of self and to my identity as a therapist.

I would like to introduce a form of contemporary psychoanalysis, referred to as coparticipant psychoanalysis, to members of our ISPS community who may be unfamiliar with this emergent psychoanalytic therapy. This is done in the spirit of not elevating psychoanalysis as a better form of psychosocial treatment, but rather, to see more clearly the aspects of therapeutic action which may overlap with other perspectives. I will primarily draw on the psychoanalytic contributions of John Fiscalini, a training and supervising psychoanalyst at the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis and the William Alanson White Institute of Psychiatry, Psychoanalysis, and Psychology. I highly recommend his Coparticipant Psychoanalysis: Toward a New Theory of Clinical Inquiry published in 2004 by Columbia University Press. My hope is that contemporary psychoanalysis continues to evolve in ways that are truly helpful to persons struggling with what we have unfortunately called 'schizophrenia.'

Fiscalini (2004) believes that on a fundamental level psychoanalysis:

...is a human encounter -- a meeting of two beings or two minds in all their unique individuality. The coparticpants each bring to their shared relationship their unique expectations, desires, and abilities as well as their imagination, curiosity, and courage" (p. 9).

As in his last edited volume, Fiscalini delves into the subject of the patient's and psychoanalyst's narcissism. There are many chapters devoted to this topic in Coparticipant Psychoanalysis . Freud, in the early beginnings of psychoanalysis (as did Paul Federn), offered important observations, theoretical speculations and insights into the narcissistic process (as has contemporary Freudian Sheldon Bach) in his paper "On Narcissism." Fiscalini noted:

"Narcissistic relatedness...is the plight of the unloved self. The pathology of narcissism is the psychopathology of the self [my own view is that severe mental illness could never be understood, let alone therapeutically transformed, without addressing the personal and interpersonal self], in particular that dimension of the self that Sullivan refers to as the sum of reflected appraisals and that Kohut calls self-object relatedness and that I define as the domain of the interpersonal self. These various perspectives point to the dimension of personality that defines the need for social approval or communal acceptance. Narcissism and self-inflation, in other words, represent a defensive substitute for healthy self-esteem.

Clinical narcissism, the defensive development of pathological grandiosity and self-centeredness, also figures in the psychopathology of the personal self; it is inimical to the free development and availability of the personal self. In fact, it could be said that clinical narcissism represents the pathological truncating of the personal self and traumatizing of the interpersonal self" (p. 109).

Fiscalini (2004) identifies several aspects of the narcissistic condition: self-centeredness (paradoxically a self that is de-centered and centered on the threatening other), grandiosity, idealization and devaluation, entitlement and demandingness, other-directedness and self-alienation.

Self-centeredness protects against:

...feelings of dependency and...needs for tenderness and help by efforts at superhuman self-control or control over others. Imperviousness, detachment, and dissociation of the need for tenderness may be seen as coercive power operations designed to protect against unconscious feelings and fears of helplessness, inadequacy, or insignificance. Such narcissistic efforts at control inhibit one's openness, ability to engage in give-and-take and to 'surrender' to oneself or another; they markedly impair one's interpersonal relations and experience of the world. For the narcissist, admitting that he or she needs others or is open to their influence carries the psychic risk of a humiliating or frightening acknowledgment of human vulnerability and emotional interdependency" (p. 113).

Grandiosity is designed:

...to compensate for self-contempt derived from early interpersonal experience, [however] it actually serves to weaken one's self-regard. When the defensively grandiose self becomes the measure of approval (the standard of self-esteem), then the actual self becomes an object of contempt. Thus, the grandiose narcissist's self-esteem is always a fragile matter, and shame and hints of nightmarish uncanny emotion are perceived as threats. In its demands the grandiose interpersonal self, the narcissistic means of security, becomes itself a potential source of shame and self-loathing. For the narcissist, shortcomings, whether clearly perceived or only vaguely felt, are inevitably experienced as humiliating. even success may feel like a failure because it doesn't measure up to the narcissist's irrational expectations [one of my patients projects and hears his voice singing on stage at the New York Metropolitan Opera performances, he becomes enraged that the stage performers are 'ripping off' his voice, and to rub salt in the wound, he is not even paid for this! Yet, he devalues actually good performances of his own as being defective]. Thus the slightest criticism, neglect, or absence of special recognition becomes a shameful and humiliating experience, a narcissistic blow to one's self esteem [the same patient of mine, if people are 'indifferent' to him on the street, experiences this as an actual shameful and humiliating attack on his personhood, to the point of concretely experiencing it as an actual rape, somatic transformation of his body into a female and/or a confiscation of various body parts leaving him in a ragefully helpless state]" (p. 114).

Fiscalini noted:

The defensive search for idealized others originates in an unconscious sense of weakness and vulnerability. Elicited by the fear of self-initiative, independent action, or individual expression of wish or feeling, it is the desire to find safety in identification or merger with the defensively idealized parent [my patient tends to become more delusionally paranoid whenever he may experience himself as doing better, separating, autonomous, etc., which leads to paranoid delusions of one kind or another and a defensive idealization, as well as underlying fear and hatred of, myself as powerful protector]" (p. 115).

Psychoanalysts, such as Post-Kleinians Herbert Rosenfeld and Anthony Bateman, often refer to narcissism as being either "thin- or thick-skinned" (perhaps Kohut worked more with the former and Kernberg with the latter-and thus their theories reflect on different aspects of narcissism). Fiscalini notes:

The narcissistic person is both thick-headed and thin-skinned. Narcissistic individuals almost automatically refuse or refute the input from others. Narcissists are deeply fearful of open contact with others, for this portends the disorganization of their narcissistic personas. While narcissistic patients may be difficult to reach, they are at the same time thin-skinned, overly vulnerable to insult or disapproval" (p. 115).

In regard to separation, Fiscalini notes that in the search for symbiotic union, narcissistic patients "are trying to transcend the terrifying anxiety they associate with unique individuality" (p. 115).

With regard to the sense of entitlement and demandingness, Fiscalini observed:

Narcissists' grandiose presumption of special privilege or prerogative, together with their repudiation of personal responsibility, social reciprocity, and interpersonal empathy inevitably vexes and alienates other people. Their demanding attitude may lead to the disintegration of interpersonal situations that might otherwise have proven satisfactory to all coparticipants. The refusal, or inability, to meet the narcissist's inordinate and inappropriate demands almost always provokes feelings of angry disappointment and projective accusations of insensitivity or hostility. Insatiable demands for unconditional love, however masked, often characterize the narcissist's relations with others. They represent the defensive demand for relatedness without reciprocity or responsibility-relationship as a one-way street" (p. 116). In this way, more narcissistically scuttled patients appear to be unable or unwilling to enter adulthood. One of my patients expects me to be available at all hours night or day without any sense of how this might be interfering with my life. However, on a deeper level, I believe it is a hostile attempt to derail my having a separate life (sort of like 'misery loves company') as well as to maintain the sense of himself as cohesive and continuous through the emotional/mental contact with another human being.

In regard to the narcissistic person's sense of other-directedness and the accompanying self-alienation, Fiscalini proposed:

Driven by their vulnerable self-esteem, compensatory grandiosity, and defensive idealization of others, narcissistic individuals alienate themselves not only from others but also from themselves-from their own deeper being and psychic center. Narcissistic individuals are focused on their interpersonal selves, i.e., on the social pursuit of interpersonal security, to the point of eclipsing their personal selves or unique individuality...Other-directedness implies self-alienation. All experience is colored, and hence altered, by the need for approval from others. The narcissist's self-centeredness, in other words, is an uncentered selfness, a self alienated from itself...Early experiences of anxiety and social pressure defensively shunt or transform the effort to live out one's psychic capacities into a narcissistic focus on a selfness that is rooted in the other, not in oneself" (pp. 116-117).

Fiscalini concluded:

In summary, narcissistic problems may be seen to develop from interpersonal interactions, starting in infancy, that: (a) promote the development of defensive narcissistic ways of being-so-called pathological narcissism; and (b) fail to meet early narcissistic needs for approval that persist in adulthood as repressed aspects of unmet childhood narcissism. These two narcissisms-defensive, or pathological, narcissism and developmental narcissism, the unconscious or preconscious narcissistic aspects of the child's needs for love, dependency, and individuation that are repudiated in the narcissistic developmental process, always coexist" (pp.124-125).

Coparticipant psychoanalysis/inquiry is especially suited to the therapeutic amelioration of narcissism through its "...radical emphasis on patients' and analysts' equality, emotional reciprocity, psychic symmetry, and relational mutuality" (p. ix). Furthermore, Fiscalini proposes that coparticpant inquiry "integrates the individualistic focus of the classical tradition and the social focus of the participant-observer viewpoint, forming, as it were, a third clinical paradigm.

Coparticipant inquiry avoids a reductionistic biological individualism (the isolated individual mind or the intrapsychic), which fails to take sufficient account of the clinical role of object relations or interpersonal relations. It also avoids the reductionistic social determinism of the participant-observer tradition in clinical work (the intersubjective mind), which has failed to take sufficient clinical account of human agency, will, and personal responsibility" (pp. ix-x).

In terms of therapeutic intervention, Fiscalini tries to steer between the countertransferential shaming of some of Otto Kernberg's approach, as well as the potential for seductive infantilization of the approach of Heinz Kohut. It is important for the psychoanalyst to not make a Procrustean distortion of the singularity of the narcissistic patient, otherwise Fiscalini believes that the patient "already stunted in his or her autonomy and individuality, is once again defined by another and is told who he or she is by the analyst" (p. 127). Furthermore:

"And whether the patient is defined as unmirrored innocent, enraged insatiate, undifferentiated symbiote, or interpersonalized ingratiate matters little. For the fact that the analyst has cast the patient in the narcissistic image of his or her theory overrides such perspectival differences" (p.127).

Fiscalini further defines coparticpant inquiry:

An important though not unique characteristic of the coparticipant approach to treatment is its acceptance of the curative role of the 'real relationship.' Many coparticipant analysts assign an important therapeutic role to the analytic formation of new interpersonal experiences, particularly in the psychoanalytic treatment of more severely disturbed and less verbally accessible patients...Coparticipant analysts ascribe great importance to the role of reality in the historical formation and analytic transformation of narcissism. This emphasis on reality is combined, however, with a perspectivistic emphasis and relativistic epistemology-a stance that does not dictate that the analyst's 'truth' must rule nor, as Kohut...and others would have it, that the patient's subjective 'truth' must rule" (pp.131-132).

Fiscalini is critical of a clinical approach which disregards the person's autonomy and contribution to her or his own difficulties. He notes:

Though all patients were once the intended or inadvertent victim of others' anxiety, lack of empathy, or even antipathy, it is also true that all patients are active participants in the neurotic perpetuation of their narcissistic patterns. Kohut's clinical approach overemphasizes the therapeutic role of the interpersonal self-other and thus fails to account sufficiently for the active and interactive role that each patient plays in his or her own development" (p. 134). I believe that some contemporary intersubjectivists do this as well -- psychopathology is solely attributed to failed selfobject relationships and that the provision of empathic resonance will correct for the interpersonal and intrapsychic difficulties of the patient without due regard for such processes as resistance to therapeutic positivization due to fear of being colonized or influenced, identification with the aggressor leading to attacking the projected vulnerable self contained in the therapist, recognition of patient as therapist, etc.

Clinical narcissism, Fiscalini believes, "results when there is severe, prolonged, or repetitive injury to the interpersonal self-that is, to the early narcissistic needs for approval (self-esteem) and consequent substitutive development of self-protective defenses of a narcissistic character (e.g., pathological sense of entitlement, devaluation, idealization, etc.)" (p, 137). Kohut, unlike Kernberg, makes a valued place for the possibility of emotionally corrective experience, particularly evident in his concept of transmuting internalizations.

Fiscalini proposes:

The process of transmuting internalization forms an important, but limited, aspect of a broader curative relational process that I call living through [a different emphasis than in the original Freudian concept of 'working through']. I believe that working through all narcissistically conflicted patterns of living inevitably involves living them through experientially in new and curatively reconstructive ways in the immediate personal relationship between the patient and therapist. The living through process occurs inadvertently, in both dialectic (i.e., as an integral aspect of the interpretive process) and direct relational (i.e., as direct reconstructive relational experience) forms. This process, particularly in its direct form, is pivotal in the analysis of core, preverbal narcissistic difficulties and deficits" (p. 136).

Narcissistic patients need to see, through interpretation and lived experience, that they only esteem themselves on narcissistic grounds-they often do not value themselves as they are, but rather, only when they feel special and superior. I have found that when patients secretly feel the need to be superior and special they often feel ashamed and are anxious lest such needs of theirs be revealed to the world. Fiscalini noted:

The resolution of the patient's narcissism requires both interpretive insight and experiential living through of the patient's pathological narcissistic self-inflation and narcissistic defenses and the underlying unmet mirroring or idealizing needs, the anxious 'not me' experience. Narcissistic 'good me' defensiveness must be worked through and relinquished; it must be transformed, as it were, into a no longer needed 'bad me'-to be replaced by previously repressed 'not me' aspects of the true self that are now reintegrated as a new, non-narcissistic 'good me.' This is often a lengthy process" (p. 147).

Fiscalini believes in a psychoanalytic therapy which is highly active and personally engaging. Such a therapeutic stance requires flexibility, particularly in response to challenges to the analysts' narcissism:

Above all, the analyst must have the personal centeredness (relative freedom from personal narcissism) to work nondefensively with the often provocative narcissistic resistances of such patients and with their equally threatening insights into the analyst's own narcissistic problems...In a way, countertransference analysis is the coparticipant analyst's first task with the narcissistic patient. Countertransference analysis by both analyst and patient plays a crucial role in working with narcissistic patients, particularly since their narcissistic anxieties, conflicts, and defenses so often evoke narcissistic countertransference experiences in the coparticipant field...the analyst who invites coparticipant inquiry into his or her narcissistic countertransference provides the patient with a therapeutic model of nonnarcissistic relatedness-a living experience with someone who is open to others' ideas, able to ask for help, unafraid of others' evaluations, or able to move forward despite being afraid" (pp. 138-139).

The analyst's and patient's reactive, self-protective anger has multiple sources, particularly the provocation of her or his own latent grandiosity, and need to be perfect, omniscient and omnipotent. Fiscalini wisely notes:

The most effective antidote to another's narcissism is to outgrow one's own narcissistic defensive needs and to develop a mature respect for one's own uniqueness (as opposed to specialness), separateness (as opposed to symbiosis), and limitations (as opposed to grandiosity). In this way, by largely overcoming narcissism in oneself, one inevitably frees oneself of the narcissistic demands of others. One can, then, chart one's own course, whether in the coparticpant field of psychoanalysis or in the coparticipant fields of everyday life" (p. 149).