Psychoanalysis and Psychotherapy
Robert M. Young Online Writings
THE UBIQUITY OF PSYCHOTIC ANXIETIES
When I began composing this paper I could not decide whether the point I am trying to make is banal and obvious or really rather important. Perhaps its both at once. As Wilhelm Reich said, it is essential to subject things to the searching scrutiny of naive questions.
My point is that the Freudian definition of the unconscious and, a fortiori, the Kleinian one, says in a quite flat-footed way that fundamentally irrational processes are going on all the time in our inner worlds. The difference between the Freudian and the Kleinian versions of this point is that on the Kleinian account these processes are in a complex interplay with other, less irrational ones, from moment to moment, and the way Kleinians write about them and make interpretations of them makes them seem more extreme - in a word, crazier, playing a larger and more manifest part in everyday behaviour. Whatever one may want to say about the difference of tone or degree between Freudian and Kleinian accounts, its not startling news that crazy things go on in the unconscious. It is worth recalling that on both accounts, by far the larger part of what goes on in the mind is unconscious, where the rules of Aristotelian logic do not apply.
Why, then, might my point be rather important? There are a number of interrelated reasons. First, one might ask why this conference seemed necessary, that is, why are psychotherapists and psychoanalysts on the whole wary of and out of touch with psychosis and why are most psychiatrists equally (perhaps more) out of touch with psychodynamic formulations of psychotic phenomena? There seems to be a barrier or, at least, imperfect communication. Therapists and analysts do not commonly treat psychotics. All but a tiny minority of psychiatrists would not dream of using the talking cure as the treatment of choice with such patients. Indeed, Im told that in America an analyst was recently successfully sued for doing so and that the ensuing debate is ongoing in the American psychiatric journals. There are notable exceptions, to some of whom Ill return: Wilfred Bion, Hanna Segal, Herbert Rosenfeld Donald Meltzer, Murray Jackson, Michael Conran in this country and Harold Searles in America. But it is not common and is usually seen as research with limited therapeutic goals. Searles work with a number of patients over decades is the object of bemusement and ridicule in some circles, though Im bound to say that the more I do psychotherapy with psychotics, the more I admire him and envy his ability to find and convey the meaning and sense in what psychotics say.
Then there is the burgeoning literature on so-called borderline states and pathological organisations, categories which are problematic and whose legitimacy are the subject of intense debate in some quarters at the same time that the literature about them is rich and fascinating for what it suggests about the inner world and the refractory structures in individuals (Searles, 1986; Rosenfeld, 1987; Spillius. 1988, vol. 1, part 4; Silver and Rosenbleuth, 1992; Rey, forthcoming).
This leads on to the question of nosology, a topic which has a narrow and a wide focus. The narrow focus is the gulf that exists between psychoanalysts and psychotherapists on the one hand and psychiatrists on the other with respect to the relevance of psychiatric nosology. This gulf may be described quite simply. Psychotherapists dont think much in terms of disease entities or syndromes. Of course they do in a loose way, but their overwhelming emphasis is on unconscious dynamics. Orthodox psychiatrists tend to think in terms of categories, while therapists tend to think in terms of levels and movements back and forth between positions or emotional states.
Not only do we find a big difference of emphasis with respect to the extent to which classifications of the sort found in DSM - III-R are used, I also find that the distinctions between normal and neurotic and psychotic arent much used, at least in Kleinian circles. I hasten to add that the distinctions are around and relevant and that I carry around in my head terms which I attach to my patients in some reflective moments and in supervision, for example, paranoid, borderline, pathological organisation, depressed, schizoid, hysterical, and so on. But these are rarely in my mind during sessions.
The wider focus of the topic of nosology is the problematic role of classifications in medicine and science. Classifications are put forward as facts of nature, analogous, in the first instance, to disease categories in medicine, which, in turn, claim some affinity to natural classifications of species in biology and particles, elements and compounds in physics. This is a central feature of the scientific enterprise: the search for a definitive specification of natural kinds. The trouble with the attempt to find a natural classification in psychopathology is that the project of achieving such classifications opens up a very large can of worms about human nature, nature and the theory of knowledge - epistemology.
By this I mean that the attempt to classify mental phenomena has no language of its own. It is a consequence of Cartesian mind-body dualism that bodies are described in terms of primary qualities - extension and figure, treated geometrically and mathematically, while mind is negatively defined as that which does not pertain to body (Young, 1989; in press, ch. 1). The languages employed by scientists, which includes medics and therapists (regarded as rather pale shadows of proper scientists), are generated by analogy from more scientifically respectable disciplines. For example, the association of ideas was itself dreamed up as an analogy to the ways physical particles were thought to interact in the seventeenth and eighteenth centuries - a sort of billiard-ball impact physics (Young, 1970, pp. 94-100). The very notion of psychopathology was an attempt, begun in the mid-nineteenth century, to found the theory of mental disturbance on the disease model - hence mental disease - and a description of the features of such disorders was made analogous to the exciting new findings of the study of the pathology of organs and cells - hence the use of terms such as syndrome and morbid anatomy. The term psychopathology entered English in 1847 as a transliteration of the title of a book by Baron von Feuchstersleben, and there were titles around mid-century such as Elements of the Pathology of the Human Mind (Mayo, 1838), Chapters on Mental Physiology (Holland, 1852) and Henry Maudsleys Physiology and Pathology of Mind (1867) . Books with psychopatology in their titles were still being written in the 1980s (Berrios, 1991), and I currently lecture on the subject in several psychotherapy trainings
The history of ideas in psychopathology is the history of the extended use of a somatic analogy which, it was thought by Freuds teachers, would soon be securely founded on the actual findings of cerebral pathology (Amacher, 1965). Indeed, it is worth recalling that it was in this field that he chose to work (Bernfield, 1944, 1949, 1951; Kris, 1950). It was the subject of his first book, On Aphasia (1891; Stengel, 1954; Riese, 1958). He turned to treating neurotics because he couldnt afford to continue working as an academic researcher (Young, 1986; Gay, 1988, pp. 22-37). Throughout his writings we find analogies and metaphors drawn from physics, anatomy, physiology and pathology. Anatomical and reflex models were pervasive in The Interpretation of Dreams, and at the end of his life he was still thinking this way in the New Introductory Lectures, one of which was entltled The Dissection of the Psychical Personality (Freud, 1933, ch. 31)
Not only is it the case that psychopathological nosology is based on an extended and increasingly dubious analogy to the natural and biomedical sciences, but these efforts at placing the vicissitudes of human suffering on the bedrock of putatively natural classifications turn out, according to recent research in the history, philosophy and social studies of science, to be eminently historical. Ill repeat that , since it is crucial to what I am trying to say. Disease categories in psychiatry are eminently historical and change over time as a result of wider forces in the history of ideas and the history of culture. If that wasnt obvious before, systematic nosological work was attempted, it should be transparent from the fact that the official Diagnostic and Statistical Manual has gone through four revisions in its short history since it first appeared in 1952 (APA, 1987, pp. xviii-xix). You could say that they are moving progressively toward a refined truth, but the changes are not of that kind. It is more like the history of encyclopaedias, which may have been conceived in the belief that knowledge accumulates in a linear way. In fact, however, its categories, frameworks and terms of reference have also changed in successive editions. I have the eighth edition of The Encyclopedia Britannica, dated 1860. It includes a long article entitled Deluge, which goes into lots of complicated matters about the Biblical flood. The next edition, which appeared less than two decades later, has no such entry but does have a new one called Evolution. There are related changes throughout the edition, including the disappearance of a preliminary volume of essays called Dissertations and Discussions, which sought to encompass all of knowledge. Between those two editions the whole interllectual landscape had been recast as a result of the publication of Darwins Origin of Species.
You might think I am leading up to a sharp distinction between human knowledge and natural knowledge, but I submit that the example I have just given points the other way and shows that the historicity of categories also applies to natural knowledge. As I have tried to show in my films and other writings, ideas of nature have a history (Young, 1973, 1985, ch. 6; Young and Postle, 1981; Young and Gold, 1982). One inspiration for this approach is Georg Lukács, who argued, the idea of nature in any period is the theoretical reflection and projection of the social milieu of the times (Lukács, 1923, p. 38). Nature is a societal category. That is to say, whatever is held to be natural at any given stage of social development, however this nature is related to man and whatever form his involvement with it takes, i.e. natures form, its content, its range and its objectivity are all socially conditioned (ibid., p. 234). What is true of nature in general also applies to the framing of natural kinds or classifications. So the attempt to found the understanding of human distress on an analogy to somatic pathology, which is, in turn, reducible to physiology, biochemistry, chemistry and physics, fails to take note that the bedrock is itself changing as a function of broader movements in the culture. This is less obvious in the physico-chemical sciences, but it is still the case. It is obviously so in medicine, as a brilliant and pioneering series of essays by Karl Figlio has shown with respect to the rise and fall of certain eminently somatic diseases - chlorosis and miners nystagmus (Figlio, 1978, 1979, 1985). He has moved on, following Harold Searles profound book on The Nonnhuman Environment, to explore we experience and deploy the external world in our unconscious projective processes (1990).
Note carefully that I am not saying that there was no such thing as chlorosis or miners nystagmus. The medical textbooks and hospital records prove that there was and that their natures changed over time. These syndromes were discovered and treated as natural kinds. One had as its pathognomonic symptom a kind of anaemia, the other a disorder of the eyes. They waxed and waned in the medical literature as the constellation of social forces which evoked them changed over decades. The same is true of the nosological categories in DSM. An example is ego-syntonic homosexuality. It has simply ceased to be a disease, though if you have the non-ego syntonic variety you are still - according to the current classification - sick. I learned this system of ideas - what anthropologists call a belief system - as a psychiatric aide in Arizona (where promiscuity and priapism were still considered grave illnesses) and got to be a dab hand at making diagnoses, just as I later learned to do assessment interviews in a psychotherapy department and to make dynamic formulations which met the prevailing standards. Even diagnostic categories which have been challenged can elicit high degrees of reliability which meet scientific standards of intersubjective validation, as Alex Tarnopolsky (1992) has shown with respect to borderline disorders.
You can be forgiven for thinking that I am spending a long time in the foothills of my argument. My reply would be that I am at the summit of it in a number of respects. Even so, if I may vary the metaphor, I am poised for re-entry to the part of my text which concentrates on the modifier psychotic. My vehicle for re-entry is Peter Barhams breathtakingly wise book on Schizophrenia and Human Value, in which he argues that we must move off the nosological relegation of schizophrenics to demented chronicity and learn to think of them as living lives, of which it can be said, thereby hangs a tale, that is, a narrative which has meaning and value and merit our attentiveness, whether or not the cause of schizophrenia turns out to be largely biochemical. (I have never understood why people think that biological causation diminshes the meaningfulness of what psychotic people say and do.) Barham has gone on to say that because they tell a recognisably meaningful story - mented, as it were, rather than de-mented - the lives of these people merit provision appropriate to fellow human beings who, like people in wheelchairs, are in need of certain kinds of spaces which facilitate their doing whatever they can, rather than the stark alternatives of hospitals or cardboard cities (Barham, 1992).
Barham argues his thesis on general humanitarian grounds but also draws on writings by Alisdair MacIntyre and Richard Rorty which are critical of the hegemonic claims of scientific rationality and seek to promote narrative, story-telling, evaluative and humanocentric ways of speaking about things, especially human things, by which I mean not treating the relations between people as if they were relations between things. This goes against the grain of the history of scientism, whereby scientific rationality and materialist explanations were offered as the models for all of knowledge - a movement which peaked in the 1950s and has recently been under attack in general philosophy and in the philosophy of both the natural and the so-called human sciences (Rorty, 1982, ch. 12).
It is at this point that two strands of my argument meet. First, there is a widespread and growing critique of reductionist explanations based on the increasingly historicised bedrock of natural science. Second, and closely allied, there is a movement of critique of rationalist views of human nature in psychology and social studies - moving away from enlightenment and positivist models and toward a more tolerant and inclusive view of the role of primitive processes in our lives. These strands meet at the point where human phenomena are increasingly described in terms which are recognisably human, rather than - as was the case at the high tide of scientism - in terms which reduce the human to the parameters of scientific rationality and human nature to a split between the rational and the Other, whereof one cannot speak.
I hope I have said enough to make plausible the project of addressing my title and pointing out the ubiquity of psychotic anxieties. I have set the stage in the way I have in order to make clear that what I shall now say about Freudian and Kleinian ideas is not just a re-hash but a repositioning of these ideas in the context of a broader movement in philosophy and the study of humanity, society and the world. It puts primitive processes in the context of a broader cultural movement which is challenging the privileging of forms of discourse drawn directly or by analogy from natural science.
That movement is not entirely new. It has a distinguished history. What is new is that the claim that primitive and irrational processes are central to human nature, and it should not provoke a scandalised response. There is a good analogy to related developments in epistemology. The word ideology and the adjective ideological have had pejorative meanings since Napoleon trashed the movement by that name in the early nineteenth century (Young, 1971, 1973, 1977). But ideology only held its terrors in virtue of being in paired opposition to science, rather as fact and value are paired. But if the strong claims hitherto made for science are seen to melt away, then ideology - the colouring of accounts of things by interest groups - becomes the norm, not the deviation (Haraway, 1989, 1990; Young, 1992a). If the science/ideology and the fact/value distinctions are undermined, because science is ideological and facts are value-laden, then the closely related split between psychotic and non-psychotic (or normal) should also be reconceptualised.
The distinguished history to which I refer is easily recalled. Plato banished the poets and songsters from his rationalist republic. The role of the senses and accidental connections was, in very different ways, one of sullying knowledge in the purest of both the rationalist and empiricist traditions. But David Hume, the deepest of the empiricists, made passion central to human nature and knowing. Illumination from witches and hermetical and magical processes remained strong themes in Renaissance thought but also in the eminently respectable writings of Paracelsus, van Helmont and other figures in early chemistry and, most notably, in Newtons world view (Webster, 1982). The point of this is that the official line - that meaning and purpose and the so-called final causes of the Aristotelian tradition were banned from scientific explanation - leaves out the hugely important fact that they remained active in the deepest assumptions of the greatest scientists such as Newton and Darwin (Rattansi, 1973; Young, 1985, 1989 1992b)
If we look at the history of painting for evidence of the profound truths which have been believed to inhere in the irrational, one need only mention Bosch, Breughel, Goya, van Gogh, Surrealism and Dada for a continuous tradition of illumination sought from primitive, irrational and disturbing images. Think of Magritte and Man Ray and the films of Buñel. Similar stories can be told about literature, culminating in the significance attached to automatic writing and stream of consciousness in recent times.
The history of psychiatry tells the same story, as Foucault has shown in Madness and Civilisation and as was made part of a movement in aspects of the so-called anti-psychiatry movement which was (in part wrongly) associated with the work of Laing, Cooper and Esterson (Laing, 1960; Cooper, 1972; Laing and Esterson,1970; Boyers and Orill, 1972; Ingleby, 1981). There is a common theme here - that we must pay attention to what is usually called psychotic. It has a meaning. This is sensitively demonstrated in Laings writings and exemplified in detail by Barhams analyses of discussions among chronically schizophrenic patients (Barham, 1984, chs. 4 and 5). It could be said that most of the four volumes by Harold Searles are demonstrating the meaningfulness of psychotic utterances (Searles 1960, 1965, 1979, 1986), while his gladiatorial dialogue with Langs defends his special competence in this utterly demanding work (Langs and Searles, 1980, esp. ch. 4 and appendix).
Lets take stock. I have granted that there are banal and potentially illuminating versions of my thesis. I have reminded you of certain differences of preoccupation and approach of psychiatrists and those who think psychoanalytically. I have contrasted nosology and dynamics. I have made a critique of the claims of classification to be based on an unproblematic idea of the natural, since the natural is itself historical - part of the history of culture. Finally, I have begun an attempt to bring the primitive and irrational - the psychotic - to the centre of our humanity. In doing so I have been implicitly undermining orthodox, ego psychology models, along with orthodox psychiatric ones.
Now to psychotic anxieties per se.. Lest it be thought that the strands of my argument are not being interwoven into a recognisable pattern, let me say what I want you to discern in the final product. It is that human distress, if we are to treat it as human, must be interpreted as intelligible all the way to its deepest roots as well as its broadest determinations. A whole set of interpreters has helped us to place ideas - including scientific, medical, psychiatric and psychological ideas - inside the broader history of culture. They have not been as assiduous in doing this with primitive forces in human nature, though, God knows, we have plenty of evidence at the moment for the baleful effects of such forces. These, too, must be treated as part of the mainstream of human nature in the individual and in groups, institutions, cultures and communities. The fact that it is hard to find a language adequate for characterising and interpreting pre-linguistic and sub-linguistic feelings only makes the problem more difficult and challenging. It does not excuse abrogating the constitutive role of intense irrational motives in how we think, feel and behave. To say with the philosopher that nothing human is foreign to me is to open the door of theory and practice to the ubiquity of psychotic anxieties and to begin to break down the barriers of mutual incomprehension and subcultural separation between psychotherapy and psychiatry. I see these as institutionalised forms of the splitting off of deep and irrational feelings from the received account of how we think. If science is to be reintegrated with meaning, purpose, goals and values - including ideology and politics - then psychotherapy, psychoanalysis and psychiatry must, as part of the overall project, be reintegrated with the deepest sources of the evalutive dimension. This has implications for both communities and for training as well as practice.
I begin with some classic texts. This from Freuds Formulation on the Two Principles of Mental Functioning (1911): With the introduction of the reality principle one species of thought-activity was split off; it was kept free from reality-testing and remained subordinated to the pleasure principle alone. This activity is phantasying., which begins already in childrens play, and later, continued as day-dreaming, abandons dependence on real objects (Freud, 1911, p.222) The strangest characteristic of unconscious (repressed) processes... is due to their entire disregard of reality testing; they equate reality of thought with external actuality, and wishes with their fulfilment - with the event - just as happens automatically under the dominance of the ancient pleasure principle (ibid., p. 225). Freud says here that the persistence of the irrational is fundamental to human nature and remains so as we develop.
This from Joan Rivieres On the Genesis of Psychical Conflict in Early Infancy (1952): I wish especially to point out... that from the very beginning of life, on Freuds own hypothesis, the psyche responds to the reality of its experiences by interpreting them - or rather, misinterpreting them - in a subjective manner that increases its pleasure and preserves it from pain. This act of subjective interpretation of experience, which it carries out by means of the processes of introjection and projection, is called by Freud hallucination; and it forms the foundation of what we mean by phantasy-life. The phantasy-life of the individual is thus the form in which his real internal and external sensations and perceptions are interpreted and represented to himself in his mind under the influence of the pleasure-pain principle. (It seems to me that one has only to consider for a moment to see that, in spite of all the advances man has made in adaptation of a kind to external reality, this primitive and elementary function of his psyche - to misinterpret his perceptions for his own satisfaction - still retains the upper hands in the minds of the great majority of even civilized adults.) (Riviere, 1952, p. 41). In claiming that experience is characteristically misinterpreted at source and that hallucination is the foundation of experience, Riviere is saying that there is no neutral observation language in everyday life. The same claim is made of science in recent work in the philosophy of science.
I want to turn now to the history of ideas about psychotic processes in Klein, Bion and Meltzer. Klein described schizoid mechanisms as occurring in the baby's development in the first year of life characteristically... the infant suffered from states of mind that were in all their essentials equivalent to the adult psychoses, taken as regressive states in Freud's sense (Meltzer, 1978, part 3, p. 22). Klein says in the third paragraph of her most famous paper, 'Notes on Some Schizoid Mechanisms' (1946), 'In early infancy anxieties characteristic of psychosis arise which drive the ego to develop specific defence-mechanisms. In this period the fixation-points for all psychotic disorders are to be found. This has led some people to believe that I regard all infants as psychotic; but I have already dealt sufficiently with this misunderstanding on other occasions' (Klein, 1975, vol. 3, p. 1). Meltzer comments that 'Although she denied that this was tantamount to saying that babies are psychotic, it is difficult to see how this implication could be escaped' (Meltzer, 1978, part 3, p. 22).
Kleinian thinking evolved in three stages. As in the above quotation, Klein saw schizoid mechanisms and the paranoid-schizoid position as fixation points, respectively, for schizophrenia and manic-depressive psychosis. Then the paranoid-schizoid (ps) and depressive (d) positions became developmental stages. Her terminology included 'psychotic phases, 'psychotic positions' and then 'positions' (Klein, 1975, vol. 1, pp. 275n-276n, 279). Thirdly, in the work of Bion and other post-Kleinians, these became economic principles and part of the moment-to-moment vicissitudes of everyday life. The notations 'ps' and 'd' were connected with a double-headed arrow - ps Ö d - to indicate how easily, frequently and normally our inner states oscillate from the one to the other and back again (Meltzer, 1978, part 3, p. 22).
In Bion's writings on schizophrenia an ambiguity remained as to whether or not the psychotic part of the personality is ubiquitous or only present in schizophrenics (Bion,1967, esp. ch. 5), but Meltzer concludes his exposition of Bion's schizophrenia papers by referring to the existence of these phenomena in patients of every degree of disturbance, even 'healthy' candidates in training to be therapists (Meltzer, op. cit., p. 28). Going further, he and colleagues have drawn on the inner world of autistic patients to illuminate the norm (Meltzer et al, 1975; Frances Tustin 1986) has essayed on autistic phenomena in neurotic patients, while Sydney Klein (1980) has described 'autistic cysts' in neurotic patients. In his most recent writings on The Claustrum (1992), Meltzer has elegantly shown that desperate defences against schizophrenic breakdown account for much of the psychology and behaviour of competitive and dramatically successful executives and leaders. Those who live in the claustrum - the lower colon of the mental digestive tract - have inner worlds dominated by virulent projective identification.
Klein's views on these matters are based on Freud and Abraham's notions of oral libido and fantasies of cannibalism (Gedo, 1986, p. 94). She begins her essay, A Contribution to the Psychogenesis of Manic-Depressive States (1935), with claims about the extreme feelings of all babies: My earlier writings contain the account of a phase of sadism at its height, through which children pass during the first year of life. In the very first months of the babys existence it has sadistic impulses directed, not only against its mothers breast, but also against the inside of her body: scooping it out, devouring the contents, destroying it by every means which sadism can suggest (Klein, 1975, vol. 1, p. 262). Once again, the projective and introjective mechanisms of the first months and year give rise to anxiety situations and defences against them, 'the content of which is comparable to that of the psychoses in adults' (ibid.).
Orality is everywhere, for example, in the 'gnawing of conscience' (p. 268). Riviere says that 'such helplessness against destructive forces within constitutes the greatest psychical danger-situation known to the human organism; and that this helplessness is the deepest source of anxiety in human beings' (Riviere, 1952, p. 43). It is the ultimate source of all neurosis. At this early stage of development, sadism is at its height and is followed by the discovery that loved objects are in a state of disintegration, in bits or in dissolution, leading to despair, remorse and anxiety, which underlie numerous anxiety situations. Klein concludes, 'Anxiety situations of this kind I have found to be at the bottom not only of depression, but of all inhibitions of work' (Klein, 1975 vol. 1, p. 270).
It should be recalled that these are pre-linguistic experiences developmentally, and sub-linguistic in adults. They are hard to characterise and hard to think about. It is a characteristic of the world view of Kleinians that the primitive is never transcended and that all experiences continue to be mediated through the mother's body. Similarly, there is a persistence of primitive phantasies of body parts and bodily functions, especially biting, eating, tearing, spitting out, urine and urinating, faeces and defecating, mucus, genitals. One of the reasons we dont like to think about these matters is that it is very hard to characterise them.
Why is all this such an innovation? Riviere points out that anxiety was of great significance to Freud, but that much of his rhetoric was scientific, especially physiological. He did not concern himself with the psychological content of phantasies. Indeed, he and many of his so-called Freudian followers have tended to use scientistic analogies instead of conveying human distress in evocative language. By contrast, 'Anxiety, with the defences against it, has from the beginning been Mrs Klein's approach to psycho-analytical problems. It was from this angle that she discovered the existence and importance of aggressive elements in children's emotional life... and [it] enabled her to bring much of the known phenomena of mental disorders into line with the basic principles of analysis' (Riviere, 1952, pp. 8-9).
This contrast between Freud and Klein takes us back to one of the major themes of my argument - the need to break away from describing the inner world in terms drawn from a metapsychology based on analogies drawn from physics and biology. I am advocating, instead, the bold use of terms drawn from the language of everyday life - including and especially primitive emotional life - and the employment of any way of representing primitive processes that comes to hand. This involves a move from the didactic and objectivist language of natural science and the epistemologies which kow-tow to it and toward evocative and phenomenological ways of attempting to convey the inner meaning of experience. Mental space need not be reduced to the realm of extended substances; it can be filled and populated by whatever kind of account helps us to keep feeling alive. Rather than defer to the canons of Cartesian dualism, our criterion should be whether or not a given account resonates with the dialectic of experience.
Kleinians have consistently written in a language which eschews physicalist scientism, albeit Klein did retain a notion of instinct, even though this was largely redundant as a result of her object relations perspective. They went on to propose elements of a general psychology, including the claim that there is 'an unconscious phantasy behind every thought and every act' (p.16). That is, the mental expression of primitive processes 'is unconscious phantasy' (ibid.). It is not only a background hum, as it were. Susan Isaacs claims that 'Reality thinking cannot operate without concurrent and supporting unconscious phantasies' (Isaacs, 1952, p. 109). And again: 'phantasies are the primary content of unconscious mental processes' (pp. 82, 112). 'There is no impulse, no instinctual urge or response which is not experienced as unconscious phantasy' (p. 83). 'Phantasies have both psychic and bodily effects, e.g., in conversion symptoms, bodily qualities, character and personality, neurotic symptoms, inhibitions and sublimations' (p. 112). They even determine the minutiae of body language (p. 100). The role of unconscious phantasy extends from the first to the most abstract thought. The infant's first thought of the existence of the external world comes from sadistic attacks on the mother's body (Klein, 1975, vol. 1, p. 276; vol. 3, p. 5). 'Phantasies - becoming more elaborate and referring to a wider variety of objects and situations - continue throughout development and accompany all activities; they never stop playing a great part in mental life. The influence of unconscious phantasy on art, on scientific work, and on the activities of everyday life cannot be overrated' (Klein, 1975, vol. 3, p. 251; cf. p. 262).
These anxieties are not only ubiquitous: they interact in complicated ways. As Riviere points out, 'It is impossible to do any justice here to the complexity and variety of the anxiety-situations and the defences against them dominating the psyche during these early years. The factors involved are so numerous and the combinations and interchanges so variable. The internal objects are employed against external, and external against internal, both for satisfaction and for security; desire is employed against hate and destructiveness; omnipotence against impotence, and even impotence (dependence) against destructive omnipotence; phantasy against reality and reality against phantasy. Moreover, hate and destruction are employed as measures to avert the dangers of desire and even of love. Gradually a progressive development takes place... by means of the interplay of these and other factors, and of them with external influences, out of which the child's ego, his object-relations, his sexual development, his super-ego, his character and capacities are formed' (Riviere, 1952, pp. 59-60).
It was on the foundation of these ideas about individual psychology that the classical work on groups and institutions of Bion, Elliott Jaques and Isabel Menzies Lyth was built. Bion argued that group phenomena required a deeper explanation than the Freudian one employing the family and id, ego and superego. He did not repudiate these but delved deeper into the realm of psychotic anxieties, which he believed operated in all groups. The forms of distress that converted sensible work groups into mad ones dominated by what he called basic assumptions, correspond so closely with extremely primitive part objects that sooner or later psychotic anxiety, appertaining to these primitive relationships, is released. The defensive measures to which the groups resort are the same as those which individual babies employ in the face of their earliest anxieties (Bion, 1955, p. 456). Bion suggests that these primitive anxieties contain the ultimate sources of all group behaviour (p. 476).
Jaques begins his essay on 'Social Systems as a Defence against Persecutory and Depressive Anxiety' (1955) by reiterating that 'social phenomena show a striking correspondence with psychotic processes in individuals', that 'institutions are used by their individual members to reinforce individual mechanisms of defence against anxiety', and 'that the mechanisms of projective and introjective identification operate in linking individual and social behaviour'. He argues the thesis that 'the primary cohesive elements binding individuals into institutionalised human association is that of defence against psychotic anxiety' (Jaques, 1955, pp. 478-9). He points out that the projective and introjective processes he is investigating are basic to even the most complex social processes and directs us to Paula Heimann's argument that they are at the bottom of all our dealings with one another (p. 481, 481n).
His conclusion is cautionary and points out the conservative - even reactionary - consequences of our psychotic anxieties and our group and institutional defences against them. He suggests that as a result of these reflections on human nature 'it may become more clear why social change is so difficult to achieve, and why many social problems are so intractable. From the point of view here elaborated, changes in social relationships and procedures call for a restructuring of relationships at the phantasy level, with a consequent demand upon individuals to accept and tolerate changes in their existing patterns of defences against psychotic anxiety. Effective social change is likely to require analysis of the common anxieties and unconscious collusions underlying the social defences determining phantasy social relationships' (p.498).
I turn finally to the investigator who, in my opinion, has made the most of this perspective, Isabel Menzies Lyth, who built her research on the shoulders of Bion and Jaques. She has investigated a number of fraught settings, extending from the fire brigade to the Institute of Psychoanalysis, but the piece of research which has deservedly made her world-famous is described in a report entitled 'The Functioning of Social Systems as a Defence against Anxiety' (1959). It is a particularly poignant document, which addresses the question why people of good will and idealistic motives do not do what they intend, that is, why nurses find themselves, to an astonishing degree, not caring for patients and leaving the nursing service in droves. It would be repetitious to review the mechanisms she describes. They are the ones discussed above. What is so distressing is that they operate overwhelmingly in a setting which has as its very reason for existence the provision of sensitivity and care. Yet that setting is full of threats to life itself and arouses the psychotic anxieties I have outlined. She says, 'The objective situation confronting the nurse bears a striking resemblance to the phantasy situations that exist in every individual in the deepest and most primitive levels of the mind. The intensity and complexity of the nurse's anxieties are to be attributed primarily to the peculiar capacity of the objective features of her work situation to stimulate afresh those early situations and their accompanying emotions' (Menzies Lyth, 1988, pp. 46-7).
The result is the evolution of socially structured defence mechanisms which take the form of routines and division of tasks which effectively preclude the nurse relating as a whole person to the patient as a whole person. 'The implicit aim of such devices, which operate both structurally and culturally, may be described as a kind of depersonalisation or elimination of individual distinctiveness in both nurse and patient. For example, nurses often talk about patients not by name, but by bed numbers or by their diseases or a diseased organ: "the liver in bed 10" or "the pneumonia in bed 15". Nurses deprecate this practice, but it persists' (pp. 51-2). She lists and discusses the reifying devices which reduce everyone involved to part-objects, including insight into why the nurse wakes you up to give you a sleeping pill (p. 69). There is a whole system of overlapping ways of evading the full force of the anxieties associated with death, the ones which lie at the heart of the mechanisms which Klein described (pp. 63-64; cf. Riviere, 1952, p. 43).
Menzies Lyth also draws a cautionary conclusion: 'In general, it may be postulated that resistance to social change is likely to be greatest in institutions whose social defence systems are dominated by primitive psychic defence mechanisms, those which have been collectively described by Melanie Klein as the paranoid-schizoid defences' (Menzies Lyth, 1988, p. 79). In recent reflections on her work and that of her colleagues, she has reiterated just how refractory to change institutions are (Menzies Lyth, 1988, pp. 1-42 and personal communications).
That completes my exposition of the Kleinian and post-Kleinian literature. I find it sobering and profoundly challenging to any hope for a better world. I do not think it can be squared with at least two other traditions. The first is the orthodox and neo-Freudian one where the egos mechanisms of defence manage to keep irrational forces at bay or to neutralise or tame them before they enter consciousness. Nor do I find it compatible with the convenient distinction between people who are either normal (or normally miserable and neurotic) and others who are in a different state called psychotic, with allowances for periods in the repair shop called breakdowns. Im not saying that there are not psychotic people or people who have breakdowns. I am saying that those people are not as strange to the rest of us as the nosologists would have you believe. My point is that we are not strangers to psychotic processes in our everyday lives, families, groups, institutions and societies. There is a lot of it about all the time - not just the wars and conflicts we see all around us, particularly at the moment. I refer also to what happens in psychotherapeutic and psychoanalytic training organisations - also particularly at the moment when a paranoid atmosphere has been generated by the divisive behaviour of a small number of elitists who, in my opinion and that of some eminent psychoanalysts, have destructively sought to undermine the United Kingdom Standing Conference on Psychotherapy. But this is not unusual. What is surprising is that this sort of behaviouroccurs in and between psychotherapeutic, psychoanalytic and group relations institutions - the cradles of the very psychodynamic enlightenment which I have been trying to lay before you. But thats not surprising, either. It is true in the churches, academic institutions and charities, the schools, asylums and major corporations, monasteries and nunneries, orphanages and sports teams, political parties and communes. I am not listing institutions for completeness sake. I have in mind quite specific incidents and histories. Not all the time but in all institutions. We are all partly psychotic all of the time and all of us psychotic part of the time. Bion insists that the move into basic assumption functioning is involuntary, automatic and inevitable (Bion, 1955, p. 458).
Having objects into which to project is the sine qua non of mental well-being. But we do so in a vulnerable space, on one side of which is nameless dread and a black hole and on the other the intense projections of outgrouping, racism and virulent nationalism. All of us become humans by learning to project and members of groups by being socialised into their projective identifications, some good, some very nasty (Young, forthcoming, chs.6 and 7). The same is true of professions, even and especially helping professions like nursing, medicine, psychiatry and psychotherapy.
I recall that eminent Freudian, Joseph Sandler, describing psychotherapy as a process of making friends with the unacceptable parts of ourselves. Just as Bion said we had to delve deeper than Freud to get at the ultimate sources of all group behaviour, I think we have to grant that the ubiquity of psychotic anxieties means that we are up against much more in ourselves that we are inclined to believe. So there are even more unacceptable parts to be befriended or neutralised or repressed by the thin veneer of civilisation. To deny their ubiquity or to overestimate the strength of that veneer strikes me as ostrich-like and to tempt us to hide our eyes from the lessons of the nursery, the family, society and international relations. I think this blinkered attitude helps to explain why psychiatrists and psychotherapists try to restrict the range of their obligations, the people with whom they work and the issues upon which they reflect.
We split off these feelings and try to confine them to scapegoats called psychotics. I suggest that much official psychopathology and classification serve defensive purposes and protect us from psychotic anxieties. These are forms of control which - like the banishment of purposes and goals in scientific explanation - sequester existential risk and politics and drive underground the legitimate angst of suffering people. The official healers in society do their jobs humanely but get turned into minders. While I was still writing this paper I saw a film about the huge oil spill of the Exxon Veldeez in Alaska, in which phalanxes of reasonably conscientious officials never got into a hands-on tactile relationship with the millions of gallons of sludge or the fatal coating their ways of working and their blinkered notion of energy had allowed to stifle life. It struck me as a metaphor for the urgency of the reconceptualisation I am proposing.
I think Freud pointed the way in the concluding passage in his presciently realistic though pessimistic essay - Civilization and Its Discontents (1930). He wrote that the history of civilisation is 'the struggle between Eros and Death, between the instinct of life and the instinct of destruction, as it works itself out in the human species. This struggle is what all life essentially consists of... And it is this battle of the giants that our nurse-maids try to appease with their lullaby about Heaven' (Freud.,1930, p. 122).
Paper presented to international conference on Psychosis: Understanding and Treatment, University of Essex, Colchester September 1992, to appear in Jane Ellwood, ed, Psychosis: Understanding and Treatment. London: Jessica Kingsley, 1995, pp. 34-53.
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