I find the emphasis on this list on the role of trauma in severe mental illness particularly important. I feel that it is also critical not to neglect the role of what some (e.g., Anna Freud) have called identification with the aggressor. Psychosis, from what I have seen in my experience is a destructive process (despite having potentially beneficial aspects whether they are an attempt to heal oneself, as Freud thought-psychotic symptoms as restitutional, an attempt at self-cure- repair of one's objects, as PostKleinian psychiatrist Henri Rey thought, or as an expression of the craziness of one's family or one's society, as RD Laing and many others thought). Directing hostility towards the system, the hospital or clinic, the family, the society, etc., can often be a split off defense against our hatred and fear of the patient, i.e., countertransference hostility and anger-sometimes the result of an identification with the aggressor in the patient and sometimes from our own identification with a hateful object within our own history.

I believe, for patients to get better, these hateful and destructive feelings, whatever their ultimate origin, must be confronted, given a steady voice and understood within the here and now relationship of the therapeutic partners (for an excellent review of this see Leon Grinberg's 1997 article "Is the transference feared by the psychoanalyst?" published in the International Journal of Psychoanalysis, 78, pp. 1-14). To be empathic also includes being empathic to feelings in our patients and ourselves which include hate and wishes to destroy the other, as well as the other in oneself, as Freud so beautifully pointed out in his paper "Mourning and Melancholia." Our patients can hit us in vulnerable areas-at the very least defeat us in our attempts to help them (see Martin Cooperman's excellent article on defeating processes in psychotherapy in which negative therapeutic reactions can be the result of the therapist narcissistically wounding the patient, and see Daniel Schwartz' paper on the problems of caring in which positive relational experiences can induce fears of fusion/loss of ego boundaries, etc. and therefore result in negative therapeutic reactions). Winnicott's paper on hate in the countertransference approaches what I am trying to articulate here, as does Harold Searles' view of the person with schizophrenia as both victim and victimizer.

In consultation with my wife Julie Kipp, she pointed out that one way patients are victimizers is to maintain their own state of being a victim. Bion's theory of attacks on linking, Sullivan's concept of the malevolent transformation and the attachment theorists’ concept of disorganized attachment and attachment signifying the threat of abandonment are also examples of how psychosis can be self-and other destructive. As therapists we should not cast a blind eye towards the hate and desire for destructiveness with which our patients and we struggle. As Benedetti pointed out, countertransferential and transferential aggression can be points of closer contact, critical points on the way to establishing duality (which is 'antipsychotic' in the truer sense of the term). Searles believed that underlying these strong feelings of hate and sadism are deeper needs for a therapeutic symbiosis, which both therapist and patient defend against.

The PostKleinians tend to grant these destructive trends an independent status (some base it on the putative death instinct and others, like Hanna Segal, on conflicts over dependency and linking with others and loving/dependent parts of oneself), separate from defense against more positive feelings and not just a reaction to narcissistic injuries. These analysts believe that the therapeutic relationship and frame must be strong, reliable and understanding enough to contain these intense emotions. And as Francoise Davoine and Jean-Max Gaudilliere (2004) point out in their excellent volume History Beyond Trauma: Whereof one cannot speak, thereof one cannot stay silent, we are co-researchers with our patients on a battleground involving past social, familial and individual traumas which have been relegated to silence because of the lack of a listening, receptive other. Martti Siirala (1983), in his profound treatise on the human condition, From Transfer to Transference: Seven Essays on the Human Predicament, also refers to the past murders which have been collectively carried out and denied (evident in much of the violence we are currently witnessing in our daily news reports): murders which must reach an attentive ear in order for the haunting placelessness/psychic (and in many situations actual) homelessness to give way to living on solid ground in a community of our fellows.

Cooperman & Schwartz were both at Austen Riggs center.

Martin Cooperman (1989). Defeating processes in psychotherapy. In Ann-Louise Silver (Ed) Psychoanalysis and Psychosis, pp. 339-357.Madison, CT: IUP Press.

Daniel Schwartz' paper The Problems of Caring was presented at a NYU colloquium I organized in the 1990s in which David Feinsilver and Dan Schwartz gave papers. Dan did not publish his paper at that time and asked for it not to be circulated since there was material on two of his patients. You might be able to reach him through Riggs (years ago after stepping down as medical director, he still maintained an office there).

Brian Koehler