Countertransference-Induced Psychosis
February 18, 2005
I had a very upsetting experience this past week, in which one of my patients had a significant decompensation in which she showed severe fragmentation of self-processes. As we were having an interaction over the phone (this contributed to her psychotic anxiety), she became increasingly irrational, paranoid, manic, panicky, hostile and verbally abusive as well as thought-disordered. I dug in my heels and became quite defensive, blaming this on her pathology. In the session before this phone contact, I had told her that I felt like she was holding a knife to my throat and that I should not make any wrong moves (omnipotent control of the object, in particular, the annihilatory threat of separation). I told her that I thought she wished to strangle and kill me. She confirmed that she was indeed feeling this way. I preemptively stopped at my defensive view that the ‘pathology’ resided in her alone, rather than the relationship, the complex and dynamic interactions occurring between us (Martin Buber astutely remarked that psychopathology was always in the ‘in-between’ rather than residing in the isolated individual -- Soviet scientists Bahtkin and Vygotsky also believed this to be true).
She tried to convey to me how she felt I was too removed and not permeable to her communications (projections of ‘evil’ non-human images of herself which she needed to locate in me). It was within the hour after our phone contact (it was very hard to concentrate on my next patient) that I realized how my countertransference hate and anxieties were inducing further decompensation in this fragile and beleaguered individual. I called her back later in the evening and apologized for my defensiveness and not being able to grasp what she so urgently needed from me. Her psychotic anxieties and fragmentation of self quickly receded.
I thought of the infant researchers’ concept of disruption-repair. More importantly, I remembered Herbert Rosenfeld’s views on countertransference induction of the psychotic transference leading to strong negative therapeutic reactions and intractable impasses. I was also left with an experiential confirmation of the dynamic nature of psychosis, how embedded we are within the other (I think Ernst Schachtel in his excellent volume, Metamorphosis, referred to us as “embedduals”), how much emotion is connected with ‘object-relatedness.’ That psychosis could be so intimately connected to separation from the other with whom one locates valued parts (negative and positive) of the self and upon whom one feels one’s sense of psychic existence rests (which in the world of psychosis and conflation of soma and psyche, one’s physical intactness as well). I highly recommend Rosenfeld, H. (1987 ) Impasse and Interpretation: Therapeutic and Anti-Therapeutic Factors in the Psychoanalytic Treatment of Psychotic, Borderline, and Neurotic Patient. London : Tavistock Publications.
Brian Koehler PhD
New York University
80 East 11th Street #339
New York NY 10003
212.533.5687
brian_koehler@psychoanalysis.net
