The following excerpts are from the following paper: The Razor’s Edge: The Struggle to Preserve Self and Object Relations in the Psychoanalytic Therapy of Patients with a Bipolar Illness. Brian Koehler, Ph.D. was presented at the first psychoanalytic conference on bipolar disorder in NYC: Storm Warning: Recognizing and Treating Mild and Moderate Forms of Manic Depression in Analytic Patients. Leon Grinberg (1990, 1992, 1997)
The term I have used in the title of my paper “Razor’s Edge” comes from Leon Grinberg (1990). I will first describe what he means by this term and proceed to further describe Grinberg’s observations to a psychoanalytic understanding of cyclothymic and manic-depressive patients.
By the term “razor’s edge”, Grinberg (1990) was describing the phenomena in certain forms of depression in which the patient feels she cannot satisfy the demands of her ego-ideal and therefore falls back on omnipotence and manic attempts to counteract her depression. Such sudden shifts from depression to manic states and vice verse, result in the phenomena Grinberg called “the razor’s edge.” The razor’s edge is shaped by painful emotions, such as persecutory and depressive guilt, and the mourning for an object loss and the loss of parts of the self involved with the object. In regard to the latter, Grinberg (1990) hypothesized “...that the temporary or permanent loss of an object causes in the individual a painful feeling that he has lost at the same time something of himself...faced with an object loss one rushes to the mirror to check what has happened to one’s own image” (p. 173). It is a type of narcissism that is like a pathological organization in the personality in which envy and aggression against both the object and the self predominate, and whose reinforcement depends on the caregiver’s attitude towards the child. When the latter is primarily negative and/or uncontaining, the narcissistic wound is deepened, resulting in a decline in self-esteem, the emergence of depressive and persecutory anxiety and guilt, humiliation, shame and helplessness, which are defended against by a sense of omnipotence and megalomania.
Another way of understanding the razor edge phenomena is by conceptualizing it as the patient passing from the non-psychotic to the psychotic part of the personality and vice versa. The concept of a psychotic part of the personality, originally described by Wilfred Bion (1967), does not imply a psychiatric diagnosis nor necessarily the loss of contact with reality but rather “a mode of mental functioning that manifests itself in the individual’s behavior and language and in the effects it produces on the obsession” (p. 178) This state co-exists with the non-psychotic part of the personality and is similar to Freud’s concept described in his 1927 paper on Fetishism in which he observed that the ego can maintain two contradictory attitudes at the same time, a more normal one in contact with reality and a more pathological one based on a disavowal of reality (similar to Bleuler's 'double-bookkeeping'). Among the most significant features of the psychotic part of the personality, is an intolerance of mental pain and frustration.
The sudden change involved in the razor edge phenomena during analysis directly impacts on the analyst’s countertransference. During states of depression and despair, the analyst may feel empathy and compassion for the patient’s suffering, but with the sudden shift to a persecutory, critical and excessively demanding position, the analyst may experience feelings of overwhelming defeat, failure, inadequacy, guilt, initiation, impotence and despair.
My emphasis in the use of the term “razor’s edge” refers to the phenomena observed by many psychoanalysts from different theoretical perspectives that an object loss, either due to actual loss or separation, retaliation or failure of containment, can suddenly and very painfully lead to feelings of self-fragmentation and self-dissolution. I have observed this quite frequently over the span of almost 27 years of clinical work with more seriously disturbed patients including manic-depressive and schizophrenic patients I am currently treating within my private practice. I believe a profound understanding of this phenomenon in psychotic patients has been offered by Peciccia and Benedetti (1998) in their concept of a “breakup in the integrative relationship between the symbiotic line of development and the separative line of development” (p. 119). This process of disintegration of the separate and symbiotic selves results “in two incompatible nuclei of the self, which are both non-self, one with respect to the other, one characterized by excessive symbiotic needs, the other by an excessive need for separation. The two nuclei of the self, symbiotic and autistic, fragment each other every time separative needs or symbiotic needs are activated. Their needs are both contemporaneously present and therefore intensely felt because they are not integrated” (pp. 119-120).
From a different theoretical perspective, a post-Kleinian one, as patients become increasingly aware of their separateness from their primary objects, they experience psychic pain as a result of a disruption of a type of relatedness that ties them to their object. Riesenberg-Malcolm (1999) noted: “The lack of a sense of separateness, as well as the steps needed to achieve this sense, depends on the operation of projective identification and its modification in analysis. This in turn depends on the person’s capacity to tolerate pain and on the nature of the pain. The taking back of projections into the self (undoing projective identification) increases the strength of the ego, which in turn increases the person’s capacity to deal with painful states” (p. 161). From a more self-psychological perspective, Meares (1993) regards the feelings of self-dissolution secondary to object loss as the result of the process of an impaired formation of a firm self boundary. The patient places herself inside her objects (including non-human objects), and the loss of the latter is equivalent to loss of self. (This is one part of a continuing series on Bipolar Disorder which I have posted on our listserve)
Brian Koehler
New York
brian_koehler@psychoanalysis.net
