Psychosis and Near Psychosis

Eric R. Marcus

Psychosis and
Near Psychosis
Ego Function, Symbol Structure,
Treatment

Springer-Verlag
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Eric R. Marcus, M.D.
College of Physicians & Surgeons of Columbia University
Associate Clinical Professor of Psychiatry and Social Medicine
Director of Medical Student Education in Psychiatry;
Facuity, Columbia University Psychoanalytic Center
for Training and Research
722 W. 168 St.
New York, NY 10032
USA

Marcus, Eric R.
Psychosis and near psychosis/Eric R. Marcus.
p. cm.
Includes bibliographical references and index.
1. Psychoses. 2. Psychoses- Treatment. I. Title.
[DNLM: 1. Ego 2. Psychoanalytic Therapy. 3. Psychotic
Disorders. WM 200 M322p]
PC512.M36 1992
616.89-dc20
DNLMIDLC 91-5231

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© 1992 Springer-Verlag New York Inc.

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987654321
ISBN-13: 978-1-4613-9199-9 e-ISBN-13: 978-1-4613-9197-5
DOl: 10.1007/978-1-4613-9197-5
To My Late Mother
Pearl Marcus

And My Father
Victor Marcus
Nodding his head politely, the stranger walked noiselessly to the bench
and sat down, and Kovrin recognized the Black Monk. For a minute they
looked at one another, Kovrin with astonishment but the Monk kindly and,
as before, with a sly expression on his face.
"But you are a mirage," said Kovrin. "Why are you here, and why do you
sit in one place? That is not in accordance with the legend."
"It is all the same," replied the Monk softly, turning his face toward
Kovrin. "The legend, the mirage, I-all are products of your own excited
imagination. I am a phantom."
"That is to say, you don't exist?" asked Kovrin.
"Think as you like," replied the Monk, smiling faintly. "I exist in your
imagination, and as your imagination is a part of nature, I must exist also in
nature."

- Anton Chekhov
The Black Monk •

• Collected Stories of Anton Chekhov.

Edited with an introduction by Robert N. Linscott.
New York: The Modern Library, 1932.
(Used with permission.)
Acknowledgments

My wife, Dr. Eslee Samberg, read parts of this book and offered helpful
advice based on her standards of psychiatric and psychoanalytic work and
also on her appreciation of language and syntax.
I have been fortunate in seeing much good therapy which serves as a
continuing model. I am especially grateful to Dr. Daniel Shapiro and Dr.
Winslow Hunt; also Dr. Will Fey, Dr. David Moltz, Frank Ferrelly, and
Arthur Schwartz.
Dr. Thomas Q. Morris, past President of Presbyterian Hospital of
Columbia Presbyterian Medical Center, and Dr. Sidney Malitz, past Acting
Director of New York State Psychiatric Institute, are mentors whose clinical
values form the basis of my work with patients.
Sarah Bradley, M.S.S.W., discussed many of my ideas with me as applied
to daily care of hospitalized patients and their families. I learned milieu
organization of hospital units from Lois Marin Mahonchak, R.N. I learned
behavioral limit setting from Mental Health Technicians Mrs. Pauline Wade,
Mr. David Whitaker, and Mr. Otis Lee Barnes. I learned about diagnosis
from patient drawings from Mrs. Phyllis Ward Reichbach.
The late Dr. Rita Rudel and her COlleague Dr. Rita Haggerty taught me
about the neuropsychology of ego dysfunction.
One of the most helpful educational experiences in clinical work is
personal supervision. I have been most fortunate in having as supervisors Dr.
Otto Kernberg, Dr. Roger MacKinnon, Dr. Len Diamond, Dr. Donald
Meyers, and the late Dr. Robert Liebert. I was also helpfully supervised by
Dr. Michael Stone, the late Dr. Harry Albert, Dr. Jerry Finkel, Dr. Joel
Hoffman, and Dr. Mark Mankoff.
Dr. Ira Feirstein has been my professional compatriot since internship.
This book is in some sense the result of his example, and he has understood
and encouraged it since its very first scribbling.
Professor Richard Kuhns and his wife, Dr. Margaret Kuhns, read an early
manuscript of the book and offered many helpful suggestions. Professor
Kuhns and I jointly teach a graduate seminar in the Department of
Philosophy at Columbia University from which my interest in symbolic
processes was greatly enriched.
ix
x Psychosis and Near Psychosis

Dr. Richard Friedman went over an early draft of this book and offered
many challenging suggestions along with encouragement to truly speak my
mind.
Susan Shaw typed the five rewritings that this book seemed to require.
Nan Jordan, who toiled on the word processor before her, was there at the
beginning for this book. Douglas Barnes formatted the book from the
manuscript with intelligence and diligence. He will soon write his own
books.
Springer-Verlag is an organization with the knowledge and courage to
like a book such as mine.
To these and many others, my thanks and my gratitude.
Contents

Acknowledgments ..................................... ix

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. xiii

1. Ego Functions ...................................... 1

2. Psychotic Structure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

3. Near Psychosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

4. Mental Status Examination ............................ 117

5. Psychiatric Illnesses and Mental Structure ................. 143

6. Medication and Mental Structure 185

7. Psychoanalytic Psychotherapy
and Psychoanalysis of Psychosis 217

8. Psychoanalytic Psychotherapy
and Psychoanalysis of Near Psychosis 251

Bibliography ......................................... 277

Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 297

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 301

xi
Introduction

The purpose of this book is to describe the experience of psychotic and near
psychotic mental states. This description is used as the basis of an approach
to treatment which integrates the phenomenology of all psychosis or near
psychosis, the symptoms and organizations of some specific psychiatric
illnesses, the mental effect of psychotropic medication, the technique of
psychoanalytic psychotherapy and psychoanalysis, and certain aspects of
clinical theory.
This can be done because daily work with psychotic and near psychotic
patients over the last 20 years convinces me that these illnesses have a
specific mental structure.
Mental stnlcture means mental experience that is stable over time, both in
content and in relationship of elements: both forms and processes (Le., the
dynamic intensity relationships). For a recent review of the concept of
structure in psychoanalytic theory see Shapiro (1988). For a different view
of psychoanalytic structure, see Slap and Slap-Shelton (1991). Many
experiences are organized in stable, dynamic forms of relationships; psychotic
and near psychotic ones, perhaps especially so.
Psychiatry has classified psychopathology into disease categories according
to conscious symptoms and behavior. Psychoanalysis has described man's
unconscious emotional life and its stable organizations. Psychoanalysis
properly calls these unconscious emotional organizations structures because
they also are registered, stored, stable, mental experiences. Therefore I use
the concept of structure to include both conscious and unconscious
elements. Because I believe conscious elements are linked to unconscious
elements in characteristic ways in psychotic and near psychotic patients,
psychoanalysis could profitably consider both conscious and unconscious
aspects without worrying that the focus will shift away from important
emotional experience.
Psychoanalysis has used clusters of unconscious mental experience with
thematic, dynamic, emotional content as psychoanalytic illness categories.
These illnesses are called the neuroses. The content and organizations of
these unconscious, dynamic, emotional structures, particularly in defenses,

xiii
xiv Psychosis and Near Psychosis

describe the different neurotic illnesses for psychoanalysis. General

psychiatry has not needed to look at the unconscious for its illness
categories, since conscious experience and easily observable behavior are
usually so extreme in psychotic illnesses. But if conscious psychotic
experiences and behaviors are characteristically linked to the unconscious
emotional life of psychotic and near psychotic patients, then the unconscious
experience of psychosis is congruent with and elaborates those psychiatric
illness categories. The unconscious and the conscious in the psychotic and
near psychotic illnesses are affected by the illness process in specific ways.
Therefore, the continuum of intensities and plastically organized contents of
the unconscious fits into the more rigidly bordered categories of general
psychiatry. The use of psychoanalytic observations about the dynamic
unconscious for description of the stable, emotional experience of illness
makes the general psychiatric categories of illness richer and more
understandable to the treating physician. It makes treatment decisions
clearer. It makes accurate, empathic, psychotherapeutic contact easier.
The conscious and unconscious structures are influenced by reality, illness
organization transformation processes, the phase of mental development in
which the illness occurs, the evolving developmental processes that may be
interrupted or altered, and innate symbolic content and processes of man's
symbolizing function. Whether psychosis is stable and unchanging or
unstable and rapidly changing, it is describable in structural terms as
characteristic stabilities or characteristic losses of stabilities. The concept of
stable mental experience structures is even more crucial for psychosis than
for neurosis, because when mental illness seems chaotic, guidelines for
treatment are lost unless one sees the deviations from normal structure that
are occurring. Actually, much psychotic illness is not chaotic but rigidly
fixed. Again, the concept of structure is so helpful because the content and
processes have a structure that, once described clearly, can guide treatment.
I will argue that psychotic and near psychotic structure results from
specific changes in ego function. I will describe the resulting universal
features of all psychotic and near psychotic structure as well what specific
psychiatric illnesses do to that structure.
Structure-process is a concept inherent in the psychoanalytic use of the
term structure, which tries to capture structure both as stable in content and
as changing in intensities and in relationship of intensities. I also feel there
is a relationship between change in intensity and change in content. The
interaction between changing, emotional aspects of mental functioning and
fixed, relatively unchanging aspects, such as ideas or attitudes, or seemingly
fixed aspects of ego function, such as intelligence, is a dynamic process that
can also be stable if its rules of organization never change. For example,
elements and the relationship of elements can remain stable while the
intensities or expressions of these elements fluctuate. This dynamic
structure-process combination is what is meant by mental structure as it is
actually observed in the clinical setting, especially in psychotic and near
Introduction XV

psychotic states. These observed structure-processes are one of the bases of

descriptive clinical theory.
Descriptive clinical theory is an early phase of scientific research in which
observation leads to a hypothesis, which leads to an observational
hypothesis. These observational hypotheses describe elements and
hypothesize how they relate to each other. Observational hypotheses can be
misconstrued to imply etiology in addition to phenomenology. Clinical work
is heavily and rightfully dependent on these observational hypotheses,
because therapeutics often must precede an understanding of etiology and
may be effective before the reason for the effectiveness is known. This is
true for all branches of medicine and surgery. Observational hypotheses of
clinical work are therefore crucial to treatment. They can also be heuristic.
But they are not yet etiOlogic.
What do psychoanalysts think about etiology in the psychoses? On this
topic, see Frosch (1983). From Sigmund Freud on, psychoanalysis has been
theoretically rooted in biological influences on mental life. Freud described
the growth and development of biologically determined libidinal stages and
their effect on emotions, especially conflicted emotional states. Freud
believed the conscious mind might be helped to gain more control over the
mental effects of these biological processes. Psychoanalysis since Freud has
also been interested in the interplay between emotions, with their innate
disposition patterns of libidinal stages, and reality experience. Since it was
not known, and scientific technology did not exist to discover the
relationship between brain biology, emotional conflict, and reality events, the
issue became a suspended question (Freud, 1917). Psychoanalytic
investigations looked at mental experience and the interplay between
emotions, experience, and illness. This led gradually to nonbiological
etiologic implications or to outright etiologic statements. These etiologic
implications have been most problematic, I believe, in psychotic and near
psychotic states. They have implied that emotional conflict and/or emotional
experiences from reality cause psychosis or near psychosis.
Those who believe emotional conflict causes psychosis, either in toto or
as a trigger, focus on the quality of the conflict, its content and phase of
emotional life, or the intensity of that conflict, or both. This statement
unites otherwise diverse authors such as Freud, Arlow and Brenner (1964),
Klein (1975), Kernberg (1975), and Pao (1979). Some look specifically to
developmental deficits resulting from childhood experience, a perspective
uniting otherwise divergent authors such as Anna Freud (1936), Mahler
(1968), Pao (1979), Blanck and Blanck (1979, 1986), Frosch (1983), and
Freeman (1988). A few believe a central problem is brain pathology in the
adult, an approach that unites modern biological psychiatry and Freud
(1917). Psychoanalysis has thus looked to emotional dynamics, inborn
energies, instinctual developmental lines, and retrospective emotional
psychogenetics of historical, external, and internal object relations in its
search for etiology. It has based this focus on the content of dynamic
xvi Psychosis and Near Psychosis

fantasies elicited in the psychoanalytic setting and on necessities of

psychoanalytic theory sometimes imposed on clinical data. More recently,
child observation has tried to understand prospective development of mental
structure: psychotic (Mahler, 1968), normal (Mahler et aI., 1975; Stern,
1985), and neurotic (Anna Freud, 1936).
The evidence for the biological-neuromental etiology of psychosis and
near psychosis includes the following:

1. Impairment in reality-organizing mental processes that are part of

neurological function as well as the mental function;
2. Neuropsychological testing of neuromental functions in psychosis and
near psychosis;
3. Neurophysiological and neuroanatomical testing of brain function;
4. Inheritance of psychotic illness predispositions;
5. Medication effects on the mind via their effects on the brain;
6. Clinical observation of dynamic similarities between neurosis, psychosis,
and near psychosis.

On the other hand, the following evidence is against the theory of

biological-neuromental etiology and in favor of emotional etiology:

1. Clinical observation of dynamic dissimilarities between psychosis and

neurosis;
2. Observations about triggering events and relationships and the correlation
of this material in dynamic Object relations;
3. The observation that psychoanalytic interpretation of dynamiCS may help
ego dysfunction.

The leading research lines follow trails of observation of brain function

via neurochemical abnormalities, often seen indirectly via clues from drug
effects. Psychiatric epidemiologists look at inheritance patterns.
Psychogeneticists look at the genes and chromosomes.
Psychoneuroendocrinologists use possible endocrine abnormalities and their
neuropathways to try to indirectly chart brain pathology. Neuroscientists
look at changes in anatomic and physiological mechanisms within and
between cells. New imaging teChniques will allow direct observation of this
neurochemistry and neuroanatomical physiology in living psychotic patients.
For a recent review in regard to schizophrenia, see Willick (1991b).
Biological research makes one thing clear. There are biological factors in
the psychoses. It is not yet known (1) what are the biological factors, (2)
what causes these abnormalities, (3) where these abnormalities operate, (4)
how the mind and its emotional experiences interact with the brain in
psychotic illness.
We have found no virus that attacks the brain in psychosis or near
psychosis. But we have not yet found the universal schizophrenigcnic mother
Introduction xvii

nor the always applicable dynamic formulation. We are therefore thrown

back to descriptive theory with which much science begins until biological
research catches up to us.
I believe there is an interaction between "biology" and psychology varying
from case to case, always with major inborn constitutional factors affecting
autonomous ego capacities and temperament. This may be magnified or
ameliorated by experience. Experience may lead to specific psychological
trigger points. However, it also seems to me clear that unknown
neurobiological factors operate directly on autonomous ego apparatuses in
the adult, because there are some patients who become psychotic and do not
seem to have typical prodromata or psychogenetics in their childhood
histories (for a recent review see Willick, 1991a).
In spite of my belief in a major biological component to these illnesses,
it is my hope that this book will encourage psychoanalysts to consider once
again their role in treating these patients. Freud and Abraham (1953)
discussed the treatment of psychotic and near psychotic patients, but since
the 1960s analysts have shown less interest. Neuroleptic and later
antidepressant medication has played a growing role in this loss of interest
because of their marked efficacy in treating certain aspects of these illnesses.
However, as I will show, they do not treat other aspects. In addition, the
Menninger study, most recently described by Wallerstein (1986), looked at
analyses of neurotic, near psychotic, and psychotic patients. It found that all
so-called heroic psychoanalyses with psychotic patients failed. However,
because of advances in medication, neuropsychology as it applies to
neuromental functioning, the psychoanalytic understanding of autonomous
ego functions (Hartmann 1939; 1964), and descriptions of autonomous ego
effects in psychotic and near psychotic illnesses (Bellak et aI., 1973), it seems
an ideal time to try again to discuss these illnesses and their treatment
within a now-broadened psychoanalytic descriptive theory (see also Karush,
1966; Bellak and Goldsmith, 1984). Also very helpful are recent advances in
psychiatry that clarify psychiatric illness categories. DSM-III, DSM-III-R, and
the upcoming DSM-IV are major advances in this regard, despite their
excesses and limitations. They have helped dispel the belief of psychiatrists,
and unfortunately some psychoanalysts, that all psychoses are the same
regardless of the psychiatric illness involved, or that all psychoses are
schizophrenia. This misunderstanding was based on the lack of specific
criteria to distinguish the psychoses and near psychoses in general psychiatry.
It was also based on psychoanalytic inability to specifically describe ego
function as Hartmann (1939, 1964), Freeman (1969), and Bellak et al. (1973)
have done. Because of this lack of knowledge, emotional dynamics were
described and given etiologic importance. Hence, all psychosis was one, and
all etiology was unconscious dynamics.
I believe a psychoanalytically based approach to an integrated treatment
of psychosis and near psychosis can now be achieved which organizes
psychotherapy, medication, and hospital and milieu interventions into a
xviii Psychosis and Near Psychosis

powerful therapeutic tool. My own observations are that this integrated

combination is dramatically successful (Marcus and Bradley, 1990). This
book describes advances in descriptive theory and their integrative use in
treatment by explaining the structure of psychotic and near psychotic states,
the effect of psychiatric illnesses on that structure, the effect of medication
on that structure, and the changes in technique of psychoanalytic
psychotherapy and psychoanalysis mandated by this new description of the
structure. I will focus on the ego and especially on ego functions mediating
reality experience.
I try to define most terms that I use, even the elementary ones. One
reason is to make the book accessible to newcomers to clinical work in this
area and also to others working in related areas. The second reason is the
ambiguity of many of these terms. Psychoanalysts often do not agree on
these definitions. I need precisely to define terms pertinent to psychosis and
near psychosis to achieve clarity of exposition. Thirdly, I emphasize certain
aspects of the definitions of commonly used terms or modify some aspects.
This is necessary in order to enlarge existing psychoanalytic theory to include
my observations about intrapsychic structural psychopathology and also to
better link with general psychiatry's advances in descriptive psychopathology.
As a result of starting with basic descriptive definitions, the book tends
to move from the relatively more elementary to the relatively more complex
within each section and chapter, and from one chapter to the next. I hope
it will thereby be useful to therapists at all levels of experience. I especially
hope that experienced psychoanalysts will read the book and rethink the
possibility of a modern, psychoanalytically informed treatment of these
states.
This is a clinical and clinical theory book. I discuss the psychoanalytic and
psychiatric literature relevant to my views. The most thorough psychoanalytic
review is Frosch (1983). My work is especially indebted to the work of
Freud, Hartmann, Winnicott, Kernberg, Schafer (1968), Bellak et a1. (1973),
and Stern (1985).
1
Ego Functions

Introduction
The ego is the term psychoanalysis uses to include aspects of mental
functioning that regulate and mediate between the experience of reality and
the experience of emotions. This chapter discusses those mediating and
regulating ego functions, experiences, and organizations of experiences that
are particularly relevant to understanding psychotic and near psychotic
illnesses.
According to Hinsie and Campbell (1963), the ego is "a part of the
psychic apparatus which is the mediator between the person and reality; the
perception of reality and adaptation to it." (Cf. Campbell, 1989).
La Planche and Pontalis (1973) review the history of the term ego in
psychoanalysis. They clearly describe the evolution of Freud's use of this
term: the ego meaning person or self, the ego meaning a collection of
emotional defenses, and the tension between these two uses.
Hartmann (1939, 1964) focused on a third aspect of the ego: mechanisms
of regulation between reality and the person, which he called ego
apparatuses. These processes mature from birth onward according to their
own time table. They are aspects of mental functioning which especially
mediate the perception, organization, and use of reality. Examples are vision,
memory and certain kinds of logic. I will later subdivide and add to these.
Because of Hartmann's focus on reality rather than unconscious fantasy,
because the apparatuses seem to mature according to a neurological rather
than only a psychological time table, because the apparatuses are said to be
relatively free of unconscious emotional conflict, and because apparatuses
correlate with conscious and cognitive functioning as well as other aspects
of general psychiatry, Hartmann's apparatus concept has been criticized as
non psychoanalytic, Le., nondynamic or nonemotional.
But the concept is not easily dismissed. Loewald (1988), Blanck and
Blanck (1979, 1986), and Schafer (1968) all focus in varying ways on the ego

1
2 Psychosis and Near Psychosis

as a set of integrative regulations. They especially focus on the superordinate

result of the functioning of this apparatus which mediates the integration we
know as normal mental life. For a review of Hartmann's description of ego
function as an integrative and regulatory process, see Friedman (1989); cf.
also Holt (1965) and Rapaport (1951, 1959).
All psychoanalysts agree that the term ego is used, in part, to describe
man's mental interaction with reality. It is this aspect of ego function in
particular that this book focuses on, because in psychotic and near psychotic
illnesses alterations in reality ego function are the most dramatic and
distinguishing feature.
When specific problems with the ego's interaction with reality are
described, one ends up describing specific ego functions that Hartmann
called autonomous ego apparatuses and ego functions. This is the clinical
fact. A careful description of psychotic and near psychotic ego functioning
leads inevitably to some apparatus concept. The exact relationship between
these functions and emotional or dynamic material varies, and hence the
degree of autonomy varies. But I believe it is damaged ego apparatus
function that gives psychotic and near psychotic organization to dynamic,
emotional material and to object relations. This hypothesis grows out of the
observation that intercurrent psychotic illness can cause a dramatic
reorganization of dynamic elements without necessarily changing the
dynamic content.
Hartmann's ego psychology divides ego functions not by reality experience
and emotional experience but into autonomous ego functions or apparatuses,
primary or secondary, and defensive functions. I will be discussing primary
autonomous apparatuses. I know that these apparatuses can also perform
defensive functions. Primary autonomous apparatuses refer to aspects of
reality-oriented cognitive thinking ability and perceptual ego functioning in
the area of reality experience. The autonomous ego function apparatuses
deal, for the most part, with outside phenomena. They deal with percepts,
their recording and organization. Schafer (1968) discusses autonomous ego
functions which include non perceptual aspects of cognition. Autonomous
ego functions are also integration functions. They are reality based and
organize reality experience. They also organize certain relationships between
reality experience and emotional experience. In healthy people, these
functions are relatively free of, and hence not completely distorted by,
emotional experience. In this sense, they are autonomous.
How do these ego functions get damaged? No one knows. I believe there
are biological factors in the etiology of psychosis which operate especially at
the ego apparatus level, because we observe that the apparatuses that deal
with reality are so altered in psychotic and near psychotic states. In addition,
the apparatuses have neurological properties (e.g., sometimes known
neurological pathways as in sensation and memory) and psychological
properties, which are clearly also influenced by learning and emotional state.
I hypothesize but am unable to prove that in psychosis the apparatuses are
1. Ego Functions 3

a major area where neurobiological factors exert their effect on adult

psychology.
Emotional conflict may play a role in triggering apparatus
decompensation in some illnesses. The mechanisms of this triggering are
unknown, but the effects and treatments are known. Psychological stress, a
crucial factor that often plays a describable role, is unique to each individual
and is encoded in mental structures along with apparatus function. This
relationship can be described. For some patients specific psychological stress
can trigger biologically determined psychotic or near psychotic reactions.
Emotional life is encoded, translated and experienced differently when ego
apparatus functions are damaged. For each patient, one can describe specific
ego deficits and conflicts. One can then prescribe a treatment that will
address the combination.
I first describe ego functions relevant to psychotic and near psychotic
structure.

The Ego and the Experience of Reality

Reality Experience

I need a term for the mental sensation and organization of outer reality. I will
use the simple descriptive term reality experience.! I distinguiSh reality
experience from reality per se and also from the perception of that reality.
There probably can be no universal agreement or descriptive definition of
the experience of reality. However, the unusual, striking, and descriptively
definitional phenomenon of psychosis and near psychosis is the special
experience of reality that occurs.
The experience of reality often involves the experience of external stimuli
(Kraepelin, 1915). Reality-mediating mental processes form perceptual
information out of sensory data. Reality experience is, therefore, often built
on perceptual information. Reality experience is the experience of external
stimuli via percepts or perception, but it is also the experience of abstract
concepts built, in part, on perception via conscious, conceptual, logical
thinking. Reali ty experience tends to be organized logically, with ind uctiveand
deductive reasoning building links between perceptual information and
concepts. Reality experience builds in complexity from the interaction of
perception with conceptual thinking.
Reality-experiencingcapacity is mediated by a complex, partly autonomous,
neuropsychological, maturational and developmental ego function apparatus.
This is why Piaget (1954) can describe its evolving course throughout
childhood (see also White, 1963; Weil, 1970; Stern, 1985; and Greenspan,
1988, 1989). See also Table 1.1. Reality experience depends on many
4 Psychosis and Near Psychosis

subsidiary, partly autonomous ego functions, the major group of which are
called logical or secondary process thinking.
One cannot equate ego apparatus function and the ego's reality experience.
Reality experience is an experience and not a function. This experience has
qualities, quantities, modalities, and domains. In addition, the ego's apparatus
function can be used at times defensively for emotional purposes. Also,
aspects of reality stimuli are registered and encoded by the emotions.
Nonetheless, reality experience is mediated by, and depends upon, certain
autonomous ego functions and integrations of functions. Those integrations of
functions are sometimes called superordinate ego function. 2

Secondary Process
Freud called conscious, reality-oriented logic secondary process, because he
thought this capacity developed later than emotional experience organization,
which he called primary process. Freud was probably wrong, because the latest
research with infants seems to demonstrate secondary process development
from birth (see also Piaget and Inhelder, 1958; Piaget, 1977; Stern, 1985). I
will use this traditional psychoanalytic term nonetheless.
Secondary processes are those mostly conscious, reality-oriented, logical
thinking processes that gather data via percepts and assemble those percepts
into information according to learned schemes and also according to deductive
and inductive reasoning. Concepts are built, abstracted, generalized, and
applied. Various levels of abstraction are used and related to each other and
to real-world tasks. Words and numbers are used to sort and arrange
information. Words and numbers are defined and specific, and therefore have
relatively finite information contents.
Autonomous apparatuses tend to be organized around these principles of
secondary process logical thinking. These logical principles include the beliefs
that cause is different from effect, the part is separate from the whole, a part
is separate from another part, and time is sequential. This type of thinking
relies upon clear categories, usually with definable boundaries and finite date
contents. Data and categories tend to be digital. Categories group ideas and
data logically and describe relationShips to larger entities. Relationships are
congruent with perceptually-based rules following spatial, temporal and
sequential experience. There are distinctions between concept, percept and
affect with concept or percept as the main organizer. These categories mature
as cognitive skills mature, and develop as reality experience accumulates.
Secondary process capacities use functions of cognition that should be
relatively uninfluenced by emotional conflict. Secondary processes mediate
and buttress reality experience but are not the same as reality experience.
Reality experience includes more than secondary process. Reality experience
is an experience and not just a group of processes.
1. Ego Functions 5

Table 1.1 Reality experience

1. Relies on percept
2. Relies on reality oriented logic
3. Evaluates inside and outside
4. Uses as information processing strategies: learned patterns, deductive and
inductive reasoning
5. Concepts are built, abstracted, generalized, and applied
6. Recruits emotional experience for validity, motivation,and decision but not
for percept or for logic
7. Requires regulating and modulating functions of the ego
8. Often relies on observing ego
9. Makes judgments for action

The Experience of Emotions

Emotional experience is quite different from reality experience. Emotional
experience is the experience especially of emotion with its own quality,
quantity, organization and ideational content. It has a different base, follows
different rules of organization,and has a different mental locus of experience.
The base of emotional experience is feelings, also called affects. The rules of
their organization are psychological rules called primary process. These
processes use different types of categories and different causal relationships
from reality experience. Emotional experience is based on but not limited to
primary process.
The mental locus of emotional experience is partly a visceral body and
sensation locus that may take pictorial form. The quality is the experience of
percept, of physical sensation, and of affect. The pictures are visual
transformationsof affects and have the quality of percepts. This percept aspect
is a normal link to reality experience.
The ego can attach and experience affect in association with events,
concepts, percepts, or as "free floating." Different levels of consciousness,
processing systems (primary or secondary process), psychiatric illnesses,
phases of illness, and stages of normal development all influence the ego's
positioning, organiza tion, and experience of affect.
Affect often provides motivating force and hence positive or negative
direction to behavior, ideas, and pictorial forms. Affects vary in quality from
pleasurable to unpleasurable. They vary in intensity from strong to faint. They
vary in domains such as anger and love.
Primary process is an information processing system especially for affects.
Hence intensities,qualities, and domains form the organizing basis of contents
6 Psychosis and Near Psychosis

and their categories. Infinite information contents, each within inexact limits
based on intensity and quality, form the basis of concepts or, more precisely,
contain the concepts.
Emotional experience builds in complexity by mixing intensities, qualities,
and domains in complex patterns according to primary process psychological
rules.
Primary process is a function of sophisticated information processing just
as secondary process is. 3 I believe primary process function has its own
developmental timetable. Some illnesses, like schizophrenia or severe
dementia, destroy this function. More commonly, the boundary between
primary process and secondary process is damaged by psychiatric illness,
leaving the primary process intact but allowing invasion of primary process
into secondary process, thereby disrupting secondary process.

Primary Process

I will focus on those aspects of primary process important in psychotic and

near psychotic organization and experience. Primary process is unconscious,
preconscious, and sometimes conscious. Primary process thinking is the
organization of our feelings in "thought" which is dominated by the content,
organization,and qualities of emotion. Aspects of reality experience play only
certain limited roles. Categories are not logically based on reality experience
but are psychologically based on emotional experience. Emotional experience
is determinate.
Primary process thinking often relies upon mental images, as in dreams.
Dreams are stories composed of series of condensed images. The images are
called symbols, because each element is composed of and represents many
feelings and experiences put together. Condensation is the ability of the mind
to form a complex representation of many related percepts, ideas and feelings.
Condensation is the fundamental principle of the primary process. One
characteristic of condensation is that the linkage of various aspects of idea,
feeling, and percept is determined by the emotional feelings about the ideas
and percepts. Another characteristic is that most of the many thoughts and
feelings represented are not conscious except as they are alluded to or
collapsed into the available conscious aspects of the condensation. Manifest,
conscious elements also condense with each other. The combination of
condensations usually involves aspects of reality experience to build the image
and express the unconscious emotion. Aspects of reality experience together
with emotional primary processing determine the representabilityor form.
Condensations involve data categories that are porously boundaried and
overlapping. Data contents within a category may be infinite in number. The
sequences of data and categories may be unidirectional, reverse-directional,
bidirectional,multidirectionalor simultaneous. In primary process there may
be a part instead of a whole, and a part greater and more significant than a
1. Ego Functions 7

whole. Cause and effect may be reversed, bidirectional or simultaneous, and

time may be of no consequence. Within the condensation, there are
transmodal changes between percept, affect, and concept. One may be used
to convey, express and represent the other. Because the main organizer of the
process is affect, its themes, qualities and quantities determine data collection,
category sorting and transmodal processings. It is an analog process. This
means tha t q uali ties es pecially, and q uan tities of those q uali ties, will determine
organization, transmodal processes, linkages, and to some extent, contents and
meaning.
The resulting primary process integration gains its coherence through this
analog process. It is by understanding especially this aspect of quality and
quantity that allows deciphering of what is otherwise a system of infinite and
ambiguous possibilities. The other crucial factor in this regard is the day
residue. There is a characteristic structure to these condensations described
in a later section, the day residue section.
The ways in which condensation occurs and the forms it takes are
characteristic of the symbolic milieus in which they are formed. Examples of
these discrete symbolic milieus are specific cultures, specific illness states, and
specific individual emotional experiences. Understanding specific condensa-
tion patterns of symbolic milieus is the task of the psychoanalyst. Displacement
is another characteristic of emotional process thinking. The most significant
emotional aspect of an idea or the affect itself may be "displaced" to a part of
the symbol that is not central according to secondary process rules of logic.
There may be displacements from one symbol to another or from one element
of one symbol to one element of another. Abstraction can also be displaced
from concept to details of the concrete thing. Specific patterns of
displacements are common. I believe that what is displaced to is as important
as what is displaced from. The reason the specific part was chosen as a
displacement target is crucial to meaning and to the emotional experience.
Therefore, "displaced to details" also means "expressed in details."

The Relationship of Reality Experience to Emotional

Experience
Complex mental experiences build from both areas. Ideas are intellectual
abstractions that are often built from reality experience but which may also
conceptualizeemotionalexperience. Emotional experience clearly records and
expresses both stimuli in reality and the affect experience of these stimuli. It
does so in the emotional locus of affect experiences with their typical
organization and qualities.
Therefore, one relationship reality experience and emotional experience
may have is a similarity of external stimulus content. Another is the
experience of percepts, which may be due to external reality stimuli or to
8 Psychosis and Near Psychosis

strong internal affect stimuli taking pictorial form in certain states of

consciousness.
Reality experience and emotional experience have other characteristic,
stable, and describable ways of. relating to each other. There are mental
phenomena that allow the experience and expression of that relationship. The
ego gives organization to this relationship.

Summary
The ego is a term used to describe certain receiving, recording, elaborating,
and regulating functions of the experience of reality, the experience of
emotions, and their relationship to each other. The ego has processes which
help keep areas and functions separate. The ego also must be able to integrate
different areas and relationships into a relatively coherent, unified, and stable
experience. While awake a person's conscious ego should be unified under the
logical control of the experience of reality.
In psychosis and near psychosis, this conscious, reality-based control is
disturbed in specific and describable ways so that reality and fantasy, percept
and affect, merge. There is no awareness that a merger has occurred. This is
almost a descriptive, ego definition of psychosis and near psychosis.

Patient example of merger of emotional experience with reality experience:

People in the old neighborhood are talking about her. They say she didn't pay
taxes after World War II. Why would they say that? She doesn't steal. Once she
was accused of stealing money when she first started working but it wasn't true.
Now they say she's a Shoplifter.

Autonomous Apparatuses
Following is an expanded description of the autonomous apparatuses
characteristically disrupted by psychotic and near psychotic illness. These
disrupted autonomous apparatuses permit psychotic or near psychotic
experience by altering the usual control of the relationship between reality
experience and emotional experience.

Boundaries

A mental boundary is the ability to keep experiences separate from each

other. There are a number of boundaries. We are not usually aware of a
boundary function, but we are aware of the result. Boundary problems are
ubiquitous in psychotic and near psychotic illnesses and playa crucial role
in their structure.
1. Ego Functions 9

Federn (1934; see also Hinsie and Campbell, 1963) first defined the ego
boundary concept in psychoanalysis. He described the repression boundary,
an inner boundary between conscious and unconscious. He also described
the boundary between the mind and the external world that involves the
sense organs. Bellak et al. (1973) review the historical development in the
psychoanalytic literature of the ego boundary description as it expanded to
include specific boundaries between self and object representations, the
boundary of bodily experience, and other ego boundaries. For a modern and
experimental view of boundary see Hartmann (1991). I further expand the
concept to include all boundaries between ego functions, between domains
and modalities of ego experiences, and between affects and affect modalities.
I do so because damage to these boundaries is seen so dramatically in
psychotic and near psychotic illness.
There has been much confusion in the psychoanalytic literature because
of the failure to distinguiSh conscious from unconscious boundary function.
The unconscious works according to primary process and is characterized by
mergers that cross logical boundaries. In normal people, most of these
mergers are unconscious or in conscious emotional experience. The
conscious mind, however, functions to a great extent by keeping certain
experiential categories and capacities separate. Very ill patients have trouble
in their conscious mind separating these mental experiences. Boundary
problems are crucial to this difficulty.

Inside-Ou tside
The most important boundary separates mental experiences of inside and
outside. The mind should have the conscious ability to perceive the origin
of stimuli that occur inside itself and to distinguish them from those that it
experiences as originating outside of itself. This is the main ego boundary.
A merger occurs when what should be two distinct experiences are put
together and experienced as one. The analytic literature uses two terms for
the merger that ensues from the loss of the inside-outside boundary: fusion
and condensation. Psychoanalysts often use these terms interchangeably, but
they should not. Both are types of merger, but the boundary that is usually
crossed by each is different. In addition, their mechanisms and results are
quite different.
Fusion is a crossing of the inside-outside ego boundary. The contents of
stimuli in reality go directly into and fuse with experience of one's own body
and mind. The content of the experience is based on the content of stimuli
in reality. This fusion is a conscious, cognitive inability, not a fantasy or a
worry. It is presumably a neuromental problem because "it" involves external
stimulus registration and not only affect or psychological content and
because proper medication rapidly repairs this boundary. The crucial point
is that mental experience that results from fusion is based on the content
10 Psychosis and Near Psychosis

and qualities of stimuli in reality that burst into mental experience from the
outside once the screening boundary between inside and outside is lost. The
resulting mental experiences are filled with the experience of those stimuli.
Which reality stimuli invade mental experience, both reality experience and
emotional experience, depends on the degree of loss of the boundary
between inside and outside and also on the intensity of the outside stimuli.
True fusion does not depend on the content or meaning the outside stimuli
have for the person.
In addition, with this boundary disturbance, intense affect may be
perceived as coming from outside in the form of percept and reality stimuli.
The stronger the affect, the more the experience will "spill over" into percept
and contaminate the experience of outer, perceptual reality.
There can be internal fusions where any content of one inside emotional
category goes immediately to the content of some other inside emotional
category if the original is intense enough. This is a special kind of fusion
that is seen in certain illnesses; like all fusions, it depends on intensity and
not content or meaning.
Condensation, on the other hand, is quite different, in two ways. First, it
is a joining of two inside experiences, the experience of inside with the
experience of outside. Condensation usually involves the inside experience
of reality joined with the inside experience of emotion. The second
difference is that only certain points merge. The aspects of reality chosen
and the precise mechanisms for joining are determined by the emotional
meaning of the reality experience. What is merged depends really upon the
person's feelings and not upon the environment, except as the environment
corresponds to and/or evokes certain feelings. Condensation is organized
according to primary process rules. The environment is only providing
emotionally relevant attachment points for those feelings. This condensation
can be conscious, preconscious, or an unconscious fantasy. The location
varies from illness to illness and with level (degree of severity) of illness.
Psychosis and near psychosis have condensations in characteristic locations
with characteristic effects on mental experience. Relevant aspects of external
reality can be chosen because there is already a coherent, organized, internal
experience of reality.
The treatment of condensations is quite different from the treatment of
fusions.
Because merger points in condensations are emotionally meaningful, they
are called symbolic. Fusions are not symbolic in their structure, although
they may have secondary symbolic elaborations.
In summary, ego boundary 1 is between inside and outside: between inside
experience and outside stimuli in reality. When this boundary function is
missing, fusion occurs. Whatever stimuli occur in reality will be fused with
the experience of thought and feelings.
Ego boundary 2 separates inner experiences of feelings from the inner
experience of reality. This boundary separates two inside experiences. When
1. Ego Functions 11

this boundary function is gone, it is usually gone only at specific points via
the mechanism of condensation. Only emotionally relevant reality experience
is merged, and only certain attachment points occur.
It is these emotionally meaningful condensations that form the unique
symbolic alterations of psychosis and near psychosis.

Percept Boundaries
Percepts are inner, mental, sensory experiences (see Friedman and Fisher,
1960). They are triggered by stimuli in reality. These stimuli are external to
the mind and often external to the body. There is no one-to-one relationship
between a stimulus and the percept, because the central and peripheral
nervous systems have their own recording properties. In addition, percept is
affected by learning, inhibition, and emotional state (see Piaget, 1981; see
also Westlundh and Smith, 1983).
The ego should be able to set a boundary to percept so that it does not
contaminate, and is not contaminated by, other mental events such as
concept or affect.
Reality experience includes more than percept, but perceptual experience
is important to the ego's reality experience (see Beres, 1960) On the
development of perception see Banglow and Sadow (1971). On the
relationship of perception to psychic representation see Karush (1966).

Concept Boundaries
The ego should be able to set some conscious boundaries to conceptual
experience so that it can remain an integration mode of abstract thinking,
and not be interchangeable with or flooded by affect or percept.
Conceptualization might use perceptual and affect information but should
also remain a separate experience. Important to conceptualization are
abstraction, generalization and application. Conceptualization and its
subsidiary processes are ego functions that should be relatively autonomous.

Affect Boundaries
Likewise, the conscious ego should be able to boundary affects so that they
do not trans modally flood conscious percept, concept, or other affects.

Affect Boundaries: Modulating and Regulating capacity

There are two different boundary functions concerning affects. One separates
different affects, such as anger and sexual desire. The other separates specific
affects from generalized mood. Although the boundaries should be flexible,
they should be stable enough to be regulatory. If these regulating boundary
capacities are destroyed, affect fuses with affect, affect spreads to mood, and
affect invades logical thinking. This causes secondary process category
disruption by condensation of secondary process categories with affect-
12 Psychosis and Near Psychosis

organized emotional experience categories. Recruitment of content based on

affect experience results in many categories of reality experience with
associated contents further condensing. In this way, affect spreads to mood.
The recruitment is based on recurrent affect themes. These themes cross
reality categories. Transcategorical crossing as determined by quality and
quantity of feelings is the whole point of primary processing, but this should
not take over reality experience.
Creative people are those who have access to transcategorical
condensations in their conscious minds but who are not massively flooded
and disrupted. They can control and use such condensation experiences to
reassemble new reality categories for real world use and communication. The
ability of the ego to use these condensations for secondary process gain is
the important ability.
Control of intensity, generalization, and spread of affect is a crucial ego
function often dramatically damaged in very ill patients. The ego should be
able to regulate the intensity of stimulus perception, the intensity of the
reaction evoked by the stimulus, and the spread of this evoked reaction
throughout conscious reality experience and emotional experience. This
means that the ego should be able to modulate and regulate the intensity of
perception, whether the stimulus is outer reality or inner drive, the feelings
these stimuli evoke, how dramatically these evoked feelings and ideas erupt
into consciousness, and how dramatically and disruptively they spread across
categories of experience. Intensity can challenge modulating capacities, which
then challenge boundary functions.
Because uncontrolled affect intensities and resulting condensations are an
important determinant of primary process dominance, the affect-affect
boundary is an important determinant of illness in the ego. The form the
lack of modulating and regulating capacity takes varies according to type and
phase of specific illnesses and will be discussed in chapter 5. The
relationship between this boundary and the other boundaries described
varies from illness to illness.

Conscious-Preconscious-Unconscious Boundaries
Another crucial set of boundaries is between those mental experiences that
are conscious, those almost-conscious mental experiences called preconscious,
and those mental experiences that are unconscious. The mind should have
the ability to screen from consciousness (1) continuous sensory impressions
from the outside, (2) continuous emotional reactions from inside, and (3)
conflicted emotions causing distress. The ability to modulate and screen is
a crucial boundary function of the ego. Having this boundary means that
there will be an ability to separate conscious reality content from
unconscious feelings about that content (Federn, 1934). Conscious thinking
is usually dominated by logical, reality-organized thinking. Preconscious
thinking includes large measures of both logical and emotional thinking.
1. Ego Functions 13

Unconscious thinking is more emotional process thinking. When boundaries

among these three levels are disrupted, aspects of a lower level predominate
in the functions of a higher level. Although one definition of mental health
is some availability between levels of awareness, very ill patients have severe
damage in this function. Distinguishing conscious from unconscious mental
functioning is crucial if one is to understand that dynamic psychological
material has not only content but place. The flooding and disruption of
conscious thinking by intense psychodynamic material is a hallmark of very
ill patients. Disrupted ego boundaries mediate this disruption.

Primary Process-Secondary Process Boundary

The boundary between primary process, emotional thinking and secondary
process, logical, reality thinking is not exactly the same as the
conscious-preconscious-unconscious boundaries, because some aspects of
primary process normally occur in conscious thinking. However, the ability
to distinguish between primary process and secondary process thinking
should be maintained at the level of consciousness. Very ill patients have a
defective boundary between primary and secondary process thinking in their
conscious minds, so that logical thinking is flooded by emotional thinking.
The specific forms of this flooding differ from illness to illness and will be
described in chapter 5.

Reality Testing

The next crucial ego function for understanding very ill psychiatric patients
is reality testing. Reality testing is the mind's ability to test emotional
experience against reality experience, to use secondary process logic in the
service of this test and, most importantly, to maintain doubt and to change
reality conclusions. 4 It depends upon an ego boundary between reality
testing experience and the rest of mental experience.
Notice that I have not said reality; I have said reality experience. This is
because someone can be sane but wrong. Likewise, someone can be correct
but insane.
Most commonly, psychotic reality testing problems manifest themselves
in one area of mental functioning. If that area is in the realm of idea
formation, the phenomenon is called a delusion. If the area is in the realm
of sensation, the phenomenon is called a hallucination. Hallucinations can
be in any of the sensory modalities: visual, auditory, or somatic.
In very ill psychotic states, reality testing is lost for all mental areas. This
condition is rare. Usually, significant areas of reality ego remain, even in
very psychotic patients. This is a key to treatment.
Losses of reality testing can be categorized according to the degree of loss.
Rigid losses of reality testing that are impervious to exploration, interaction
14 Psychosis and Near Psychosis

and even confrontation in a psychiatric interview are psychotic losses of

reality testing (Kernberg, 1977). Near psychotic patients only suspend their
reality testing function. If this occurs in the realm of sensation, it is called
a pseudo-hallucination. If it occurs in the realm of ideas, I call it a
pseudo-delusion.
There is an intermediate category of phenomena where reality testing is
preserved but a strong sensory perception is registered without a reality
stimulus. This phenomenon is called hallucinosis.
A chart organizing this important material is shown in chapter 4 (Table
4.1, p. 130). The important point for now is that reality testing in the
psychoses is rigidly absent. Reality testing in the near psychotic states is
suspended in functioning, but the capacity is potentially present. In the
neurotic illnesses there may be intense emotional experiences and/or
rigidities of mental content, but the ability to test reality experience is
neither lost nor suspended.
It is usually believed that the ability to test reality experience depends on
the ability to distinguish internal from external. But there are patients who
show fusion of inside and outside experience who can test reality, especially
during the period that the therapist is helping them. Some of these patients,
however, cannot do so. Conversely, there are patients who camiot test reality
even with the therapist's help, but who are quite able to keep inside and
outside separate. The point is that reality testing is a separate ego function
from the ego function of maintaining a boundary between inside and outside.

Observing Ego
Observing ego is the mind's ability to mentally look at its own experience.
The ego should be able to both experience itself, the experiencing ego, and
to mentally observe itself, the observing ego. This ability is crucial to call
upon when treating the very ill, as will be made clear in chapter 7.
Observing ego is a quite separate ego function from reality testing. A person
may be unable to distinguish real from unreal and still be able to observe his
or her own mental functioning and experience. By definition, psychotic
illness affects reality testing. It need not affect observing ego capacity. A
patient can be delusional and know he or she is delusional. This is readily
observed in many psychotic patients and is a crucial step to help them take
in their treatment. A delusional patient with observing ego may say, "I know
what I believe is part of my illness but I believe it anyway."
An exploration of observing ego as distinct from reality testing is a crucial
part of the evaluation of any psychotic patient. The careful separation and
use of observing ego for the therapeutic alliance and beginning treatment is
the crucial first step in psychotherapy with psychotic patients. Interferences
with observing ego, even in psychotic patients, are often of a nonpsychotic
nature. Commonly, interferences are due to non psychotic character defenses.
1. Ego Functions 15

They will be described in chapters 2 and 3 on psychotic and near psychotic

structure, chapter 7 on the psychotherapy of psychosis, and in the section
discussing the relationship of character pathology to psychosis.

Integrating Capacity
Integrating capacity is the ability of the mind to put together emotional
experience and reality experience in a regular organization within each of
these areas and also between these areas, especially consciously. What one
sees, hears, thinks, feels, remembers, and fantasizes should fit together. The
way the mind does this varies from person to person, and failures in this
function vary from illness to illness. A second definition of very ill patients,
psychotic and near psychotic, is severe and characteristic disruption in
integrative capacities, especially conscious capacities.
Crucial to secondary process integration are the faculty of
conceptualization and the subsidiary capacities to abstract, generalize and
apply. Secondary process attends to affect, but under the auspices of
conceptual organization. Primary process has a different integration system,
in which affect is the crucial organizer to which logic and concept are
subsumed.
Neurotic patients may weigh some aspects more heavily in their
integrations, such as ideas (obsessive) or emotions (hysteric), but these
cognitive styles (Shapiro, 1965) do not interfere severely with real-world
functioning because they are not severe disturbances of secondary process
reality experience. Very ill patients show extreme disturbances in integrating
capacity that affect secondary process and reality experience. Although they
are often based in and reflective of severe boundary disturbances, such
integration problems can also be in addition to or instead of boundary
disturbances. This is a separate capacity or deficit. The distinct and
characteristic integrative problems for each of the illnesses are described in
chapter 5. There are various kinds of integration problems, which disturb the
relationship of content to content, affect to content, affect to affect
(splitting), and affect or ideational content of emotional experience to reality
experience.

Regulation of the Relationship of Reality Experience

to Emotional Experience
The ego functions just described are crucial to the ability to control the
relationship of reality experience to emotional experience. The relationship
of reality experience to emotional experience involves the regulation of the
overlap between the two experiences.
16 Psychosis and Near Psychosis

The intermediate or transitional zone between the two areas is a crucial

area of human experience (see Winnicott, 1953, 1971). Characteristic of
normal experience are the availability in the preconscious. and conscious
intermediate zone of emotional experience for reality view, the availability
of reality experience for evoked emotional reaction, and the condensations
between the two that result in symbols. There should be dominance, control,
and use of this intermediate experience by reality experience and its rules of
secondary process logic. The intermediate or transitional zone involves
mixtures of primary and secondary process, called tertiary process by Arieti
(1976). Here reality experience and emotional experience mix. There is
preservation of a separate reality experience, as in a daydream (Schafer,
1968). In psychosis this intermediate function moves into reality experience.
Psychotic experience does not occur in the intermediate zone. Psychotic
experience occurs in the zone of reality experience. Psychotic process occurs
when autonomous ego boundaries are broken through and emotional
experience invades reality experience, usually at specific condensation points.
The form this takes as the material enters reality experience depends on
illness-specific patterns of autonomous ego disruptions. The form will also
depend on specific primary process content and mechanisms from the
invading emotional processes.
In psychotic and near psychotic patients, the content and process of
emotional experience may change, but more importantly, the content and
process of reality experience changes. There are changes in the rules of
organization of the relationship between reality experience and emotional
experience. There is a change in the level of consciousness where this
relationship is out of control.

Day Residues

The primary process with its major features of condensation and displace-
ment is most clearly illustrated by dreams. Dreams build their images and
stories, in part, around events that occur during the day. These events are
often conscious reality events. Freud called them the day residue. They are
a crucial organizing part of the primary process. They may appear unchanged
but used for emotional purposes, or they may be symbolically represented
and altered according to primary process rules. They are aspects of reality
experience. 5
Often the day residue in psychosis and near psychosis is present day
reality repetition of the reality past, displacement from the emotional past,
and displacement from the emotional present-all condensed. The
condensation preserves some aspects of the reality day residue and
symbolically alters other aspects.
The waking mind should have the ability to keep the day residue, if
conscious, separate from the emotional reaction and symbolic use or
1. Ego Functions 17

alteration of the day residue. In psychosis, and to an extent in near

psychosis, the day residue is experienced with the experience of its symbolic
alteration.
Delusions are stories experienced by psychotic patients that are analogous
to dreams. (See Freud, 1900, 1917,1922 for his discussion of the similarities.
I have somewhat different views.) Delusions are structured with an organ-
izing center from reality experience akin to the day residue of a dream. This
center of reality experience is condensed with feelings from emotional
experience and symbolically altered in reality experience. The alteration and
the reality are represented and experienced as one. The exact construction
is described in chapter 2.
The day residue, then, in psychosis and near psychosis, is an event, usually
in reality, usually significant, that evokes feelings. In dreams often, and in
psychotic and near psychotic phenomena sometimes, the day residue may be
just a thought. It may be an insignificant reality event that receives its power
solely through displacement from another reality experience in the past or
from emotional experience in the past condensed with emotional experience
in the present. 6 In either case, the day residue originates from reality
experience, either factual or imagined, and in psychosis is condensed with its
symbolic representation. The condensation retains reality experience
qualities.
The day residue is therefore a bridge between reality and fantasy, present
and past, secondary process and primary process, abstraction and concrete
things, concept and percept. Obviously, any day residue is a crucial point in
the structure of both dreams and delusions.
The sequence and context of the day residue are crucial for psychotic and
near psychotic states. The day residue is not just an event involving an
Object, animate or inanimate, but also an event in sequence and context with
other reality and emotional events. A day residue is meaningful not just
because it happened, but also because of when it happened and what else
was happening or not happening. The day residue might, in fact, be
something that was wanted but that failed to happen at a certain sequential
point.
The structure of psychOSis and near psychosis tends to encode sequence
and context in the symbolic representation differently from the static day
residue event, person, or thing. This is one of the reasons psychotic
phenomena seem, at first glance, so inexplicable (see chapter 2).
Conclusion: There are usually highly specific points where reality and
fantasy condense in psychotic and near psychotic phenomena. These points
are located at the day residue. This is the point at which the most obvious
condensations occur. It is the ego that determines the structure of the
condensation in psychosis and near psychosis.
18 Psychosis and Near Psy,chosis

Thing Presentation
Freud used the term object presentation to refer to the central nervous
system encoding of mental representation. He believed the object
presentation had two components: a verbal component called word
presentation and a visual component he called thing presentation (Freud,
1893-95, 1900, 1915).
Freud meant thing presentation to refer to a neurological encoding. A
stimulus is presented to the central nervous system for encoding as percept.
I believe that affect, also a central nervous system response, is encoded, in
part, along with percept to form a combined affect-percept presentation. I
believe the crux of the psychotic and near psychotic experience is a
particular mental experience of these rigid, formed, stereotyped, repetitive
affect-percepts. These affect-percepts are neuromental phenomena and
have no psychoanalytic name. I believe Freud was getting close to describing
them with his thing presentation term. This term has the advantage of
calling attention to the perceptual encoding, the presentation characteristics
of the representation, and the neuromental relationship. This term may also
help remind us that the entire perceptual environment, not just people, is
encoded with affect and used symbolically (see Searles, 1960).
For a more standard view of what Freud meant by word presentation and
thing presentation see Arlow and Brenner (1964), chapter 10. For a modern
view of the cortical processing of words see Ojemann and Mateer (1979).
For a recent review of the psychoanalytic implications of word presentations
see Rizzuto (1989, 1990). For the relationships of Freud's view of aphasia
to his view of representation and mental organization see Grossman (1992).
Words are capable of rendering concept and abstraction directly. It is
crucial for the understanding of psychosis and near psychosis to understand
that thing presentations must express concepts through the medium of
perceived physical things and the altering of perceived physical things and
events. The reality-experienced thing is used to express an emotional
metaphor (see Freud, 1915; cf. Arlow, 1989). The metaphor is contained in
the picture of the reality thing that is used. An example is an image of the
female breast used as a metaphor for the concept of a longing to be taken
care of. The thing presentation is therefore the experience of something in
reality used to express feelings. An aspect of reality experience, usually
perceptual, has been borrowed by emotional experience. The emotional
language of the experience of reality things occurs in all primary process
phenomena. The things are used as symbols that make up a story. The affect
is experienced as a perception experience of the thing as well as or instead
of an affect reaction to the thing. The thing presentation is a way of
perceiving, thinking, and feeling at the same time, through the experience
of concrete images. Perception is encoding affect, conflict of affect, and the
primary process synthesis.
1. Ego Functions 19

Sometimes emotional meaning is conveyed by experiencing a group of

things collected according to emotional theme. A detail may be used.
Changes in reality things to convey emotional experience are called symbolic
alterations of reality experience. Sequence and context can also be altered
for purposes of symbolizing. Symbolic alterations of reality experience are
emotional alterations of day residues according to primary process rules of
conceptual organization. They involve the emotional transformation of the
experience of real things for the purpose of symbolizing emotional
experience.
Thing presentations are symbol experiences which combine concept and
affect together with percept. Thing presentations act like central nervous
system encodings that, under certain conditions such as dreaming or
psychosis, are presented to conscious mental experience. Thing presentation
is an involuntary brain/mind event. Thing presentation experience is a
mental experience of great emotional power. In psychosis and near psychosis,
the thing presentation experience dominates conscious, cognitive,
superordinate reality experience.

Example:
The young woman is frightened. The world is coming to an end. God is killing
all the people by burning them, because of their sins. She is Judas who has
betrayed. God's voice says she can fly. If she opens a window and jumps she
could save the world and get forgiveness for sins. She heard God tell her to
jump. She smelled burning. She told her family but they did not believe her.

Thing Presentation Quality

Thing presentation means not just the concrete image, but most importantly,
a quality of experience. The quality is that of an intense perceptual
experience of reality condensed with intense affect. A reality thing is used
for emotional metaphor, but the metaphor has the quality of a reality
experience. Thing presentation quality refers to the affect- perceptual quality
of reality experience. Affect is thus also experienced as part of the reality
experience of the thing. Thing presentation quality is a condensation of both
affect quality and perceptual quality.
The phenomenon also includes a displacement of the quality of felt reality
away from the concept or the emotion and onto the perceptual qualities of
the thing itself. Therefore, experience of reality, experience of emotion, and
experience of the quality of reality are all condensed together but
experienced as a property of the thing and not of how one feels about the
thing. Emotional validity and veracity have moved out of the realm of
emotional experience into a validity and veracity experience of reality.
Children sometimes think this way.
20 Psychosis and Near Psychosis

Example:
A six-year-old girl complains to her parents, not about the sleeping
arrangements of the family, but about the actual beds. "How come you two get
the most comfortable bed in the house?"

In the primary process, then, the quality of felt reality is attached to the
thing or symbol. In psychosis, this quality is consciously experienced and is
in the manifest content of thoughts. In delusional illness, if secondary
process logic is not disrupted, thing presentation quality may be the only
aspect of primary process thinking present to indicate the condensation of
reality experience with emotional experience.
Psychotic patients often try to describe the perceptual experience of an
idea in their delusion. They stress the reality, strength, and clarity of it, the
conviction it carries, and the peculiar quality it has. They ascribe to the
delusional idea all the qualities of the perceptual reality experience except
standard visual, auditory or somatic sensation. It is perhaps for this reason
that Freud (1900) spoke of words "treated in dreams as if they were things."
There are thus two aspects of primary process. One aspect is the thing
presentation symbol itself, which is a condensation of psychological meaning
with details of the physical thing taken from reality experience. The second
aspect is the quality of reality that perceptual things have in our experience
of them. This perceptual quality dominates the experience of feelings, and
therefore of meaning, in the patient's experience of psychotic or near
psychotic condensation.
Where in consciousness the quality of reality is experienced is
characteristic of the different levels of illness. It depends on how the illness
affects the ego. Whether the quality of reality is attached to a thing, an
affect, or a concept is also characteristic.
The concept of thing presentation, therefore, describes an affective
experience of wishes, fears, and their conflicts, together with experiential
qualities of perceptual reality, that are rigidly bound and contained within
the confines of the concrete symbol. In the primary process, the thing
presentation is concrete. However, very ill patients experience the concrete
as real. Damage occurs to the ego's translating mechanisms between thing
presentations and word presentations, primary process and secondary
process, percept and concept, affect and concept, affect and percept, and
emotional experience and reality experience. The task of the analytic
therapist in psychosis and near psychosis is to diagnose the specific form,
causes, and associated illness of the ego damage and to treat it with
medication and words. This is in addition to the usual analytic task of
understanding the content and origin of mental conflict.
Pictorial symbolic thinking has advantages and disadvantages. It may be
that the aphorism "a picture is worth a thousand words" is a description of
a certain necessity of emotional experience. Therefore, for affects and their
plastic integrations, thing presentations may well be able to express
1. Ego Functions 21

emotional experience and creative transcategoricals better than words. This

is why metaphor is so powerful and so adaptive. It can express and
synthesize many different aspects, conflicts and levels of mental life.
However, a picture is ambiguous. It contains within it many different
feelings and conflicts. It expresses many different complexities of
relationships among feelings and between feelings and reality. It must be
translated for precision and for causality, especially sequential causality in
reality experience. The treatment for all thing presentations is to decode
them by translating into words the metaphorical image that has invaded
reality experience or behavior. This will allow concept and affect, reality
experience and emotional experience, to separate. Translating mechanisms
are broken in different ways in psychotic and near psychotic illnesses. To
release the emotions contained, translate thing presentations into words and
concepts. Affects will then emerge as feelings. Describe them in context with
the relevant realities and emotions of present and past (see chapters 7 and
8). It is important to realize that thing presentation has its own integration
process just as secondary process and primary process do.

Integration Processes:
Secondary process: concept related to affect.
Primary process: concept condensed with affect.
Thing presentation: concept and affect condensed with percept.

Agency Contents

Psychological content is divided by psychoanalysis into content areas called

agencies. Id is the name given to drive content (see Freud, 1923; Schur,
1966). Superego is the name given to certain aspects and functions of
conscience content. Ego is the name given to certain reality-mediating
functions, experiences of emotions and defenses against emotions, and
regulations between the two areas of reality and emotion. All agencies deal
in their own way with aspects of reality and emotions. All have aspects that
are conscious and major areas that are unconscious. Because of this overlap,
the agency labels refer only to psychological content and function.
An understanding of the agency content is important, because all
symptoms-neurotic, near psychotic, and psychotic-are composed of conflicts
within or betweeen agencies, symbolically altered. The symptom is the
disguised symbol, which is derivative of the agency conflict and constitutes
a compromise formation between agencies. In psychosis and near psychosis,
as well as in some neurotic symptoms, one of the elements of the
compromise symptom is a condensation which involves reality experience.
This condensed reality experience takes a particular structural location in
psychosis and near psychosis which differentiates it from the neuroses.
22 Psychosis and Near Psychosis

Boundary Between Psychic Agencies

Although mental functioning is normally an.integrative blend of all agencies,

this integration requires regulation of the contribution of each. Such
integration requires flexible, porous, subtle, but definite boundaries between
psychic agencies. These boundaries are special boundaries. They are
permeable and permit integration. They always allow a relationship, but they
usually prevent flooding of one agency's contents by another.
The mind should be able to repress from consciousness aspects of the
agency categories of emotional experience called id and superego and
defensive ego. There should be the ability to keep these emotional agency
contents separate from reality experience and from perception. Although
agency contents are mostly emotionally experienced categories, the
boundaries between them should involve some autonomous regulating,
modulating and integrating functions.
Unconscious conflict among these agencies is etiologic in the neuroses.
Condensations within and between these agencies and their conflicts, which
then dominate conscious or preconscious reality experience, are
characteristic of psychosis and near psychosis. Any boundary disturbance
described between reality and fantasy includes the boundary problem
between psychic agencies. The only reason a boundary is listed here is that
certain psychotic phenomena are dominated by one of the agency content
areas as it floods into conscious or near conscious reality experience. Certain
illnesses are characterized by the domination of one agency content area (see
chapter 5).

Defenses

The mind has specific emotional maneuvers to deal with charged and
conflicted affects. Because these maneuvers are used as self-protection, they
are called defenses. 7
Defensive apparatuses are preconscious, primary process mental functions
that organize emotional experience in an attempt to prevent flooding of the
conscious mind with either too much or too painful emotional material.
Defenses are primarily concerned with emotional states and intersect with
reality experience mainly in terms of the emotion that is evoked by reality
experience. Reality experience and secondary process predominate in
organization of autonomous apparatuses. In defenses, emotional experience
and primary process predominate in the organization. Defenses are
emotionally organized and are not autonomous of emotional experience.
They are crucial aspects of emotional experience.
The content of the defenses, how they are organized, the specific
mechanisms used, what is being protected, and what is being defended
1. Ego Functions 23

against, all vary according to individual, type of illness, phase of illness, and
severity of illness. Some general statements can be made.
Defenses attempt to compromise mental conflict. Are psychotic and near
psychotic defenses different from neurotic defenses? Put another way, are
psychotic and near psychotic symbolic alterations composed of defenses or
used defensively? When we try to apply the concept of defense to psychotic
and near psychotic phenomena, a number of problems arise.
"Defense" has two meanings, depending on what is defended against.
Defenses, (e.g., repression, a basic defense) operate to screen mental conflict
but also to regulate internal stimuli. In psychosis and, to some degree, near
psychosis, this internal stimulus barrier function may be damaged. Likewise,
the in-out barrier may be damaged. This use of the word defense is different
from the defense against conflict that psychoanalysis speaks of in neurosis.
This stimulus barrier problem, I believe, is in part due to a direct biological
attack on an autonomous neuromental boundary. It is not primarily due to
conflict formation, and as a result treatment may not involve only conflict
resolution. However, defense against painful emotional conflict is important
in psychosis and near psychosis. But here, too, there are problems.
The problem is whether psychotic and near psychotic defenses are
different from neurotic defenses and, if so, whether the difference involves
defenses against reality in psychosis and near psychosis but not in neurosis.
What is usually meant by the concept of defense against reality is a defense
against reality experience. This does not actually distinguish neurotic from
near psychotic from psychotic. The neurotic hysteric who represses the
memory of a sexual incident, and the obsessive who "overlooks" a crucial,
emotionally laden detail are both defending against aspects of reality
experience. But in these cases aspects of reality experience have been
repressed into unconscious emotional experience. In psychosis and near
psychosis, emotional experience, with its layered defenses, has invaded
preconscious and/or conscious reality experience. Instead of, or in addition
to, repressing reality experience, psychotic and near psychotic defenses alter
reality experience in consciousness or near consciousness. Within the
psychotic phenomenon itself, however, there may be layers of defenses that
defend against more unconscious aspects of the emotional experience. This
is true in a delusion or hallucination. The delusion is usually a condensation
of conflict. It is not necessarily more in conflict with reality than in a
neurotic symptom, but in psychosis and near psychosis it is always a conflict
erupting into conscious or preconscious reality experience. Therefore, only
the location of the conflict is different, because of the autonomous ego
boundary separating conscious and near conscious reality experience from
emotional experience through which the conflict has erupted.
In the psychoses and near psychoses, reality experience is overwhelmed.
Reality experience is usually overwhelmed in highly specific ways according
to the emotional significance of the content of reality experience. This has
led psychoanalysts to believe that the overwhelming itself is a defense against
24 Psychosis and Near Psychosis

conflict. This theory, however, does not explain symptom level, global
psychotic states with fusion experiences determined by reality stimuli, and
the action of medication.
Defense as a concept describes neurotic illnesses where a childhood
experience, whether factual, emotional, or both, underwent repression from
consciousness because of conflict and anxiety. The emotional reaction
reappeared in the form of a primary process organized symptom, containing
the memory of the original event(s) and their conflicted feelings, highly
disguised by the defensive alterations. The symptom does not impinge on
conscious, adult, reality experience, even though it may affect behavior. At
worst, it impinges on the emotional experience of adult reality, and even
then, mostly preconsciously and especially unconsciously.
Although it is true that psychotic and near psychotic phenomena contain
psychological conflict in their structures, ego boundary functions that should
be independent of emotional conflict lose the ability to contain emotional
conflict away from conscious reality experience. This distinguishes psychosis
or near psychosis from neurosis or conscious fantasies. See Table 1.2.
It is more parsimonious to say, therefore, that psychosis and near
psychosis involve defenses that have erupted through autonomous ego
boundaries and functions. This leaves the etiology of the ego dysfunction
open, and a search for direct (biological) as well as indirect (psychological)
causes can ensue. A brain tumor, a drug, or a metabolic alteration, can all
cause forms of psychosis and near psychosis. Focusing on the relationship
among defenses, conflict, and autonomous ego from the viewpoint of
autonomous ego is more congruent with descriptive psychopathology,
physical pathology, neuropsychological studies, medication effects, and
necessary psychoanalytic treatment parameters.
The degree to which reality experience alteration is due to conflict and
defense against conflict, or the degree to which reality experience alteration
is used in the service of defense, in fact, varies according to illness type,
severity, and phase. In general, however, there is a direct attack on ego
function that is biological and neuromental instead of, or in addition to,
psychological conflict and ensuing defensive maneuvers.
However, psychotic and near psychotic process can be used defensively
and contains defenses in its structure. And conflict can be part of etiology
in terms of vulnerability, just as there is an as yet unclear biological
vulnerability.
The exact relationship among stress, temperament, psychological conflict,
and psychosis or near psychosis is unknown. My own clinical experience
tends to indicate a spectrum of vulnerability (see Weil, 1978) from little or
no discernable stress or consistent psychological conflict to highly specific
stress and conflict. For patients at this latter end of the spectrum, combined
psychological and biological treatment or, in some cases, just psychological
treatment is crucial. In all cases, however, otherwise autonomous ego
functions are damaged and/or captured.
1. Ego Functions 25

Table 1.2 Defenses in psychosis and near psychosis

Defense Defense Defense Defense

against location location in location in
in psychosis near psychosis neurosis

Reality Conscious Preconscious Unconscious

experience

Deeper layers Conscious and Preconscious Unconscious

of psychosis preconscious and
and near unconscious
psychosis

Observing ego Conscious and Preconscious Preconscious

preconscious

Integration Conscious and Preconscious Preconscious

preconscious

Regardless of the etiology of the autonomous ego deficits, emotional

conflicts and defenses are phenomenologically very apparent in psychotic and
near psychotic states. But the striking thing is always their effect on reality
experience. The flooding of reality experiences is due to any or all of the
following autonomous ego problems:

1. Boundary disturbances between reality experience and emotional

experience;
2. Contamination of perceptual representations by emotional representations
and consequent acquisition of reality experience quality by emotional
quality;
3. Loss of secondary process integrating and translating ability.

Defenses, being primary process, are usually less disrupted in their

organization in psychosis and near psychosis than autonomous functions.
One can see this most clearly in a patient's defensive organization and
content as the patient recovers and moves from psychotic organization to
neurotic organization, without necessarily changing the content of their
defenses.
Defenses are more important than damaged ego boundaries in psychosis
and near psychosis when they defend against observing ego and against some
26 Psychosis and Near Psychosis

aspects of the integration of emotional experience. These, however, are

particular defenses at particular spots in the psychotic and near psychotic
structure. They are usually more important in near psychotic phenomena
than in psychotic phenomena (see chapters 2 and 3).

Summary

Defenses are for two purposes. One is primary, involves repression, and is
merely an inner stimulus barrier for material that is never conscious. The
other is a secondary defense against conflict, aspects of which were at one
time conscious. The first is an autonomous ego boundary. The second is an
emotional, primary process, preconscious experience characteristic of
individual neurotic symptoms and personality. Both are usually involved in
psychosis and in near psychosis.
In psychosis and near psychosis, autonomous ego boundaries fail to keep
the conflict (1) away from reality experience (always), (2) repressed (usually),
(3) under dense disguise (usually), and (4) integrated (usually).
In psychosis, defenses condense with conscious aspects of reality
experience, and reality testing is lost.
In near psychosis, defenses condense with aspects of reality experience, but
only preconsciously and reality testing is not fully lost.
In severe psychosis, the stimulus barrier is damaged, and reality stimuli
from without and emotional and perceptual stimuli from within determine
experience and are called fusions.
A major emphasis of this book is that damaged autonomous apparatuses
primarily, and the ego defensive mechanisms only secondarily, determine the
organizational structure of experience in the psychoses and near psychoses.

The Primary Process and Conflict

The relationship of agency content, conflict, and defense to the primary

process form of symptom formation and symbolism is a topic of
psychoanalytic disagreement. For me, the problem is that conflict is a
categorical process with feelings and contents from different categories in
conflict with each other. The primary process, however, is unitary and
transcategorical in its form. Primary process, therefore, is a phenomenon
that synthesizes conflict as well as being composed of conflict elements.
Primary process symbolically alters and transcategorizes in its
condensations. To transcategorize means to categorize across logical category
boundaries. Condensations are groups of emotional aSSOClatlons
transcategorizing and hence synthesizing categories of emotional conflict, day
residue, the present, and the past. The term compromise fomwtion (Brenner,
1. Ego Functions 27

1976) expresses the concept of conflict but takes no particular notice of the
synthesis. That is, it takes no particular notice of type, location, or quality
of the compromise. 8 Condensation is a specific term for a primary process
form of compromise.
In psychosis and near psychosis, synthetic aspects are primary processed
condensations, dramatically available and specifically organized, are
specifically located, and have certain specific qualities.
The synthesis is in the primary process symbol. The conflict is in the
dissociations between the symbol and the rest of emotional and reality
experience, and also, in the classical sense, when the symbol content itself
is psychoanalyzed into parts that are in conflict. But conflict elements within
the symbol are condensed in different types of psychotic and near psychotic
synthetic processes that are typical of different types of psychotic and near
psychotic illnesses.
Psychotic and near psychotic patients often feel they have special access
to new transcategorical syntheses and therefore experience their psychotic
and near psychotic phenomena as revelatory. They are not wrong. But it is
an emotional revelation which they experience as a reality revelation. The
psychoanalyst can help the patient understand the emotional revelation and
thereby help the patient separate revelation from reality experience. It helps
if the psychoanalyst does not immediately analyze the parts of the conflict
within each symbol before understanding the newly revealed synthetic
solution of the psychotic and near psychotic phenomenon, and the revelatory
quality of that experience.

Object Relations

The mind tends to organize its functions of compromise, defense, agency,

symbolic representation, and affect into mental experiences of people and
their relationships. Freud used the term object to describe the object of the
drives. But it was Klein who described early fantasies of these objects in
relationship to self-representations. Her early defenses were mechanisms that
operated on the basis of these fantasies of self- and object representations.
Jacobson (1964) described the relationship of object relations to the self,
psychic structure, and development, an endeavor continued and expanded on
by Kernberg (1976b). I will not discuss the exact relationship in the history
of psychoanalytic theory of object relations to drive, structure, function,
memory, and reality experience (see Pine, 1990; cf. Modell, 1968), because
I am concentrating on the ego function aspect of descriptive
phenomenological theory in psychosis and near psychosis.
However I will discuss the distinctions between fantasy and reality objects,
presentation and representation of objects, conscious and unconscious
objects, cause and effect of illness, and ego dysfunction and object relations.
The experiences of oneself and other people, combined with memories,
28 Psychosis and Near Psychosis

fantasies, and feelings about these experiences, are called object relations.
Descriptions and hypotheses about their reception, recording, organization,
and elaboration through development and symbolic transformations are
called object relations theory. The term object relations includes one's view
of others (object representations) and also of oneself (self representation).
An object relationship can be conceptualized as composed of a self-
representation in an emotional relationship (affect) with an object
representation (Sandler and Sandler, 1978; Kernberg, 1976b) and contains
id, ego-defensive, and superego elements in both the object representation
and the self-representation (Schafer, 1968).
Aspects of object relations experience are in the experience of outer
objects in reality, in inner object reality experience, and in feelings about
objects in our emotional experience.
I will ascribe the experience of object relations to the ego, both reality
experience and emotional experience, both conscious and unconscious
(Schafer, 1968). Psychoanalysts do not agree about this. Aspects of content
and affect are determined by agencies other than the ego, but whether actual
felt experience can occur in other agencies than the ego depends on
definitions of id and unconscious that have never been agreed upon. For the
more severe illnesses, which disrupt ego function, and for this book, which
focuses on ego function in those illnesses, it is most helpful to look at the
ego aspects of the experience of object relations. Autonomous ego
functioning disturbances result in the most profound and dramatic
disturbances in the ego's experience of object relations.
In the ego, there are conscious elements of attributes of the object in
reality, conscious aspects of memories, fantasies, and feelings that these
objects evoke, and large unconscious areas of memories, fantasies, and
feelings. I believe attributes of the object in reality are also stored in
unconscious object representations. Everything that has been said about
object representations holds equally true for self-representations.
The crucial point is that distortions that will be described for psychosis
and near psychosis occur not only in the unconscious realm of object
relations but also, because of autonomous ego dysfunction in very ill
patients, in the conscious part of object relations. The illness affects their
integration, their relationships with each other, and most crucially, the
relationship between reality experience of objects and the emotional
experience of object representations.
We shall see the distortions and characteristic integrations of these object
relationships in very ill patients. Typical distortions, typical emotional
experiences, typical contents, and typical integrations guide treatment.
In summary, the term object relations refers to (1) an external self or
object that is (2) represented in the mind and also to (3) an internal,
emotional view of oneself and objects. The term usually refers to conscious,
preconscious, and unconscious aspects of 2 and 3 but may refer to 1, 2,
and 3.
1. Ego Functions 29

Object Relations: Boundaries

Now we have a problem. The term object relation is most unclear in
psychoanalysis because it refers both to inside and outside and also to two
different kinds of inside experience. These phenomena are condensed in the
unconscious of neurotic patients who consciously have the ability to tell the
reality experience aspect of object relations from the emotional experience
aspect. 9
Psychoanalysis focuses in neurosis on the unconscious, and therefore the
ambiguity of the term with regard to reality versus emotion is no dis-
advantage. In sicker patients, however, we must distinguish, because they
consciously do not. I will do so now by using different terms to describe the
different ego aspects of the Object world experience that are important in
understanding psychotic and near psychotic patients.
The object in reality will refer to the stimulus properties of the real world.
In the realm of people, objects in reality will refer to people in reality, to
their behaviors in reality, and to their feelings as they feel them. The Object
in reality does not refer to a mental experience of the patient. It refers to
stimulus properties of the external world. It includes inanimate things in
reality.
The real object will refer to the recording of this outer reality in the mind
of the patient. This is the inner mental experience of reality.
The object representation will refer to emotional experience. The Object
representation contains fantasies, hopes, and fears.
The same is true for the self in reality, the real self-experience, and the
experience of the self-representations. How we are in reality is not the same
as how we experience ourselves to be in reality, nor is it the same as our
self-representation composed of our hopes, fears, and wishes about ourself.
Much of the real self- or real Object experience is usually conscious. Most
of the self- or Object representation is usually unconscious. See Table 1.3.
There are two further confusions. One is the confusion between using
"self' to mean self-representations but also to mean the total self of all
emotional, inner experience, including Object representations, self-
representations, and one's own view of one's self in reality. I will avoid
especially using "self' to mean the totality of all mental life in order to avoid
confusion when discussing condensations and fusions. I will also avoid the
use of the term "self' when only self-representation experience is meant but
not specified. The second confusion in reading the literature on Object
relations is that it is usually unspecified whether the phenomenon under
discussion is conscious or unconscious. Such specificity is crucial to
discussions of psychotic or near psychotic phenomena. In neurosis, usually
the author is referring to unconscious. But in psychosis and near psychosis
these phenomena are conscious, and this fact is crucial in understanding and
treating the ego structures that organize psychotic and near psychotic
experience.
30 Psychosis and Near Psychosis

Table 1.3 Object Relations Definitions

I.
A Object in reality
1. Behavior and feelings of others as they act in the real world and
as they really feel
2. What occurs outside the mind

B. Self in reality
1. Our real stimulus properties. How we are in reality, including our
behavior in reality
2. Outside the mind

C. Thing in reality
1. Stimulus properties of the real world of the inanimate
2. Outside the mind

II.
A Real object
1. Recording in the mind of outer reality of others
2. The inner experience of others in reality
3. Mostly conscious

B. Real Self
1. The inner experience of our real selves
2. How we experience ourselves to be in reality as opposed to how
we really are to others
3. Mostly conscious

c. Real thing
1. The inner experience of reality stimuli of inanimate things
2. Mostly conscious

III.
A Object representation
1. The inner, emotional experience of another
2. Our hopes, fears, and fantasies of others
3. Mostly unconscious

B. Self representation
1. Our inner, emotional experience of ourselves
2. Our hopes, fears, and fantasies of ourselves
3. Mostly unconscious
1. Ego Functions 31

C. Thing representation
1. The emotional experience of inanimate things
2. The representation of inanimate things as determined by the
feelings they evoke
3. Mostly unconscious

Because of these confusions when one reads in the psychoanalytic

literature that in psychosis the self is merged with the object, it is impossible
to know what is meant. With various authors various phenomena are meant.
I will try to be careful to specify. An example of the confusion that results
when specificity is not adhered to is when "self and object fusion" is used to
mean "self-representation merged with object representation." This is
actually relatively healthy on the ego scale of psychotic and near psychotic
phenomena. Both self-representation and object representation are
emotional experiences, not experiences of reality. For reality to be con-
taminated, there must be a further step into real self or real object.
Now disturbances of the boundary between reality experience and
emotional experience cause merger. Two types of merger have been
described: fusion and condensation. In fusion, the object in reality merges
with some inside experience, usually with many inside experiences. In
condensation, the two merged experiences are already inside the mental
apparatus but more importantly, the merger is determined not by stimuli in
reality but by emotional significance. The merger of condensation tends,
therefore, to be at specific and limited points of internal experience. These
points are symbolic because they express emotional significance in their
content and perhaps in their processes.
Fusion is a more chaotic process than condensation, since the merger is
across a totally open boundary from organization inside to stimuli outside.
The mental result is determined by stimulus properties of outside.
It is important to realize that in both types of psychotic merger, fusion
and condensation, the merger is occurring in the conscious area of the ego
experience of reality. This is what makes psychoses so dramatic and so
different from neuroses. The relationships of the object in reality to real
object to the object representation and the corresponding relationship in the
self representation system are mostly unexplored in psychoanalysis. I will
attempt no systematic description other than the definitions I just gave.
Using these definitions I will explore for psychosis and near psychosis the
relationship of the real object to the object representation, the real self to
the self-representation, the real self to the object representation, and the
self-representation to the real object. This is because the most common
disturbances, and the psychoanalytically interesting symbolic alterations, are
at these loci in psychosis and near psychosis.
In summary, ego boundaries between real object and object represen-
32 Psychosis and Near Psychosis

tation, real self and self-representation are the boundaries between the
experience of reality and the experience of emotions in the area of people
and relationships. When these boundaries go, psychosis and near psychosis
ensue.
The crucial conclusion to be drawn from this description is the ego
organizes the forms of object relations.
In the neurotic illnesses, the therapist is dealing only with unconscious
aspects of the Object representations and self-representations and their
emotional connections. Reality memory, if condensed in the representation,
is unconscious.
The therapist of very ill patients needs to attend to badly distorted
conscious elements because of the effect of illness on what should be
primary autonomous ego apparatuses and boundaries. In very ill patients,
the Object representation or self-representation overwhelms the part that is
real object, or real self. The content of the overwhelming is conscious at the
point of the overwhelming. Only the process, the fact of the overwhelming,
is unconscious either descriptively or dynamically or both.
I will now summarize the relationship of the real Object to emotional
feelings in the various illness states, from psychotic to neurotic.

Hierarchy of Organization of Real Object: Psychotic to Neurotic

1. Psychotic: Merger occurs; in condensation type of merger, consciously

cannot tell the difference between real object and feelings about the
Object called the Object representation, between symbolic transformations
of the real object based on feelings and the reality experience of the
object; i.e., between real Object and object representation or between real
self and self-representation.
2. Near psychotic: Consciously can tell the factual difference but consciously
does not care because the contents of real object and Object
representation or real self and self-representation are condensed just
below awareness in preconscious, latent content; this latent condensation
is compelling and overwhelming in its emotional effect on conscious
reality experience.
3. Very ill neurotic: Consciously can tell the difference and does care, but
preconsciously wants to change the Object in reality as if that would
change the inner real object.
4. Healthier neurotics and normals: Consciously can tell the difference and
no great preconscious push to actualize (to change the real object);
effective separation of conscious aspects of real object from unconscious
levels of object representation.
1. Ego Functions 33

In summary, then, the ego's alteration of reality experience in object

relating takes place:

1. In the psychotic: in manifest content of conscious material;

2. In the near psychotic: in preconscious upper layers of latent material;
3. In the neurotic: in unconscious deeper layers of latent material as seen in
free associations, dreams, parapraxes, and highly disguised in daily
interpersonal life.

Psychotic and near psychotic are distinguished from neurotic and normal
by the part of a person's mental organization in which the experience of the
object representation occurs. This distinction involves boundary apparatuses
that should be autonomous. Chapters 2 and 3 describe how these
distinctions are organized in psychotic, near psychotic, and neurotic
structure. Chapters 7 and 8 will describe the implications these differences
have for psychoanalytic psychotherapy. Some attention in treatment must be
paid to how the real Object is handled, because psychodynamics, the way one
feels, can be similar in all of these states and yet the manifestations can be
so different. Attention to the dynamics of feelings may not deal with the
alterations of autonomous boundary and other apparatus functions that
determine psychotic and near psychotic experiences of the object
representation.

Symbolism, Symbolic Representation and

Symbolic Alterations of Reality
Symbolism means the standing of one element for another. The simplest
symbol is a signal that stands for something in a one-to-one relationship.
Complex signals have many parts used to signal. In addition, they may refer
to more than one referent, or to a referent with a number of parts. There
is a specific number of referents with an exact, specifiable, even
mathematical relationship to the signal. In both simple and complex signals,
the form the signal takes may be related to the form of the referent or it
may be arbitrary. In either case, signals are usually chosen from conscious
reality experience and always according to some logical rules of secondary
process.
The expression to represent or symbolically represent is used by
psychoanalysis instead of the terms to signal or stand for (cf. Beres and
Joseph, 1970). To represent, however, is different than to signal. A symbolic
representation stands for many, perhaps unlimited, referents. There is a
relationship of theme and not of number. Representation can also imply that
what is stood for is actually pictured or represented, albeit changed, in the
complex signal or symbol. This implies a relationship between manifest and
34 Psychosis and Near Psychosis

latent contents which psychoanalysis has never clarified. I believe the

relationship is specific in psychosis and near psychosis.
Symbolic representation may mean either a reality representation, an
emotional representation, or both (see Yahalom, 1967). The symbolic
representation's form and content is not consciously chosen in
psychoanalytic symbols. The organization of the symbol is usually primary
process. The symbol is always experienced emotionally, not just consciously
but also unconsciously and preconsciously, where unconscious means not just
subliminally unconscious (unchanged in form and content) but dynamically
unconscious (changed in form and content).
When psychoanalysts use either the terms symbol or representation, they
usually mean a symbolic representation that refers to many, many latent
referents. It is united by one or a limited number of themes of emotions,
preconsciously and/or unconsciously experienced. The form and content of
the experience is different at different levels of consciousness. The form and
content of the experience is different at different levels of consciousness.
The relationship ofreality experience to emotional experience is unspecified,
but the term represent implies one in the other. The representation may
be mostly an emotional representation in form and content. tO
Symbolic representation is a broad term. All self- and object
representations in usual psychoanalytic usage are symbolic representations
because they are composed of mixtures of reality, fantasy, memory, percept
and affect. However, it is these components, their various integrations and
illness-caused disintegrations, that need to be precisely described in order to
understand psychotic and near psychotic phenomena.
The broad term symbolic representation includes symbolic processes and
nonhuman contents not always implied in the term object representation. In
addition, the term symbolic representation correlates with other fields
psychoanalysis ought to interact with, such as philosophy (Langer, 1942;
Cassirer, 1955; Werner and Kaplan, 1963; Kuhns, 1983), anthropology
(Obeyeskere, 1990), and art (Waldheim, 1984).
For an introduction to the literature on symbolism, see Jones (1912,
1961), Symons (1925), Langer (1942), Cassirer (1955,1979), Ferenczi (1952),
Matte-Blanco (1959), Segel (1961), Werner and Kaplan (1963), Blum
(1978), Segal (1978), and Loewald (1988).
On the development of the symbolic process see Piaget and Inhelder,
(1971), and Sarnoff (1967, 1987).
If emotional experiences use reality experience for symbOl, then reality
experience is changed in order to convey emotional meaning. Percept,
content, and sequence or context of the reality thing or object, or a
combination of these features, may be changed. An example of sequence or
context change is a group of things collected according to emotional theme
rather than logical category. This is the primary process. An example of
change in the content of the thing itself is a change in details of form or
type.
1. Ego Functions 35

Table 1.4 Comparison of signals to psychoanalytic symbols

Signal Symbol

Form/content From reality From reality

experience experience and/or
emotional
experience

Referent Reality experience Emotional

experience

Organization Secondary process Primary process-

condensations and
displacements

Experience Reality experience Emotional

locus experience and
reality experience

Experience level Conscious or Referent always in

subliminal dynamic
unconscious,
usually
preconscious,
sometimes
conscious

Experience quality Neutral Affect-ridden or

evoked, emotional
qualities, often
with thing
presen ta tion
qualities

I will call symbolic representations that alter reality experience symbolic

alterations of reality. This has crucial relevance to psychotic and near
psychotic phenomena.
The ego helps organize symbolic forms. Because the ego is changed by
various types and degrees of psychiatric illnesses, the organization of
symbolic forms will also be changed. This change will be characteristic of the
specific illness and level of illness. The important aspect of symbol formation
in psychosis and near psychosis is the use of and alteration of conscious or
36 Psychosis and Near Psychosis

near conscious reality experience. This is because emotionally determined

symbolic alterations invade and dominate reality representations. The
symbolic alteration of reality in psychosis and near psychosis has a special
locus, a special structure, and a special experience. This varies from illness
to illness and will be described in chapter 5. There are also commonalities
that will be described in the chapters 2 and 3 on psychotic and near
psychotic structure. For now, I will only describe the result in symbol
formation of the ego function disruptions described in this chapter.
The ego organizes symbolic forms and uses. Ego problems of boundary,
regulation, and secondary process integration permit a significant area of
reality experience to be symbolically altered in the conscious and manifest
content of reality experience. This determines the form of psychotic and near
psychotic symbols.
The ability to use these primary process symbols varies with ego function.
The ego functions especially pertinent are the abilities to abstract,
generalize, apply, integrate, reality test, observe, and keep reality experience
and fantasy experience separate.

Ego functions important in use of symbols as symbols:

1. Ability to boundary (especially between reality experience and emotional

experience, i.e., between percept, concept, and affect).
2. Ability to reality test.
3. Ability to abstract.
4. Ability to generalize.
5. Ability to apply.
6. Ability to observe.

Psychoanalysis has looked at emotional aspects of symbol formation,

because neurotic patients can tell reality experience from emotional
experience and also because the interesting aspects of neurotic symptoms are
the preconscious and unconscious emotional symbols. The manifest,
conscious symbolic elements are interesting in neurosis only because they
refer to the latent content and condensations of deeper affects and conflicts.
In neurosis, referents are unconscious. They are events and associated
object relations in the past with associated painful, conflicted affects. An
emotional compromise appears highly disguised in the conscious aspects of
the emotional experience of the neurotic symbol or symptom.
Psychosis and near psychosis are different because the emotional symbol
has invaded and condensed with present and ongoing reality experience. The
condensations occur at specific, meaningful points and emotionally alter
reality experience at those points. Therefore, what aspects of reality
experience are chosen, and what alterations take place, are symbolically
meaningful. Understanding this meaning will enable an understanding of the
emotional meaning, in the present as well as the past, of the psychotic and
1. Ego Functions 37

near psychotic symbol process and symbol content. This is why the manifest
aspects of the symbolic alterations of reality in psychotic and near psychotic
symbolic experiences are important. Because reality experience is specifically
invaded at conscious condensation points, the symbolic alterations of reality
in psychosis and near psychosis can be observed to be linked to the latent,
emotional aspects of the symbol. These linkages occur at conscious
condensation points of reality and fantasy.
Thing presentation symbols of this condensation have the reality quality
originally borrowed from reality experience and the affect quality from
emotional experience condensed. It is important to realize how much of the
pertinent affect experience is encoded in the thing presentation symbol and
experienced as a reality thing. This means that affect is experienced along
perceptual lines of reality things. Therefore, the reinvasion into reality
experience by this symbol has thing presentation quality of perceptual
experience, emotional quality of affect experience, the location in conscious
reality experience, but the organization of primary process emotional
experience.
A definition of all psychotic and near psychotic experience is that thing
presentations reinvade reality experience by the condensation mechanism,
resulting in specific and structured symbolic alterations of reality experience
in consciousness or near consciousness. This happens primarily because of
ego boundary disruptions.
Symbolic processes are, in part, biologically determined by cognitive
phases of maturation and developmental object relations phases. But Object
relations are also influenced by Objects in reality and reality experience.
Specific illnesses within each of these categories have characteristic
mechanisms of symbolic representation, and hence characteristic effects on
the organization and content of symbolic alterations of reality experience. In
addition, specific illnesses may have specific themes to the content of the
reality experience alterations chosen. Therefore, this book is really a
discussion of illness-specific symbolic alterations of reality.

Notes
1. There are problems with subdividing mental experience heuristically into
faculties or compartments, especially a compartment called reality
experience. Mental life is integrative as well as compartmentalized; reality
experience and perception are always influenced by emotion. But
conscious reality experience has its own typical mental organization and
qualities. These are dramatically altered in psychosis and near psychosis.
Although somewhat artificial, the focus on reality experience allows
clinical descriptive accuracy for the purposes of accurate diagnosis and
treatment of psychosis and near psychosis. The distinction between reality
38 Psychosis and Near Psychosis

experience and emotional experience is clear in the conscious mental

experience of normal patients and neurotic patients. Psychotic and near
psychotic illnesses involve reality experience alterations resulting from
condensations of reality experience and emotional experiences that are
typical for psychosis and near psychosis and their respective illnesses. In
order to describe these particular condensations, it is helpful to describe
their categorical components.
The division I describe is actually an old one in the philosophy of
knowledge. Plato's categories were the real versus the ideal; Freud's
categories were secondary process versus primary process.
The complications involved in this distinction arise not from the
definitions, nor from the experience, but from the decision about which
phenomena belong where. It is a decision that philosophers of knowledge
have discussed for centuries. Psychoanalysts working with very ill patients
can avoid this discussion if they wish, because psychotic and near
psychotic patients have their own characteristic method of sorting and
characteristic type of failure to sort.
The other problem with the distinction is the influence that emotions
always have on the perception and experience of reality. However, the
conscious mental experience of reality is often different from that of
emotional feelings about reality. Psychotic and near psychotic patients
have difficulty experiencing a division between these two mental qualities.
One difficulty in sorting phenomena into these two categories is the
experience of the body. The body can be experienced as a source of reality
stimuli external to the mind or it can be experienced emotionally.
Emotions also have their place as "real" occurrences (see preface), but
they are internal in the experience of the mind.
Again, the careful study of psychopathology can be clarifying because
the sorting and categorizing process is characteristic, not of our
philosophy, but of patients and their illnesses. This book describes the
effects of psychotic and near psychotic illness on mental sorting and
categorizing.

2. Reality experience, as I use the term, requires superordinate or compound

ego functions (see Hartmann, 1939, 1964; Blanck and Blanck, 1986; and
Bellak et al., 1973). The concept of superordinate ego function is reviewed
extensively in Blanck and Blanck. They discuss the similar ego psychology
concepts of synthetic function (Nunberg, 1931), executive function,
(Glover, 1958), and integrative function or organizing function,
(Hartmann, 1964). complex ego functions working together are called
superordinate ego functions.

3. Dr. Greg Heimarck, faculty, Columbia University Center for

Psychoanalytic Training and Research, points this out in his section on
1. Ego Functions 39

affects as part of the third year theory course. He brought my attention

to Plutchik (1980), and also Izaard (1978).

4. General psychiatry (CampbeIl, 1989) defines reality testing as "a

fundamental ego function that consists of the objective evaluation and
judgement of the world outside the ego or self."
Freud dealt with the issue of how we "decide if something is real or
not" (SE, Vol. 1, pp. 325, n2, Strachey's explanation) in many different
papers looking at different aspects of this function. La Planche and
Pontalis (1973) point out the lack of a systematic description in Freud
and the lack of agreement in the later psychoanalytic literature about the
descriptive distinction of reality testing. Different authors stress different
ego aspects from perception, to memory, to imagination, to quantity, to
quality, to the more narrow comparison function (see Frosch, 1964).
La Planche and Pontalis point to two different meanings in Freud's use
of the term: (1) a distinction between mental representation and
perception, and (2) a comparison between mental representation and
perception.
My own view is to limit reality testing to the comparison function, as
is common in general psychiatry, because perception and representation
in psychosis can show various alterations (the discrimination function)
while the comparison function is always altered. Furthermore, the
discrimination function in the psychotic symptom may be altered, but this
is not limited to psychosis. There are non psychotic alterations of
discrimination function in haIlucinosis (see chapter 4), near psychosis (see
chapter 3), eidetic fantasy, and, indeed, in all thing presentations that
enter conscious experience (see chapters 1 and 2). For a review of the
recent psychoanalytic literature see Frosch (1983); see also Hurvich
(1970).

5. Freud (1900, chapter 6, section D) was interested in the variables

determining the form of primary process condensation. He called this
representability and defined it as "the selection and transformation of
dream thoughts so as to make them capable of being represented by
images" (La Planche and Pontalis, 1973, p. 389). But psychotic and near
psychotic patients select and transform reality so as to make reality
capable of representing latent thoughts. How are the aspects of reality
incorporated into the delusional systems and haIlucinations chosen?
Just as important day residue events, people, and things in the life of
the psychotic and near psychotic patient are often chosen, reality elements
are chosen because they are imagicaIly (pictorially, physicaIly) suited to
symbolically express concepts. In this sense, representability means the
selection of the day residue reality experience according to realities that
are graphicaIly capable of representing latent thoughts (Freud, 1900).
40 Psychosis and Near Psychosis

6. There is a major theoretical difficulty in applying Freud's observations

about dreams to psychotic phenomena. Freud believed the day residue
might be insignificant in reality experience. Some psychoanalysts restrict
the concept to this view. The insignificant reality event then gains its
emotional power, not by the present-day evoked emotion of reality, but
through its past emotional significance. There are two ways this emotional
significance can be achieved. One is that the day residue had an emotional
similarity to a significant reality experience in the past. The significance
of the day residue was, by association, an emotional displacement from
the past event. The other way is that the physical characteristics of the
reality event were well suited to represent the past emotional experience.
The significance of the day residue is then a displacement from emotion
onto physical details of the reality-experienced thing or event. In either
case, a repressed affect memory is stirred.
However, Freud did not restrict his concept of the day residue to the
insignificant in reality experience. Although he said it was often
insignificant in reality or even absent in reality experience and only
present as a conscious or preconscious thought, day residue could
certainly consist of significant reality experiences and evokers of strong
emotional reactions in the present. This is amply illustrated in DID
(1900) in many of Freud's dream examples. The role of present,
emotionally provocative, reality-experienced day residues is often
neglected by psychoanalysts.
Traditional psychoanalytic interpretations of psychosis and near
psychosis tend to look at the emotion and/or events of the past in
hallucinations and delusions just as psychoanalysts do in neurotic
symptoms. But many times these events have an important echo in a
reality, present-day event. This present-day event plays an important role
in organizing the emotional structure of the symptom and even in
triggering and organizing a psychotic or near psychotic episode. The
triggering events can be identified because when they occur they become
the day residues in the structures of psychotic and near psychotic
phenomena and are characteristically encoded (see chapter 2).

7. For a complete discussion of the history of the concept of defense in

psychoanalysis, see La Planche and Pontalis (1973); Anna Freud (1936);
and Brenner (1976). There are two arguments in the literature, one
relevant to us and one not. The irrelevant one is between Anna Freud
and Brenner. They disagree as to whether the defenses are limited to
specific preconscious primary process maneuvers, or can involve any
aspect of mental function. The former is somewhat Anna Freud's view
and the latter is Brenner's. The second argument is whether psychotic
illness is a defense, and whether the etiology therefore is psychological
conflict. A more complete discussion of this issue follows in chapter 2.
Suffice it to say, as I have before, that autonomous ego usually is damaged
1. Ego Functions 41

independently of defense in the psychotic and near psychotic illnesses,

allowing emotional defenses to dominate reality experience. When mental
processes are used for defense, regardless of their original organization
and function, they become subtly infiltrated with primary process content,
organization, or use.

8. There are several terms that, while different, refer to aspects of the same
phenomena. Freud (1900) called certain putting-together processes of the
primary process condensation. In this phenomena, different "associations"
or aspects are put together in a new form. Brenner (1976) uses the term
compromise formation to mean putting together aspects of all agencies but
not necessarily in or only in primary process condensation form.
Waelder's (1936) principle of multiple [unction, from which Brenner's
concept is derived, merely states that in analysis of a patient anyone
mental phenomenon can be shown to serve many purposes, e.g., the
purposes of all three agencies.
The point for this book is that in psychosis and near psychosis, certain
aspects of autonomous ego are captured; not just averaged like a vector,
as in the compromise formation concept, but actually primary processed
as in the condensation concept. Nersessian (1989) makes a similar point
about dreams. The compromise formation term takes no particular notice
of level of consciousness, symbol elements, or primary process
organization. It does not distinguish unconscious emotional experience
from conscious reality experience. There can be no way, therefore, to
define a psychotic compromise.
It is the ego which is the major organizer of the form of the
compromise. In this sense, the ego is not co-equal with other agencies.
When the ego is damaged, the elements and the organization of the
compromise formation will be different than when the ego is not severely
ill. Furthermore, the specific illnesses-their type and severity- will have
characteristic effects on the elements and organization of the compromise.
For instance, primary process organization and thing presentation
experience may predominate in psychotic consciousness. Compromise
formation as usually described may be organized with secondary process
revisions.
In addition, because compromise formation is so broad a term, it can
easily be used to also imply etiology thereby equating psychotic and near
psychotic illnesses with neurotic illnesses. The compromise formation does
not cause a capture of reality experience in psychosis; the psychotic illness
attacks and destroys the autonomous ego boundary and the resulting
capture is the result, not the cause.
In summary, in psychosis and near psychosis, the term compromise
formation may be reductionist: of etiology, process organization,
elements, and symbol experience. This is especially so in psychosis and
42 Psychosis and Near Psychosis

near psychosis, where such symbols are conscious, primary process, thing
presentation experiences.

9. Klein (1940), who, after Freud, elaborated the concept of the object
world, was actually quite clear about the relationship of objects to drive,
representation, symbol, and reality. She understood that there is a
difference between the real object, which she called the actual object, and
the object representation. She elaborated the object representation
because this was the new contribution she had to make, just as Freud
(1900) concentrated on primary process rather than secondary process.
Schafer (1968, p. 142) describes the object representation as including
the real object, thereby acknowledging the real object. I say the conscious
mind should be able to distinguish a relatively autonomous real object
from its emotional representations.

10. The term symbol in psychoanalysis has been debated and misunderstood.
Freud (1900) first used the term symbol, as translated by Strachey, in his
dream book to mean signal. Symbols were manifest content signals always
referring to the same unconscious meaning. The meaning was a bodily
experience. His term for what we now call symbol was translated as
plastic representation, meaning condensation symbols with many referents.
Many psychoanalysts have followed Jones, who used the word symbol
for what Freud called symbol but was really a signal (1948). Jones went
one step further. He defined, along with Ferenczi, a psychoanalytic
symbol (signal) as affect symbols.
My own view of these matters is that a psychoanalytic symbol is a
primary process symbol (plastic representation), not a signal, and that is
the only universal descriptive. The role of affect, level of awareness, and
relationship to symbolic elements all vary. This is true in psychosis and
near psychosis, in dreams, and in all other phenomena that have been
used as definitional. In psychosis and near psychosis, the variations occur
mainly because of the structure of the ego. I say, therefore, that
descriptive aspects of all symbol formation depend on ego functioning.
This can be observed in the various illness effects on symbol formation
(see chapters 1 and 5). Elements that are conscious, preconscious, or
unconscious and affect that is manifest, latent, encoded, or free-floating
all vary with illness effect on ego functioning. For instance, in psychosis
and near psychosis, affect may be free-floating and all-encompassing. AlI-
encompassing means that it is experienced directly and affects all
conscious mental contents. The affect may be free-floating and
dissociated, experienced directly but separated from conscious contents.
The affect may be experienced only as a thing presentation, consciously
or preconsciously, but always in reality experience.
There is another problem in the psychoanalytic use of the term
symbol. Freud meant, in his earliest use of unconscious symbol, the
1. Ego Functions 43

mnemic symbol, in which there is a memory hidden and symbolized in

the plastic representation of a symptom. That memory contains the
unconscious affect. Some psychoanalysts restrict their use of the word
symbol to this. In psychosis and near psychosis, the present is also
symbolically represented. Freud also said the present was always
important, even in the outbreak of hysterical neurosis.
2
Psychotic Structure

Introduction

This chapter describes the common features of the psychological

organization of psychotic phenomena. Although the psychoses are a variety
of illnesses that have different mental organizations, they have two common
structural aspects: a loss of reality testing and a condensation of reality with
fantasy. This condensation takes place in a particular way and is in a parti-
cular relationship to the rest of mental experience. This is why we can
describe a category of mental experience called psychotic structure.
A structure is a mental organization that is specific and stable. Elements
in the structure and relationships among elements are, therefore, reasonably
predictable. This fact can guide diagnostic inquiry and treatment.
Neurotic, near psychotic, and psychotic structures differ with respect to
what mental processes are involved, what areas of experience are involved,
where in consciousness the processes are occurring, and whether certain
autonomous ego apparatuses are involved.
Aspects of psychological structure may be conscious, preconscious, or
deeply unconscious. Psychoanalysis, in describing structure, is usually
describing the preconscious and unconscious structure so important in
neurosis. In psychotic structure, however, some elements are in
consciousness. Therefore I will describe not just stable mechanisms of
psychotic processes but also their location in levels of awareness. I start with
ego boundaries, because these are crucial aspects in the organization of
psychotic structures.

45
46 Psychosis and Near Psychosis

Autonomous Apparatuses

Boundaries

Four boundaries do not show universal changes in psychosis: in-out,

conscious-unconscious, primary process-secondary process, and
affect-affect boundaries. Although changes in these four boundaries are
common, the presence, degree, and role of the changes vary. Many analytic
writers about psychosis consider them universal and pathognomonic, but I
do not agree. When present, they are important and readily observed, but
because they are not always present, focusing on them will limit the ability
to make general statements about psychotic structure. In addition, these four
boundaries may be altered in nonpsychotic states.

In-Out Boundary
Acute psychotic states that are rapid in onset or wide in ego effect, some
psychoses that are untreated, and some that have deteriorated may show
complete loss of the in-out boundary. Outer and inner experiences fuse
depending on the intensity of stimuli in the real world and/or the intensity
of affect (see Chapter 1). An unstable, rapidly changing, chaotic mental state
results. Some illnesses are more likely to produce severe damage to this
boundary than others (see chapter 5).
Although this boundary is not universally damaged in pSYChoses, the
analytic literature says it is. Because fusion and condensation are not clearly
distinguished, it is not clear whether the boundary refers to mental-world,
or internal person-other person boundaries.

Conscious-Unconscious Boundary
For this boundary also, there is no description universally true of all
psychotic states. The degree of porosity of the repression barrier varies
enormously, from extreme states with in-out boundary and
conscious-unconscious boundary gone, to those tightly organized, logically
contained, and rigid psychotic states where only thing presentation quality
is contaminating consciousness and merging with reality testing and reality
experience.

Primary Process-Secondary Process Boundary

Here also, the contamination of logical thinking by primary process varies
widely in extent, depending on illness type, severity, duration, and treatment.
There is no universal description true of all psychotic structure. Some
2. Psychotic Structure 47

psychotic states show pure primary process organization with condensations,

displacements, affective links, and thematic integrations between ideas.
Other psychotic states are logical and tightly organized, operating almost
entirely according to secondary process. This boundary problem thus varies
according to illness type and severity.

Affect-Affect Boundary
Again, damage to this boundary varies. Extreme, chaotic psychotic states may
show affect fusions and dissociations, with intense discharges into impulses,
like a string of firecrackers going off. Other psychotic states are tightly
organized, rigidly repress affect, and show only a monotonal affect
generalized to mood as in certain schizoid or apathetic psychoses.
Four ego functions that are universally affected, but variably so, are
conceptualization, abstraction, generalization and application. Concept
moves out of abstraction as abstraction becomes concrete. Generalization
and application are lost in the psychotic area and perhaps separated and
sequestered in nonpsychotic areas of the ego. Application is affected
separately and apart from the psychosis, as an aspect of nonpsychotic illness,
or it is damaged secondarily because psychosis has concretely rendered the
generalization. These changes are the first sign, and in some cases the only
sign, of primary process intrusions in psychosis.
But the preservation of these ego functions in psychotic illness varies
depending on the type and severity of the illness and on whether these ego
functions ever developed. Because there is so much variation, all that can be
said is that these ego functions are always damaged in some way in
psychosis, but are not components of the psychotic structure. The next
section describes the universal, always present, and invariable ego structure
of psychotic experience.

Relationship of Reality Experience to Emotional

Experience in Psychotic Structure

Chapter 1 described the experience, content, and organization of different

areas of mental life. Psychotic experience consists of specific mergers
between areas that occur across normally uncrossed, autonomous
boundaries. Emotional experience dominates reality experience and
consciousness in psychosis. This occurs in stable forms with predictable
illness organizations, autonomous boundary problems, and content themes.
Hallucinations and delusions are examples. The particular, stable, and
predictable relationship that emotional experience and reality experience
have in all psychoses I call psychotic stnlcture.
48 Psychosis and Near Psychosis

Percept-AJfect-Concept Boundaries
In psychosis a boundary disruption universally and invariably occurs in the
relationship of percept to other mental events. Containment and protection
of percept fail. In psychosis affect and concept spread past percept
containment boundaries to fuse transmodally with percepts ahd
transcategorically with other concepts and other affects. In psychotic
condensations, concepts and/or affects may condense with and/or initiate
percepts. Freud (1900, 1923) described this for dreams. In all psychotic
illnesses, condensations of concept-affect-percept take an organized,
conscious primary process form called thing presentation. In psychosis,
concept and affect initiate the percept. In psychotic ideas, the experience of
validity is a sensory, often perceptual, validity (see chapter 1).
Where and how affect is experienced depends on ego structure. In
psychosis, crucial affect experiences are transmodally processed and
experienced as percept with thing presentation qualities of both percept and
affect. An example is the psychotic depressed patient who instead of saying
he feels bad about himself says that he "smells like shit" and believes that he
is literally covered with feces.
Freud (1915, appendix C) describes how thing presentations are "open to
a complex of presentations," and how word presentations are linked to thing
presentations by sound image-visual image links. Piaget (1981) describes
affects that become linked to percepts. Stern (1985) reviews experiments
showing the appearance in the three-week-old infant of the ability to "cross
modally" recognize in one sensory modality an object first perceived in a
different sensory modality. He also describes perception eliciting affect as in
the viewing of art. I extend these ideas to describe the thing presentation
trans modal crossing of concept and affect into percept. Concept and affect
may condense with percept, or may actually change into and initiate percept.
In this way, conflicted affects and their compromise formations may be
synthesized in condensed percept symbol experiences.
Le Doux (1989) may be describing the neuroanatomy of this hypothesized
transmodal processing system. He describes amygdala-hippocampal affect
encoding areas. These affect encoding areas are connected to thalamic
regions which have their own sensory input which comes directly from
peripheral sensory organs and not through the cerebral cortex. There are
then outflow tracks from the thalamus to the cortex. Thing presentations
may thus be presented to the cortex. I believe there are also input tracks
from association areas of the cortex (see chapter 1).
2. Psychotic Structure 49

Condensation of Fantasy with Reality

The usual type of merger in psychosis is a condensation. Normal mental

experience is a mixture of reality experience and emotional experience of
various degrees, availabilities, and relationships. In psychosis, fantasy and
reality are merged and indistinguishable by the patient, even with conscious
effort. This merger is organized and structured by mechanisms of
condensation around the reality experience of the day residue. This is the
crucial aspect of the reality experience merger in psychotic structure.
Unfortunately, reality is a variously used term in psychoanalytic writings.
It may refer either to the Object in reality or to the experience of the real
object. Some analysts include fantasy: so-called psychic reality (Arlow, 1985).
It may also mean a specific, complex psychic reality experience called the day
residue, an emotionally precipitating reality experience of events, their
sequences, and contexts. This day residue plays an organizing role in dreams
(Freud, 1900, 1922). But these are all different aspects of reality experience
and are differently encoded in psychotic structure. Because the day residue
is often an event in reality, there is often a kernel of truth in psychotic
phenomena (Freud, 1907). The term reality can also refer to this kernel.
Delusions or hallucinations, like dreams, are stories. The stories relate to
reality as well as to the patient's feelings. It can be hard to understand the
delusional story because of the organization of the conscious story and
because parts of the story are not conscious. Knowing where various parts
of the story are and how they are encoded in the structure of delusions can
be helpful in understanding delusional experience and communication.
Psychotic structure tends to locate and process the day residue real Object
experience quite differently from the day residue sequencing experience. The
day residue object is usually in consciousness, undisplaced, but always
condensed with fantasy in the manifest content. Day residue sequence and
context may be disorganized but are usually only repressed subliminally into
preconscious experience where they are often intact. In addition, primary
process derivatives of event, sequence, and context are encoded in the
psychotic material.
An aspect of reality experience often evokes, or is incorporated into, the
emotional experience a hallucination or delusion expresses. The
hallucination or delusion expresses this through the particular
transformation process of the particular reality experience chosen by
emotional experience. The emotional experience and the reality experience
are thus condensed. For this reason, we can talk about symbolic trans-
formations of reality and their illness-specifiC forms. In a hallucination or
delusion there is usually a kernel of accurate reality perception and
experience (Freud, 1907). This reality experience may be the precipitating
event of a psychotic illness, just as it may be a day residue if a dream is
50 Psychosis and Near Psychosis

precipitated. The day residue precipitating event is usually a repetition in

reality of an event or a fantasy meaning to an event that happened, in reality
or emotionally, earlier in life, evoking the same strong feelings then as it
does now. Very ill patients condense these past and present feelings in the
psychotic structure with reality in the present. This is another important
example of the particular condensation phenomena of psychotic structure.
Psychotic patients use these reality events not just as precipitants of
emotional reactions, but also, because. of the condensation between
emotional experience and reality experience, as condensed symbols. The
emotional themes play themselves out and are revealed in the patient's
psychotic experience of reality, his or her behavior in reality, and reality's
reactive behavior back toward the patient.
Reality, in delusions as in dreams, can be altered symbolically from a little
to a lot. Major symbolic changes may be in manifest content as well as in
latent content. This varies according to the type and severity of illness.
Regardless, the merger of reality and fantasy and the loss of reality testing
invade consciousness in psychosis.
Delusions and hallucinations vary in the relative amount of story material
that is primary or secondary process, conscious or unconscious, organized or
disorganized, changing or unchanging, and manifestly affectively ridden or
ideation ally ridden. The various illness states tend to produce psychoses that
vary along these axes. Hence, the forms of symbolic alterations of reality are
illness-specific.
Dreams or delusions have three components in their structure. The first
is the mental experience of perceived reality. This perceived reality involves
both a perception of real people, called real Objects (or real self), and of real
event occurrences, sequences, contexts, and causalities. The second
component is the feelings evoked by the reality experience (Freud, 1915).
These feelings are organized and include memories and emotionally
associated ideas, wishes, and fears (Freud, 1900, 1922). The third component
is some psychological phenomenon that expresses the condensation of the
first two components. The condensation takes the form of an image or
fantasy. The third component is a symbolic alteration because of how the
patient feels about reality based on what the perceived experience is, how
the patient tends to feel, and what his or her past experiences have been.
The third component may be a sequence of symbols dramatized to form a
fantasy story, a dream, or a delusion. In psychosis, this third component
becomes conscious and enters the experience of the first component.
Dreams or delusions can therefore be used for information about feelings,
the unconscious, and the past. They can be used for information about
emotionally relevant reality experiences and feelings in the present. They can
be about the relationship between past and present.
Dreams contain wishes and conflicts (Freud, 1900). So do hallucinations
and delusions. These wishes and conflicts determine psychotic content
(Freud, 1915-16). But to say that therefore wishes and conflicts are the sole
2. Psychotic Structure 51

cause of hallucinations and delusions is to equate phenomenology with

etiology, and psychodynamics with psychopathology (for reviews of
psychodynamics in psychotic illnesses, see Frosch, 1990; and Gabbard, 1990).
In the normal person, perception of reality can be separated from feelings
about reality. The normal person can consciously connect feelings with ideas
and with reality perceptions without confusing the categories. Sometimes in
the normal person condensation occurs so that category reality and category
feelings become one and there is no distinction. But this occurs
unconsciously, or in the form of a dream while asleep, or a fantasy while
awake, with reality experience preserved. Only in dreaming or in waking
psychotic experience is reality experience captured by emotional experience
without reality testing.
In the neurotic, the unconscious condensation reappears in the form of
a symptom, whether the symptom is a fear, a behavioral avoidance, or a
behavioral action. The condensation, with lack of distinction between reality
and feelings, remains unconscious.
In the psychotic patient, the condensation of reality experience with
emotional experience appears in manifest content consciousness, includes
reality testing, and is dominating and predominant. This is the most
important phenomenon of the structure of psychotic experience.
The psychotic experience is the experience of this condensation structure.
The experience of becoming psychotic is the experience of this structure as
it invades conscious reality experience and reality testing. The experience of
being psychotic is the experience of this structure over time. In summary,
psychotic structure consists of primary process condensations between an
aspect of reality experience, an aspect of emotional experience, and reality
testing. This condensation is located in conscious reality experience. The
particular primary process mechanism of the condensation varies depending
on illness and characteristic individual psychological mechanisms.

Reality Testing

As described in chapter 1, reality testing is the mind's ability to compare its

experience of perception and logic with its experience of feelings and to
modify conclusions about the perceived world based on new perceptions and
logical conclusions rather than feelings. This capacity always is lost in
psychosis. Where is this loss located? How is the loss organized? What form
does the loss take? All of these factors play a special role in the
condensations of psychotic structure.
Reality testing in the neuroses is relatively separate from the emotional
structure of symptoms. In psychosis, reality testing is completely captured,
in content and process, by an emotional content and process allowing a
psychotic content and experience (cf. Freud, 1924a, 1924b). Reality testing
52 Psychosis and Near Psychosis

Table 2.1 Reality testing in psychoses

Location of loss of reality Always involves conscious

testing reality testing

Organization of loss of reality Usually organized according to

testing primary process

Form of loss of reality testing Always a condensation of

reality testing content and
processes with emotional
content. All three are
condensed with reality
experience content

is then part of the psychotic structure. Although consciously still experienced

as part of reality experience, reality testing in the psychoses has primary
process rather than secondary process organization. Furthermore, the
content in the reality testing area becomes merged with the emotional
content of the psychotic process.
Loss of reality testing by merger with the content and specific primary
processes of emotional experience is a central feature of the structure of
psychotic phenomena; a delusion or hallucination.
Reality testing should be experienced apart from other experience,
especially emotional experience, but also, to some extent, separate from
reality content. Reality testing should use secondary process, not primary
process. The boundary between the separate faculties of reality testing and
emotional processing and contents is lost. The combined psychotic
experience invades and determines the process and content of reality
experience and reality testing.
Conclusion: In psychosis, reality testing, reality experience, and emotional
experience are all condensed in the psychotic structure.
Certain acute or severely chronic psychotic states in certain illnesses show
fusion among these three elements. In such cases psychosis is only partly or
even negligibly mediated by condensation. Such fusion states are not
common. They are extreme neuromental difficulties. They are dependent for
their content on stimuli in reality. Their symbolic processes are secondary
or negligible. I will therefore omit them from the psychoanalytic description
of psychotic structure.
The experience of psychosis can now be restated. Psychosis is the
experience of a specific and organized condensation between a segment of
reality experience and a segment of emotional experience, invading and
capturing reality testing, content, and process, and moving along into
2. Psychotic Structure 53

conscious reality experience. The linkages are specific primary process

condensation mechanisms among the three components: reality experience,
emotional experience, and reality testing. There are further linkages, primary
and secondary process, causing condensations with the broader reality
experience into which the psychotic condensation moves.

The Day Residue in Psychotic Structure

We are now ready to further describe the structure of psychotic

condensations. We will look again at the day residue because it structurally
forms an organizing center in manifest content of those psychotic
phenomena that are organized. I will now compare the day residue in a
psychotic's delusion with the day residue in a neurotic's dream.
The day residue was first described by Freud (1900) as an important part
of the psychological structure of dreams. The day residue is the reality
experience that is the nidus around which latent feelings appear in the
night's dream story and images. The day residue may be merely a conscious
thought of the day, later repressed. Freud (1922) said that usually the
significant precipitating event of the dream was unconscious and appeared
in the latent dream content, while a displaced, insignificant day residue
appeared in the manifest content. My own observation is that this mayor
may not be true of dreams. It depends on the type of dream. In any case, in
waking psychotic states the significant day residue often appears undisplaced
in the psychotic manifest content but is symbolically altered in the manifest
content through a condensation with emotional experience. Freud (1900,
1922) also said the day residue might be insignificant in reality, but it has
strong emotional associations from infantile instinctual wishes that give it
its power (see chapter 1, n6). But he also gives examples of day residues that
would be potent evocators for anyone, granted that the particular
significance and power for an individual is unique to that individual's
associations. In some psychotic illnesses, the day residue is a potent
traumatic evocator as well as a unique individually relevant symbol.
The day residue concept contains two aspects of reality that are handled
separately in psychosis. One is the reality experience of the self or object in
reality. The other is the reality experience of the event with its sequences,
especially cause and effect, and associated contexts. Sequence and context
provide clues to reality meanings which trigger and shape emotional
meanings. The reality sequence and context are best processed consciously
or subliminally, by the secondary process.
Because sequence and context are the upsetting trigger, even more than
the real Object event occurrence, sequence and context are defended against.
A crucial part of the therapeutic process is to reassemble the day residue
sequence and context. Interestingly, and most important for psychoanalytic
psychotherapy, the sequence and context are often not part of the psychotic
54 Psychosis and Near Psychosis

Table 2.2 Location of the day residue in pathological structures

Psychosis Near Psychosis Neurosis

Structure Delusion Pseudo- Dreams or

delusion symptoms

Day residue Merged in Merged in the Merged in the

object consciouness preconscious unconscious
with emotional with emotional with emotional
experience experience experience

Day residue (a) Disorgan- Preconscious Conscious and

sequence ized (rare) or and primary unaltered or
(b) dis- processed repressed,
associated and subliminal,
repressed into unaltered
subliminal
preconscious

structure but are dissociated and/or repressed and defended against by the
psychotic structure.
The location of this sequencing varies with level of illness. In near
psychosis, the sequencing is preconscious. In neurosis, the sequencing is
mostly conscious, with the evoked feelings unconscious. (Note that in all
three levels, I am describing the location of recent evocative sequences and
not past, genetic sequences.) See Table 2.2.
The day residue sequence is mostly conscious in neurotic patients, but the
emotional significance is unconscious. The day residue sequence in neurosis
is therefore free of the symptom. This is so even though an aspect of the day
residue event may be suppressed or repressed in neurosis. In the near
psychotic, the day residue sequence is captured in the preconscious,
condensed and primary processed, but potentially available through analysis
of primary process mechanisms. In psychosis, the day residue sequence may
be captured in deeper areas of the delusion and handled by primary process,
which contributes to difficulty with reality testing and to extreme distortions
of reality, but also is often intact and unaltered, although dissociated and
partially repressed.
Summary: Psychotic structures, such as delusions, are like dreams in their
structure, except that (1) reality testing is lost in the waking state; (2) the
day residue object is usually undisplaced and always condensed with primary
process fantasy in the manifest content of consciousness; (3) the day residue
sequence and context are dissociated and partially repressed into subliminal
2. Psychotic Structure 55

experience where they are often preserved separately from the psychotic
condensation structure. (In some acute organic psychoses, however, they may
be disorganized and/or never registered. In these states, fusion is usually the
dominant psychotic mechanism.)
I described sequence and context location so carefully because they are
not a priori expected in considering psychotic structure and because
dissociation of sequence and context plays a crucial role in the
psychoanalytic psychotherapy of these states. This will be described in
chapter 7. For now, it is important only to realize that psychotic structure
mayor may not contain sequence or context, but in addition, sequence and
context are often preserved separately from psychotic structure.

ObseJ1ling Ego

Although by definition reality testing is lost in the area of delusion

formation, observing ego may be present. If observing ego is fully present,
then the patient is aware that he or she has an illness and even that the
delusional idea is part of the illness. However the patient still believes in the
delusion and will act on that belief. It is important to realize that observing
ego may not be fully blocked by the psychotic process. If observing ego is
lacking, it may be blocked by non psychotic character defenses rather than
the psychosis. This means that the analytic therapist can use interpretation
of character defenses to make observing ego more available and to attach
the therapeutic alliance at that point. This is often the only point of
attachment possible. Observing ego is often not captured by psychosis; it is
not usually part of psychotic structure. Although it may be seriously
overwhelmed, it is often not part of the psychotic condensation, and this
contributes to the horror of the psychotic experience.

Object Relations

Object relations, the experience of our feelings in the form of people and
stories about people, including ourselves, have both conscious and
unconscious aspects in the ego. Clearly, then, the organization of the ego
will affect the organization and experience of Object relations. In psychosis,
severe Object relations disturbances occur. However, the different psychotic
illnesses affect the ego differently. What can we say in general about
psychotic Object relations?
In psychosis, reality experience and emotional experience of objects
condense. The experience of the real object condenses with Object
representations in the conscious and manifest content of an area of mental
life. The location of this particular condensation in the conscious manifest
content is a definition of the usual type of psychotic structure.
56 Psychosis and Near Psychosis

There are some psychotic illnesses that result in condensations of the

experience of the real self and the experience of the self-representation.
Exactly the same rules hold as when the object is involved, except that the
psychological content of the structure is self-experience rather than object
experience. This is particularly important in the affective illnesses
(chapter 5).
The psychotic condensation may, on occasion, involve the real self and the
object representation, or the real object and the self-representation. Rarely,
there may be a condensation between the real self- and the real object
experience.
Much more rarely, the merger in manifest content occurs as a fusion
between the object experience and the self-experience. In psychosis, this
fusion is between the object in reality and the real self-experience. This is
a different type of psychotic structure. It usually involves fusion, not
condensa tion.

Example:
Doctor scratches own leg.
Patient says, "Why are you scratching my leg?"

All psychotic structure involves some merger, either condensation or

fusion or both, in conscious, manifest content of object relations, which
includes reality experience of aspects of the self and/or object system.
However, most psychoanalytic literature describes merger of self with
object (see Kernberg, 1986; Jacobson, 1964, 1967). This is ambiguous.
Sometimes merger of self-representation with object representation is
specified and described as characteristic of psychosis. Under my definitional
scheme, both self-representation and object representation are emotional
experiences. Their merger, whether condensation or fusion, would not be
psychotic unless they were also merged with the reality experience of object
or self. This can occur as multiple, changing, chaotic fusion states in some
types of acute psychosis. The more common situation, however, when aspects
of self-representation merge with aspects of object representation, is a
condensation, not a fusion. Furthermore, if the condensation is of self-
representation and object representation, more commonly it is unconscious,
as in neurosis, or preconscious, as in near psychosis. By far the most
common mergers of self-representation with object representation are, at the
worst, near psychotic. The usual invasion occurring at the upper level of
consciousness in psychosis involves the condensation of object representation
with the real object experience or self-representation with the real self-
experience. If the self and object are both involved, one of them is a reality
experience. The different illnesses have different likelihoods of these
different mergers (see chapter 5).
2. Psychotic Structure 57

Table 2.3 Object relations in severe mental illnesses

Real self fusions with the object Some schizophrenics,

in reality and the self in reality especially acute
Some organic brain
syndromes, especially acute
Severe mania

Real self condensations with the Some schizophrenics

real object Some extreme mania
Some organic brain syndromes

Self-representation condensing Severe depression

with real self Mania

In summary: In the usual psychotic structure, real object condenses in

consciousness with object representation or real self condenses with self-
representation. In chaotic, usually acute pSYChoses, real self-experiences fuse
with the stimuli from objects in reality. See Table 2.3.

Vertical Dissociations

Psychotic experience usually does not involve all areas of mental functioning.
Reality testing is present in large areas. A patient can, therefore, have two
very different conscious experiences of reality. Because the nonpsychotic
reality experience does not affect the psychotic reality experience, although
both are conscious, the two are said to be dissociated. Psychoticdi.ssociations
are constructed of areas of mental content in conscious reality experience
that are separated from other areas of conscious mental functioning. In the
dissociated psychotic area, reality testing is absent and condensations of
reality experience with fantasy occur. The boundaries of the dissociation are
often well delineated and stable.
I will use the term vertical dissociation! because the psychological content
of the delusion travels down into the preconscious. It does so in rather
sharply defined and organized paths, with theme and affect consistent, rather
than integrating horizontally with the rest of mental life at a given level of
mental awareness. Vertical dissociation is almost always present in
delusional structure, and it is the major ego-integrative dysfunction of
psychotic and near psychotic structure.
A vertical dissociation is one type of lack of integration in the ego.
Splitting is a vertical dissociation based on separation of oppositely valenced
affect in the preconscious defensive structure of the ego. Vertical
dissociation is a more inclusive term and refers to an area of psychological
58 Psychosis and Near Psychosis

content, sometimes with both positive and negative affect, but separated in
conscious reality experience from other conscious reality experiences, which
then extends down into the preconscious and upper layer of the unconscious,
maintaining the dissociation at those levels also.
What we are describing, then, is one aspect of conscious experience
unintegrated with other aspects of conscious experience. In neurotic
structure, two mental experiences are cut off from each other because one
is not conscious but is behind a repression barrier away from the rest of
experience in the conscious. This can be called a horizontal dissociation
(Kohut, 1971). The only indication is a mysterious conscious symptom. The
symptom may be experienced as "not me"--ego dystonic. Neurotic, ego
dystonic symptoms are horizontal dissociations secondarily vertically
dissociated only in the conscious, "not me" experience. Character symptoms
are pure horizontal dissociations and are not experienced as ego dystonic.
Lack of integrative ego function is a crucial aspect of psychosis. Vertical
dissociations are part of most psychotic structure, at the edges of the
psychotic experience.
There are other lacks of integration possible, from affect splitting to
fragmentation to subtle discoordinations between levels of abstraction and
their application. These usually apply to nonpsychotic areas as well as being
distributed throughout the psychotic material and thus are nonspecific, i.e.,
have no predictable relationship to psychotic structure. Nonetheless, they are
crucial to diagnosis, to specific illnesses, to empathic understanding, and to
treatment.
In summary: Stable psychotic structure is usually vertically dissociated
from non psychotic structure.

Thing Presentation, Thing Presentation Quality, and

Delusional Stnlcture

Reality condensations with fantasy appear as the consciously experienced

thing presentations of primary process thinking. The intensity, rigidity,
stereotypy, and consuming quality of the delusional or hallucinated
experience is due not only to the loss of reality testing and to the
condensation of reality with fantasy, but also to the quality of thing
presentation experience. The key experiential aspect of thing presentations
is the quality of perceptual reality organized according to primary process
rules and with primary process contents. There is a condensation of affects
in an experience of a concrete, perceived thing that seems real and therefore
quite consuming. The compelling quality of these percept experiences may
not be apparent to the observer of the manifest content. For example, a
patient wanted to kill himself because voices were calling him a bird.
Also compelling is the intense affect in the thing symbol. The experience
2. Psychotic Structure 59

of the thing presentation, its affect, and its perceptual reality quality may be
associated with additional dissociated conscious affect, unconscious affect,
or disguised, conscious derivative affect. This will depend on the extent to
which the psychotic process has infiltrated, disorganized, or spared the rest
of the personality organization.
Affect has partly determined symbol choice, so the thing presentation
represents affect and has an affect quality experience. In addition, affect
plays a role in the aspect of reality experience chosen. Often, there is an
overlap between psychotic experience and things in reality because the
psychotic experience has a things-in-reality nidus and serves as a defense in
reality experience. The themes in reality Objects occur over and over, just as
the themes repeat over and over in emotional experience. This leads to an
uncanny experience of summation and to further recruitment of reality
content and to affect intensification and further blurring of the ability of the
autonomous ego to maintain reality testing. This is true of both psychosis
and near psychosis. It is a particularly characteristic feature of psychotic
structure and is the psychotic equivalent of the neurotic repetition
compulsion.
Neurotic symptoms, in contrast, are disguised actions, avoidances, and
fears, and are not consciously experienced as living thing presentations. The
patient. can speak of them more dispassionately, because the affect and
perceptual quality in symbolic things are horizontally dissociated in the
repressed unconscious and tend not to be available for summation cycles in
reality experience, except sometimes in derivative form, especially in severe
character neurosis.
Another description of psychotic structure, then, is the eruption into
reality experience consciousness of a thing presentation. These are eruptions
of specific, intense, emotional experiences contained in a concrete and
specific symbol taken from reality experience. A thing is representing and
providing an emotional experience. It has the reality quality of a percept but
the primary process emotional organization of affect. It is then vertically
dissociated from the rest of autonomous ego function.
Therefore, we can again further summarize psychotic experience. It is the
experience of a condensation structure composed of a specific segment of
reality experience, a part of emotional experience, and reality testing,
erupting into consciousness with the percept-affect quality of a thing
presentation.
The real Object and Object representation condensation or the real self
and self-representation condensation is experienced as a thing presentation
involving the perceptual features of the self and others.
The condensation is a process. The thing presentation is a specific visual
image and also a felt quality.
60 Psychosis and Near Psychosis

Example:
A middle-aged homosexual man is hospitalized with the delusion that his face
is swollen. The illness occurred after his lover left him for a younger man.
Because the patient's self-esteem has always been concentrated in his physical
appearance, and because his lover left him for a younger man, the patient
experiences himself as no longer beautiful, especially in comparison to the
younger man, who he thinks is more beautiful and thinner. Because the lover
left, he feels worthless and ugly. Because his worthlessness is experienced as a
humiliation, the affect of the experience is a shameful, crying sadness. His face
is swollen from age, shame, and crying. In his life history is a mother who left
him several times when he was young.

In psychosis, thing presentation and thing presentation quality capture a

total area of reality experience and reality testing. Neurotic symptoms are in
emotional experience. In creativity, if thing presentations are experienced,
it is in a third space, preconsciously and consciously, between reality
experience and emotional experience (Winnicott, 1953). Not all creative
people experience conscious thing presentation qualities, but when they do,
it is in the third space, and autonomous ego can use the experience for
creative, esthetic constructions and communication.

Classification of Psychotic Structures Such as

Delusions and Hallucinations
Psychopathology has always been classified, as have all diseases, in an
attempt to find coherent treatment. General psychiatry has categorized
delusions usually by manifest content. These categories determine drug
treatment. The question for us is whether the general structural classification
of psychosis already given in this book can be usefully further subcategorized
so that traditional psychiatric illness categories are included. If so, the
categories themselves will be coordinated, and this will help lead to
coordination of drug treatment and psychoanalytic psychotherapy.
The concept of psychotic structure implies stability in organization, and
so one should be able to categorize the different psychotic structures.
There are various classifications for delusional structure. Delusions
typically found in psychotic depression or in psychotic mania are classified
by content and the relationship of typical manifest content to typical mood
states. This is a general psychiatric classification of manifest content
according to illness category. However, sometimes to classify delusional
structures according to illness nosology, more than the manifest content
alone must be considered when the manifest content themes are not clear.
This involves getting the more latent, preconscious layers during the
psychoanalytic interview. This is done in two ways. The first way is to listen
and ask for the patient's associations to the delusional material. The second
2. Psychotic Structure 61

is to observe the relationship of the delusional material to the content of the

rest of mental functioning, especially personality psychology, and the
relationship of both of these to affect, the reality circumstances of the
patient, and normal life phase development.
The latent content is hidden in very ill patients, however, not only by lack
of conscious availability but also by dissociation. Although it is dissociated
to the patient, it may be obvious to the observer that there is a thematic and
affect connection between the psychological delusional content, the rest of
the patient's personality psychology, and the reality circumstances. Especially
helpful in understanding the proper integration of these three are the
associations which reveal the deeper layers of latent content and affect and,
therefore, a unifying theme or relationship. Access to this latent material
may even liberate a helpful missing piece, like the organizing sequence and
context of the reality event. Delusions are then more clearly characteristic
in their content and organization of the illnesses with which they together
appear. In this, I differ from many other psychoanalysts and general
psychiatrists who see no connection between the content or organization of
psychological material and the descriptive illness nosology used by general
psychiatrists. I think a lack of concordance has been found in the past
because not enough attention has been paid to the methods of (1) eliciting
the latent content and (2) reintegrating the dissociated delusional
phenomenon along thematic lines. Both these techniques result in a clearer
and more coherent delusional story that is more easily classified.
Classifying the structure of delusions by the psychological themes they
contain also enables classification of delusional systems according to the
model of traditional ego psychology with the tripartite divisions of superego,
ego, and id. Location of thematic content within these agencies is possible
because when the latent material is known, a theme from one mental agency
may predominate. For instance, in delusional depression, guilt, foreboding,
and punishment appear in the story, either manifestly or latently or both,
and are important diagnostic aids. In addition, this content is organized
within superego structures of the patient's personality, and treatment leads
even further into the pathology and distortions of superego functioning in
character and in non psychotic defenses. One can therefore classify the
depressive delusions as superego delusions.
Another method of classification has to do with the organization of the
ego. Chapter 1 discussed how varying levels in organization of defenses and
autonomous ego are the rule rather than the exception in ego functioning.
The description of varying levels of organization becomes crucial in the
classification of psychotic pathology, because ego variation within the
psychotic individual is, again, the rule rather than the exception. Patients
may be seen not only with pure psychotic mental functioning, but with
mixtures of psychotic and neurotic, psychotic and near-psychotic, or
psychotic, near psychotic, and neurotic mental functioning. These mixtures
can be classified. The classification is important in treating the very ill
62 Psychosis and Near Psychosis

patient (chapters 7 and 8). Each treatment must be specific for each level of
ego function.
Variable levels of ego function have important ramifications for the purely
psychiatric descriptive phenomenology of psychosis. If variability in the ego
caused by illness or by lack of development is not considered, classification
will be confused or impossible and treatment will then be confused.
An example of development problems that confound classification is the
issue of depressive guilt-ridden delusions which presuppose a level of
psychological development that has reached the stage of organized superego
development. We should expect, therefore, in the history of such psychotic
patients, to hear that they in fact did develop through oedipal phases into
organized superego functioning. In addition, if the illness is not too severe,
there will be large areas of nonpsychotic and integrated mental functioning
involving conscience material with associated neurotic defenses based on
repression. A patient who is borderline, however, and without well-
integrated, guilt-infused ideational content from superego functioning, who
then becomes psychotically depressed, cannot have neurotic, guilty content
in the delusional system. It is said, therefore, that such delusional systems
cannot be classified according to general psychiatric nosology, or that the
borderline patient is not suffering an additional illness called delusional
depression. This crucial aspect is then not treated effectively. However, if the
latent content of retributory rage is elicited and the superego is found
characteristic in content and organization of borderline patients, and the
remainder of ego structure is noted to be borderline, and if the history of
the patient demonstrates the stable borderline integration before the
psychotic event, one can then understand that the retributory rage, together
with early shame and humiliation experiences, classifies this psychotic
delusional material as a psychotic depressive reaction in a patient with
borderline character and hence early superego organization.
Structurally, then, patients can be categorized according to levels of ego
organization including levels of nonpsychotic defenses and other mental
agency organization. There are, in fact, neurotic, borderline, and psychotic
patients with psychosis.
Neurotic patients with psychosis have intact areas of autonomous ego
functioning, defenses based on repression, and integrated superego function,
with an area of eruptive psychological material about which reality testing
is lost. In these patients, within the delusional material itself, repression may
be the dominant defensive mechanism.
Borderline patients with psychosis have the autonomous ego weaknesses
characteristic of borderline patients, with impulse control dysfunction, affect-
dissociative integrative problems, affect-blocked observing ego problems, and
defenses riddled with primitive projective mechanisms and primitive denial.
2. Psychotic Structure 63

Table 2.4 Psychotic ego phenomena

according to mixtures of ego organization

Neurotic with psychosis

Focal area of psychotic, conscious condensation of reality experience with

emotional experience

Psychotic area dissociated from remainder of ego function and personality

Remainder of autonomous and defensive ego neurotically integrated

Psychotic area often integrated and layered

Borderline with psychosis

Focal area of psychotic, conscious condensation of reality experience with

emotional experience

Remainder of autonomous and defensive ego with typical borderline

weaknesses and failures of integration

Psychotic area organized by splitting of affect

Psychotic with psychosis, two types

1. Global, conscious, psychotic condensations of reality experience with

emotional experience

2. Global, psychotic condensations and in addition an area of organized

and stable content in a psychotic delusion; usually extensively
disorganized

Therefore all aspects of ego function are involved

Psychotic without psychosis (Le., without stable delusional system)

Changing area of psychotic condensations of reality experience with

emotional experience depending on events, intensity of feelings, and
content of ideas
64 Psychosis and Near Psychosis

Table 2.4 continued

No safe area of mental experience; psychotic ego organization always
possible; psychotic attitudes

Psychotic content phenomena, when they coalesce, may be variably

organized depending on illness; usually with splitting of affect

Within this, there is an eruption into idea formation and behavior of

psychological material about which reality testing is lost. Therefore, they are,
in addition, psychotic. Of note may be the presence of splitting mechanisms
within the area of lost reality testing as well as within the defensive
structures of the rest of the personality.
Psychotic patients with psychosis have a global loss of reality testing in
every area, and in addition may have an organized delusional system.
In addition, there are patients who have an ever-present delusional
potential because their character attitudes are psychotic in regard to theme
but are not stable in regard to specific content. These patients show
psychotic character structure. They do not have stable delusional systems,
but for every intense affect state they enter, reality testing may be lost. I call
them, ironically, psychotics without psychosis, i.e., without stable delusions.
In all psychotic patients, the integration features within the psychotic
areas themselves tend to vary according to the level of overall ego function
attained before the psychotic illness intervened. Neurotic patients who
become psychotic tend to have integrated affective valence in their psychotic
content. Borderline patients with psychosis show splitting of affect in their
psychotic content. Globally psychotic patients have the most disorganized
delusions and hallucinations. See Table 2.4.
I have now demonstrated four ways of classifying delusional systems. The
first is a correlation of thematic content, especially latent, with psychiatric
disease category like depression or mania. The second is a characterization
of the dominant thematic material, including latent themes, according to
psychoanalytic mental agencies of superego, ego, or id. The third is the
mixture of ego organization, autonomous and defensive, i.e., neurotic,
borderline, or psychotic, found in the non psychotic areas of the patient's
character organization when compared with the psychotic areas. Related to
this third way is a fourth; to categorize the integration of the psychotic
material itself according to its dominant method of ego defensive
organization. These four methods coincide to provide an in-depth diagnosis
of psychotic patients that can guide biologic and psychoanalytic treatment.
The dynamic feelings and ideas represented in delusional symbolic
representation will organize themselves according to these structures.
2. Psychotic Structure 65

Defensive Structures in Psychosis

Crucial to psychoanalytic ego psychological theory and treatment is the
concept of defense. As stated in chapter 1, defenses are preconscious mental
experiences that defend against other, more unpleasant mental experiences.
A broader view would be that any mental function could be used defensively.
However, the process, reason, and content of the use are preconscious and
unconscious, and in emotional experience and not in reality experience for
neurotic illness even when autonomous ego is used for defense. This is not
so for psychotic illnesses.
In neurotic illnesses, when the defensive nature of the symptoms is
understood consciously, the symptom disappears. The emotional material
which the symptom represents and against which the symptom defends can
be experienced and integrated into the rest of ego functioning. The origin
of the particular choice of defense within neurotic illness is not well
understood, but the symptomatic use of preconscious defense for
unconscious purposes is almost a structural definition of neurosis for
psychoanalysis.
This defense concept has difficulties in application to psychotic illness
where the distortion of autonomous ego is so crucial. Purely biological
illnesses such as brain tumors can cause psychosis. Biological interventions
can suffice to repair these autonomous ego dysfunctions. I therefore do not
believe that the defensive aspects of psychosis are solely etiologic in the
illness. However, the psychosis, once triggered, is used for defensive
purposes by the mind, and within the structure of the psychotic event itself
are layers, or splits, one of which defends against the other. These defenses
capture aspects of reality experience, usually by condensation.
Reality experience capture by defense occurs in many levels of illness, but
the capture in psychotic illness occurs in conscious reality experience. This
is a characteristic of psychotic structure.
If one observes which aspects of reality are captured by which aspects of
the defensive processes in delusional systems, one sees that there are typical
captures in the structure. Personality conflicts and defenses can provoke or
experience reality in stressful ways that may trigger a psychotic event.

Example:
A late adolescent male felt access to a sexual partner blocked by his parent's
disapproval. He was afraid to feel angry and take reality steps toward either
defying his parents while still remaining with them or moving out of the
household. He became depressed and fearful and developed the delusion that the
girl he was attracted to was in love with him and was looking for him night and
day, unable to find him because he was locked up in the hospital where he was
taken after accosting the girl. The illness served as a defense against anger at his
66 Psychosis and Near Psychosis

parents which would, in the extreme, have led to his separating from them and
moving out of the house. He was terrified of taking this step. He unconsciously
felt that he could not live on his own. In this sense, the delusional psychosis was
the defense against a deeper neurotic illness, which was a fear of growing up and
separating from his family. His psychosis was used as a defense against a real-life
problem and the associated feelings which constituted his chronic neurotic
psychological conflict. The defense of projection of love and seeking in the
delusion captured the reality experience of the girl.

Defenses against reality in psychosis are defenses against the reality

experience of fact, especially the fact of sequence and context. The psychotic
symptoms function to defend against logical and evidential confrontation of
the delusional system with secondary process and reality. The delusional
phenomena also protect against deeper layers of idea and affect. The
delusion selects or changes reality experience to correspond more closely to
the unconscious view of the Object world, or it changes reality experience to
correspond more closely to the conscious view of the Object world for
psychological reasons that are unconscious.
Neurotics avoid reality experience which is at odds with their unconscious
fantasies and/or try to alter reality experience unconsciously. The borderline
patient takes action to alter preconscious reality experience. The near
psychotic (see chapter 3) takes action to alter preconscious reality experience
not in behavior but in preconscious ideas. The psychotic patient alters reality
experience by incorporation of emotional experience into the conscious
manifest experience of reality (for a somewhat different view see Jacobson,
1967).
The significance of personality defense to psychosis is thus not just the
content of the defensive fantasy but the location of that defense structurally.
Defenses that cross into reality experience enter into the psychotic structure.
This relationship is determined by autonomous ego boundaries to reality
experience. Psychotic defenses are aspects of psychotic condensations. They
defend against deeper layers of feeling and also against reality. Psychotic
defenses are those defenses that condense with conscious reality experience
and reality testing in the psychotic structure.
There are, in addition, two non psychotic defenses important in psychotic
states: mediating defenses against integration of the vertical dissociation of
the psychotic structure, and defenses against observing ego.
(For a general discussion of the relationships of ego function to defense
in psychosis see Arlow and Brenner, 1964. For a critique I agree with see
Frosch, 1983.)
2. Psychotic Structure 67

Mediating Defenses

What kinds of mental experiences are at the boundary of vertically

dissociated psychotic experience? Around most delusions is an area of
pseudo-delusion; around every area of psychosis is an area of near psychosis.
These areas reveal emotional processes that are basic to the patient's
character. Defenses around a delusional system, not in the delusional system,
are not psychotic. They are open to reality testing and hence open to
interpretation. They enable the continued existence of a delusional system
as much as the lack of autonomous ego integration, loss of boundaries, and
loss of reality testing do. I call them, therefore, mediating or enabling
defenses. Mediating defenses are not part of conscious reality experience.
Psychotic structure, thus, may have a crucial non psychotic aspect
consisting of the character defenses that surround and enable the vertical
dissociation of psychotic phenomena. The defenses are said to su"ound the
psychotic phenomena because when you talk to such a patient about a
delusional system, no matter what angle or approach you take, you are
blocked from full access, exploration, consideration, and integration of the
psychotic area by these defense mechanisms.
Enabling or mediating defenses are defenses against integration of a
vertical dissociation. As such, they defend the psychotic structure against the
secondary process and reality perceptual evidence of the non psychotic ego.
There are also non psychotic character defenses against observing ego.

Definitions of Levels of Illness

We are now ready to define sicker patients according to the descriptions of
structure just elaborated.
Sicker patients have damage to what should be autonomous ego function.
The sicker patient's structure shows less and less reality testing. The sicker
patient's structure shows less and less integration of one aspect of his or her
conscious mental life with other aspects of conscious mental life. The patient
also shows less integration of his or her behavior with the reality of his or
her environment. The sicker patient's structures are more and more rigid in
his or her defenses. These defenses capture conscious reality experience. All
of this leads to less and less facility at adapting to reality experience, with
less adaptive means of satisfying emotional experience. Notice that observing
ego is not on this axis because, in my observation, observing ego can be gone
in neurotic, borderline, or psychotic conditions and also because the
interference with observing ego usually has to do with nonpsychotic
character defenses.
68 Psychosis and Near Psychosis

It is said that in sicker patients psychological theme and content is

conscious that is unconscious in neurotic patients. This is not always quite
so. In some very sick patients, aside from the loss of reality testing, the
material that erupts in a delusional system is quite integrated and layered
with neurotic defenses structuring the delusion. Even in borderline organized
patients with an intercurrent psychosis, the material that is revealed, though
more primitive, has defensive functions against unconscious material, just as
in the neurotic. However, in these very ill patients the manifest is congruent
with latent layers of thematic material. This is because the very ill ego
phenomenon is a vertical dissociation in which one or several related strands
of psychological life erupt and become separated from the rest of emotional
organization, both conscious and preconscious.
The neurotic symptom has an integration and disguise. This is because the
neurotic ego can integrate conflicting themes and affects in the symptomatic
area.
Another measure along the sickness-to-health axis is the degree of
"primitive material" that is apparent in the manifest content. Primitive may
mean that aspects of drive, instead of being defended against, erupt,
infiltrate, and are expressed, relatively undisguised, in the manifest content
of the material (Kernberg, 1975; Reich, 1933). At the same time, primitive
means that the associated fears are likewise erupting and expressed
simultaneously either in the delusional system or in behavior. Even here,
however, there is still a latent content, although the latent in each content
area tends to be congruent with the manifest content area. Primitive usually
refers to contents. Primary process refers to organization. If primitive is used
to refer to process, then all primary process is primitive.
I, however, use primitive to mean that aspects of autonomuous secondary
process reality experience are captured by feelings. (For a somewhat similar
view see Willick, 1983.) This is what makes certain mental processes
primitive. Since I believe the primary process develOps, there is complex,
sophisticated primary process and simple primary process. In this sense,
primary process may be primitive or not.
But the most difficult-to-treat marker of very ill structure is the rigidity
with which a psychological phenomenon is encoded and dissociated. In fact,
rigidities of structure and defense are more difficult to treat than absences
of reality testing or eruptions of primitive content or of primary processing.
In that sense, a very rigid neurotic patient can be sicker than a more plasti-
cally organized borderline patient. Rigid in this sense means very resistant
to Change. Sicker in this last sense clearly means harder to do psychotherapy
with or to structurally Change. The rigidity manifests itself in two other ways.
One is the rigidity of the repression brought to bear against psychological
material. The other is the rigidity of the dissociation of the psychological
material.
Therefore, not just the content, organization, and autonomous ego
deficits, but especially the rigidities of psychological structure will determine
2. Psychotic Structure 69

the ease of treatment and therefore the prognosis. Psychoanalysts should

remember this when making prognostic evaluations of very sick patients.

Character and Psychosis

The psychodynamic relationship between psychological themes in character
structure and themes in psychotic symptoms is the same as the relationship
in the neurotic between neurotic symptom and character structure, except
for the loss of reality testing and the condensations with reality experience
in the psychotic. Dynamic themes in personality may be congruent with
symptoms, whether neurotic or psychotic. Personality conflicts color reality
experience with emotional meaning and may trigger symptoms, whether
neurotic or psychotic.
No one knows why psychological conflict may trigger or form the nidus
of a psychotic symptom rather than a neurotic symptom. Others and I
presume that biological, neurological, or constitutional factors are involved.
Character defenses are emotional defenses characteristic of an individual
and characteristic of a diagnostic category and not perceived by the person
as a symptom but as part of his or her personality. In psychoses these
defenses:

1. Are potential stress points in psychological functioning; they block

emotional and reality confrontation and adaptation;
2. Contribute their themes and conflicts to the content of the psychotic
material and to the condensation with reality experience;
3. Defend against integration of psychotic dissociation, as in mediating
defenses;
4. Block the observing ego and hence the therapeutic alliance.

Character themes are both inside and outside the psychotic structure.
Character defenses, the processes, are probably best reserved in description
for nonpsychotic defensive processes of character outside psychotic structure.
When they enter the psychotic structure itself, as they often do, it is
probably best to refer to them as psychotic defenses, since they are so
different from usual character defenses in that they:

1. Are condensed with reality experience, reality testing and the rest of the
psychotic structure;
2. Are intense, perhaps more so than in the rest of character structure;
3. May involve content that is unavailable to the rest of personality defense,
both consciously and preconsciously, although deeply unconscious in the
rest of personality.
70 Psychosis and Near Psychosis

An example is a man with a neurotic symptom of phobic avoidance of

school performance and career, especially the focal-neurotic symptom of
panic in test situations. Associations to this symptom revealed one of the
meanings of a test to be a competitive situation. It was very difficult to deal
with the symptom in treatment, because the character defenses were reaction
formations against competitive loss and these defenses were activated in the
transference. This meant that the patient constantly competed with me. He
interrupted me and would not let me say anything. If I insisted on saying
what I had to say, he either said no and went on with his story, or yes but
would promptly change the topic. So we have a layered neurotic symptom
with equivalent layering of the same theme in character structure, with the
reaction formations against the underlying fear expressed in the transference
relationship.
It is the same in the delusional system of a psychotic patient where the
background character structure is the same in organization. An example is
a female patient who had a character problem of preconscious controlling,
aggressive, and dominating character reaction formations against the
unconscious fear of being controlled. But she had a conscious sexual
symptom in which orgasm could only be reached by a fantasy of a strong,
assertive, and controlling man using his hand to masturbate her. Sexual
fantasies often, like dreams or delusions, involve eruptions of otherwise
unconscious character dynamics. In reality, she avoided assertive lovers.
When she became intercurrently psychotic, the manifest content of her
delusional system involved nurses sticking needles into her hands! This was
probably associated to as punishment, not for adult sex, but for childhood
masturbation and associated screen memories of seductions in which she had
been masturbated, controlled by the man, but highly aroused and so felt
actively complicit. Thus, there are aspects of the same dynamic conflict in
character, in sexual fantasy, and in delusion.

The Structure of Symbolic Representation and

Symbolic Alterations of Reality in the
Structure of Psychosis
The typical structure of symbolic alterations in psychosis is the use of reality
day residue experience for symbolic purposes. This reality day residue is
symbolically altered by the primary process. Thus, primary processes and
contents change the reality day residue in ways that symbolize and express
affect responses to the reality day residue. This may be called a symbolic
alteration of reality. In psychosis, this symbolic alteration of reality (symbol)
is condensed with the original day residue (referent). The condensation is an
intense, perceptual quality, thing presentation experience. Psychotic symbols
are, therefore, thing presentation experiences in which the day residue and
2. Psychotic Structure 71

Table 2.5 Definitions of symbolic processes

Symbol

Manifest element standing for something else

One standing for another

Especially where one represents another, more abstract (Webster's New

Unabridged Dictionary)

Primary process

Rules of organization of emotional experience and its symbols

Condensation of representations according to affect themes

Refers to complex, condensed, affect referents

Thing presentation

Name of an experience of affect-percept and concept-percept

A complex, perceptual quality symbol experience organized according to

primary process rules

Psychotic symbol

The experience of a complex, primary process, symbolic condensation of

a reality day residue together with its symbolic alteration of reality.
Captures and condenses with reality testing processes. An intense,
affect-percept and concept-percept thing presentation symbol experience
which dominates conscious, superordinate reality experience

its symbolic alteration of reality are condensed together in conscious reality

experience. Reality testing is also similarly altered and condensed into the
psychotic symbol. See Table 2.5.
In the normal and in the neurotic, day residue, while altered symbolically,
is also separate. It is conscious or preconscious and unaltered. In addition,
the symbol experience is not in reality experience but in emotional
experience or intermediate experience. There is no thing presentation exper-
72 Psychosis and Near Psychosis

Table 2.6 Validity and veracity experiences

Reality experience: "I think it is true"

Superordinate
Percept
Secondary process logical organization of concepts
Deduction/induction
Concept
Abstraction
Generalization
Application
Discrete, boundaried categories

Emotional experience: "I feel it is true"

Superordinate
Affect
Primary process concepts
Thematic
Infinite content categories
Blurred intermixing of thematic trends
Plastic, only relatively stable, repetitive processes

Thing presentation: "I see it is true"

Percept/affect
Percept/concept
Primary process organization
Concrete

Psychotic experience: "It is true!"

Validity and veracity experience from all three, forming a new, psychotic
validity and veracity experience. The strongest contribution is from thing
presen ta tion.

ience of the symbol. If there is, it occurs in the intermediate experience

(Winnicou, 1953) and not in reality experience.
Symbolic alterations of reality are those symbols which result from
processes that use or alter reality and reality experience to gain or create a
2. Psychotic Structure 73

discharge target for dynamic conflict (Sarnoff, 1987). Emotional experience

and latent layers are condensed into the undisplaced reality experience and
the affect usually follows (cf. Freud, 1900; Kubie, 1978; and Frosch, 1983).
The symbolic alteration of reality in psychosis is not experienced as
symbolic. The symbolic structure has incorporated a piece of conscious
reality experience. It has condensed emotion with it and, in addition, takes
on the new symbolic form of a thing presentation, with perceptual thing
presentation quality. This complex condensation has then moved into and
captured a major section of superordinate reality experience. The originally
incorporated, conscious reality day residue is then experienced only in the
symbolic alteration of reality in psychotic structure. This is another unique
feature of psychotic alterations of reality.
Psychotic thing presentation quality has its own characteristic intensity,
veracity, validity, and esthetic.
Different illnesses impose different forms on psychotic symbol structure.
Some illnesses symbolically alter reality extensively in manifest content.
Some merely use the manifest reality without alteration but with thing
presentation quality experience, condensed with reality testing and without
conscious ability to tell that this is happening. In this case, the content of
reality experience will not be altered. The experience of reality will be
altered in quality. Psychotic symbolic representation is in the quality of
experience and in the loss of reality testing about the veracity that this
quality lends to the experience of personal and concrete meaning to the
patient.
But usually a reality experience is altered extensively with content and
organization characteristic of illnesses, level of prior development, content
of emotional conflicts, and content of reality experiences. These are always
condensed and usually extensively primary processed. They have
characteristic structures, with the day residue or proVOking experience
forming a nidus, condensed with psychotic elaboration from primary
processes, surrounded by pseudo-psychotic elaborations in the layered,
mediating defenses of character structure.

Table 2.7 Psychotic structure

In summary, then, psychotic structure = delusional structure = hallucinatory

structure. This structure is characterized by:

Always:

1. reality experience and emotional experience are condensed in

conscious reality experience

2. condensation includes reality testing, contents, and processes

74 Psychosis and Near Psychosis

Table 2.7 continued

3. day residue real object and object representation (or real self and self-
representation) are condensed in the manifest content of reality,
forming part of the psychotic structure

4. thing presentation quality is present in conscious reality experience

5. day residue context and sequence are disorganized or repressed in

deeper layers of latent content

Usually:

1. primary process infiltrated

2. vertically dissociated from the rest of reality experience and from the
rest of personality experience

3. mediating defenses surround psychotic phenomena and help maintain

vertical dissociation; these mediating defenses are near psychotic

The form the psychotic material takes depends on:

1. how the particular type of illness disrupts the ego

2. the cognitive and emotional organizational level of development

reached before the psychotic illness

The content depends on:

1. content of past and present emotional and reality experience

2. psychological conflicts in and between the areas of reality experience

and emotional experience

Brief summary of results of transformations of autonomous ego in psychosis:

1. fanatasy moves into reality experience

2. word presentations move into thing presentations

3. conceptual and affective experience move into perceptual experience

2. Psychotic Structure 75

Table 2.8 Ego functions affected by psychosis

Not invariably part of psychotic structure but often damaged

In-out boundary
Conscious-unconscious boundary
Primary process-secondary process boundary
Affect-affect boundary

Universally affected but not part of psychotic condensation

Conceptualization
Abstraction
Generalization
Application
Integration
Observing ego

Universally affected and part of psychotic condensation

Reality testing
Reality experience, especially percept boundaries
Aspects of emotional experience
Secondary process integrity of day residue (becomes primary process)

Secondary process integrity of day residue as to sequence and context

(becomes dissociated)

Secondary process superordinate integration principles of the relationship

of emotional experience to reality experience(becomes primary processed
and/or dissociated)

Easy flow of fantasy and reality (becomes fixed at point of psychotic

condensation)

Distinction between real object and object representation, real self and
self-representation, real self and Object representation, real object and
self-representation (become condensed)

Word presentation (shift to thing presentation; concept and affect shift to

percept)

Symbolic processes (shift away from fantasy to use of reality)

76 Psychosis and Near Psychosis

Notes
1. Freud first used the term dissociation to mean the separation of idea,
usually a mnemic image or memory filled with affect, from the rest of
mental functioning (ego). These were important aspects of what he
described as hysterical neuroses (Freud, 1893-95). We now believe many
of these original cases to have been sicker, borderline patients where lack
of mental integration is prominent (see chapter 3).
Freud introduced ambiguity into the term by later using splitting of the
ego to refer to this dissociation phenomenon. Klein used the term,
shortened it to splitting, but then used it to refer to only one type of
dissociation, the unconscious dissociation of object relations fantasies
based on positive or negative affects (love or hate). Kernberg follows this
usage and has popularized this use within psychoanalysis in America.
Rosenfeld and others did the same in England.
But what about those patients who dissociate ideas or complex
affects/ideas and, furthermore, do so across boundaries of consciousness?
This is actually closer to Freud's use of the term.
Kohut (1971) resurrected this use to describe the integrative pathology
of a type of sicker patient. He used the term vertical dissociation to mean
conscious, preconscious, and maybe unconscious separation of ideas and
associated complex affect, both positive and negative. I follow his use
because it is accurately descriptive of a common, almost universal type of
ego pathology in sicker patients where the dissociation is based not on
affect, or not only on affect, and not on fantasy/emotional/unconscious
experience, but also on conscious reality experience, and not just in
defenses but also in autonomous processes. He also used the term
horizontal dissociation. Fliess (1973) used the terms transverse split and
longitudinal split.
3
Near Psychosis

Introduction
Near psychotic states are usually called borderline. In spite of considerable
work on these states, ambiguity remains about their definition and
descriptive nosology. What elements are to be used as criteria, and whether
those elements are to be mental or behavioral or both, are still undecided,
because the relationship of the behavioral to the mental in near psychosis
has not yet been specifically described.
General psychiatrists tend to describe behavior in borderline patients
because it is so dramatic and easily observable. In addition to behavior,
psychoanalysts also describe the intrapsychic but tend to look especially at
emotional experience and defensive organization. The two can only meet if
behavior has a specific defensive organization in mental experience. I believe
it does in near psychosis, especially when the relationship of autonomous
ego function to defensive organization is considered.
The term borderline has been used by general psychiatry in two different
ways. One use was to delineate a midpoint between a type of psychiatric
illness and normal. Borderline therefore sometimes means a partial
expression of a psychiatric illness. Schizophrenia is an example, and from the
beginning, an intermediate form was described (Bleuler, 1950). The other
use was to delineate a midpoint between two levels of illness, the neurotic
and the psychotic. Psychoanalysts tended towards this use, although some
psychoanalysts were aware of both the illness use and the level use.
I am interested in both illness and level because both are always part of
the diagnosis. But I will describe the mental organization characteristic of
this level, concentrating on descriptions of ego function. Knight (1953) also
did so, but he concentrated on describing only a few of what Hartmann
(1939) called autonomous ego apparatuses. He also described, but did not
well define, the primitive defenses in these conditions. Klein (1975),
Fairbairn (1952) and Jacobson (1964), focused especially on object relations.

77
78 Psychosis and Near Psychosis

Kernberg (1975) and Frosch (1988) discussed many aspects of ego function,
but especially object relations, in defenses (Kernberg) and in the ego
dysfunctions of impulse control and reality relations (Frosch). The above
discussion is based on the best review of the general psychiatric literature on
near psychosis, Michael Stone's The Borderline Syndromes (1980).
DSM-III-R lists ego criteria for borderline states that focus on apparatus
dysfunction, especially behavioral dysregulation, and are heavily influenced
by Kernberg (1975) and Gunderson (1984) criteria.
I will describe all aspects of ego functions: apparatuses, Object relations,
and defenses. More importantly, I will describe the universal structural
organization of all these functions in near psychosis. It is this particular
organization that I believe defines the near psychotic state.
My own view is that near psychosis is a specific organization of mental
experience, with specific ego apparatus dysfunction and typical defensive
organization. Behavior dyscontrol is only one aspect and must be diagnosed
not on the basis of the manifest behavior but on whether there is near
psychotic organization of this behavior. The ego apparatus dysfunction
shapes the mental organization of all near psychotic phenomena and the
near psychotic form of defenses.
Near psychosis, like psychosis, is a mental state in which reality experience
is used for purposes of expressing emotional experience. I call it near
psychosis because the resulting condensation has nearly invaded conscious
reality experience. Near psychosis is distinguished from psychosis by two
main features: (1) the condensation structure is in preconsciousness and not
consciousness, and (2) reality testing processes are not part of the near
psychotic condensation.
There are two types of near psychotic states. In one type, the near
psychotic condensation expresses itself intrusively in behavior. These are the
states that have most recently been called borderline. In the other, behavior
is not severely affected and the near psychotic condensation is intrusively
present only in the area of a circumscribed mental phenomenon, usually an
idea. I call this type the pseudo-delusional type.
The only crucial autonomous ego difference between the two types of near
psychosis is at the behavioral ego boundary. It is usually an affect-behavior
boundary.
Because these two SUbtypes of near psychosis have not been clearly
distinguished, very common near psychotic states which do not affect
behavior are often treated in psychotherapy as neurotic problems and
therefore may fail to show improvement. Nonbehavioral near psychotic
states are extremely common in office practice and may require special
psychotherapeutic consideration of their particular structure for
improvement. This type of near psychotic condensation may be the major
feature of a depression, and if it is overlooked, needed medication or
pscyhotherapeutic focus may be withheld.
The psychological structure of all near psychotic states has characteristic
3. Near Psychosis 79

features, because, I believe, specific autonomous ego functions are altered.

I will discuss the autonomous ego problems common to all near psychotic
states before discussing the characteristic near psychotic condensation, its
location, and the two subtypes of near psychotic states. However, it will be
difficult to neatly separate the description of near psychosis into a
description of the autonomous ego dysfunctions and a description of the
near psychotic condensation, because near psychotic condensations involve
autonomous ego functions.

Autonomous Apparatuses
The autonomous apparatuses in near psychotic states are not as severely
affected as they are in psychosis. However, just as in psychotic states, the
apparatuses affected are specific. These disturbances of autonomous ego
functions in the near psychoses can result from neurological, biochemical,
or psychological causes or from combinations of these three (see chapter 5).

Boundaries

Most of the autonomous ego apparatuses affected are boundaries. The

boundaries are between unconscious and preconscious, reality experience
and emotional experience, concept and affect, the concrete and the general,
the word presentation experience of reality and the thing presentation
experience of percept-affect, and feelings and behavior. More importantly,
the relationship of conscious and preconscious reality experience to
emotional experience moves from mostly autonomous secondary process
control to mostly emotional primary process control.
Near psychotic patients are said to have "boundary disturbances." It is
extremely important to understand the exact form these boundary
disturbances may take.

Inside-Outside Boundary
In near psychotic states, there is no difficulty in the conscious ability to
perceive the difference between stimuli originating inside the mind and
stimuli originating outside the mind. Therefore fusions across this boundary
are neither usual nor characteristic. There is an experience of inside and an
experience of outside.
Merger phenomena do occur across the quite separate barrier between the
experience of inside and the experience of outside. The mergers in near
psychosis are condensations and are determined emotionally. In near
psychosis, these condensation crossings occur at the preconscious inside
80 Psychosis and Near Psychosis

experience-outside experience boundary between emotional and reality

experience, especially between affect and idea.

Boundary Between Levels of Consciousness

Although the boundaries between levels of consciousness should be
somewhat porous in all people, in the near psychotic there is a typical type
of porosity. There is an easy access into the preconscious near psychotic
structure from unconscious emotional experience, but very reluctant and
rigidly defended entry into the near psychotic structure from the inside
experience of conscious reality. It is this structural aspect that makes the
near psychotic so reactive, yet so difficult to treat. The person is reactive to
the reality-evoked emotional experience, but not to the characteristics of the
conscious reality experience per se.
In the near psychotic states, the preconscious contains the major
mechanisms, the major condensations with reality experience, and the major
affective states. What are the implications of the preconscious level for near
psychotic experience?

The Preconscious and Near Psychosis

The mind experiences differently at different levels of consciousness and
according to whether primary process or secondary process is most
dominant. It is especially in the preconscious, just below full awareness, that
these two processes mix. (For discussions of the preconscious see Freud,
1900, 1915, 1922; Kris, 1950; Eissler, 1962; Sandler and Holder, 1973.)
The specific organization of near psychosis is due to disturbances,
particularly in autonomous boundary function, between ideational content
categories and emotion, between this aspect of reality experience and that
aspect of emotional experience. These boundary problems result in an
exaggerated experience of the preconscious, because the boundary between
feelings and ideational content is less rigid and the two become condensed.
The two become one and express each other and evoke each other
interchangeably. What one feels suddenly becomes the idea, or is
indistinguishable from the idea.
The enlarged preconscious can come about in either or both of two ways.
First, affect intensity may contaminate thinking as primary processing
attempts to express and synthesize intense emotional states. The intensity of
feelings and imagery strains the boundary between primary and secondary
process and between conscious and unconscious. There is a compensatory
attempt at repression which only holds the process in the preconscious.
Affective illness is an example. Second, the boundary between primary
process and secondary process may be damaged independently of affect
intensity. Such patients show primary process dominance without intensity
of affect. Intermediate forms of schizophrenia are an example.
The preconscious also contains the near psychotic condensation. This
3. Near Psychosis 81

partially repressed, specific condensation and its porous relationship to the

conscious and unconscious is another reason for the exaggerated
preconscious experience in near psychosis.
Because it is held in the preconscious, the near psychotic condensation is
unavailable to certain conscious ego functions. The location of the near
psychotic condensation of reality experience with emotional experience just
out of awareness in preconsciousness protects the near psychotic experience
from conscious reality testing, conscious observing ego, and new conscious
reality experience.

Primary Process-Secondary Process

Because of the preconscious location, primary process captures secondary
process in the near psychotic pathological area. The primary process
functions to express emotional intensities as specific ideational contents.
Rules of condensation predominate. Emotional symbols acquire aspects of
captured preconscious reality experience with perceptual qualities. The
primary process-secondary process condensations of form that occur in near
psychotic patients occur just out of awareness and strongly influence
conscious reasoning, decision making, and experience.

Affect Boundaries
Affect boundaries regulate (1) the separation and mixture of different
affects, (2) their intensity, and (3) their spread. All three functions are
usually damaged in near psychotic structure, because of either affect intensity
problems or direct damage to affect-regulating boundaries, or both. Manic-
depressive illness is an example of the first and schizophrenia or attention
deficit disorders are examples of the second. In any case, the result is an
affect intensity of flooding proportions. This results in dramatic content,
intensity, and behavior. Discharge becomes a goal. When this discharge is
content organized in a stable fantasy, the patient talks about seeking
satisfaction. Because this stable fantasy links emotion with ongoing reality
experience, the satisfaction is sought consciously in terms of a reality
experience even though it is intensity discharge of emotion that is
motivational. It is this pressure of the fantasy, which is a near psychotic
condensation, into the reality experience of behavior or ideas that is so
characteristic of the near psychotic state.
The affect boundary borders the interchange between affect and affect,
affect and concept, affect and percept qualities, affect and mood, affect and
logic, affect and behavior, and affect and judgment. This summation gives
the near psychotic condensation its power.
The degree to which an affect experience is organized and stable over time
in near psychotic fantasy structure depends on the stability and organization
of the ego and superego. This is more true for the pseudo-delusional type.
In the behavioral type, there may be thematic stabilities of affect that are
82 Psychosis and Near Psychosis

quite flxed, although the content and details of the plot may never quite
condense or may change over time.

Affect-Modulating Capacity

The capacity of the near psychotic ego to modulate affective states is

severely impaired. Affects are seen in purer form or in fused form. Fusions
of affect summate their intensities rather than integrate and neutralize each
other. The lack of modulating capacity prevents a regulation of the intensity
of affect. Affect, if intense enough, recruits affects from different domains.
It is this characteristic of many near psychotic states that links them to the
affective illnesses. However, the autonomous ego function of modulating
capacity can be damaged directly, as in certain types of neurological damage.
The exact diagnosis of the lack of modulating capacity is crucial to the
treatment of these conditions. Medication or interpretative psychotherapy
will be variously effective, alone or in combination, depending on the exact
diagnosis and etiology of the particular ego deflcits. In any case, the lack of
modulating capacity leading to exaggerated intensities of affective experience
means that the integrating capacity of the ego is under great strain.

Reality Testing

Reality testing in the near psychotic states is said to be suspended but not
totally lost. I This means that the behavior of the borderline or the thoughts
of the pseudo-delusional are not constrained by the secondary process of
conscious reality testing nor by the content of conscious reality experience.
Instead, reality testing is highly influenced by the near psychotic
condensation, especially its affect and quality, but also its content. However,
when confronted by an outside overwhelming reality or by the psychiatric
interviewer who seeks to do this in words, reality testing processes will be
shown to be functional and not captured by the near psychotic condensation
(see Kernberg, 1977). This means that reality testing in the near psychotic
has maintained its separate, secondary process, logical reality testing
processes. Intact secondary process reality testing means that reality testing
experience does have a potentially available, although dissociated, reality
experience process, quality and affect that do not coincide with the near
psychotic condensation. This is true even if reality testing content is heavily
influenced by the near psychotic condensation. The extent to which reality
testing content overlaps or is condensed with the near psychotic structure
varies from patient to patient and from etiology to etiology. Traumatic near
psychotic states involve considerable overlap, although not true
condensations. One thing is always true, however. Although content may
3. Near Psychosis 83

overlap between the near psychotic condensation and reality testing, reality
testing process in near psychotic states is never part of the near psychotic
condensation structure. This means that the capture of reality experience
is potentially not as rigidly fIxed as in psychosis. The use of reality as a
vehicle for emotional conflict and as a resistance to the exploration of inner
states can be more easily interpreted at this junction, engaging deeper layers
of the patient's psychology.
Another aspect of near psychotic reality testing is its dissociation from the
near psychotic condensation. Even though the condensation can influence
reality testing, reality testing does not influence the near psychotic
condensation until the condensation is made more fully conscious and
defenses guarding the dissociation are interpreted.
This reality testing problem broadly affects behavior in the borderline
patient and narrowly affects ideational content in the pseudo-delusional near
psychotic. For pseudo-delusional patients, reality testing is suspended in only
one specifIc area of mental functioning: a pseudo-delusion or pseudo-
hallucination. This can occur in the absence of a broad infIltration of near
psychotic condensations into reality experience. This is particularly true of
otherwise neurotically organized patients who enter a time of very severe
mental illness. The autonomous ego functions, better developed and
integrated, and better organized neurotic ego defenses, serve to better
contain the near psychotic illness. The autonomous ego structure of
boundaries may be breached at one area only. The primary process affect
eruption can be contained in one affect-laden idea and does not immediately
spill into other ideas or action. (For a historical review of the reality testing
concept in psychoanalysis see Frosch, 1983.)

ObseIVing Ego

The observing ego in near psychotic states is most often only suspended but
may be captured. The observing ego may therefore be part of the near
psychotic condensation, almost a part of it, or dissociated and blocked from
it.
Because the observing ego looks partly toward reality experience,
especially reality experience of mental functioning, the potential
reinforcement by the observing ego to reality experience is great. Its
interference is almost always through primitive defenses that capture its
reality view. This fact often makes the analytic psychiatrist despair about
patients who lack an observing ego. Sometimes such patients are said to lack
psychological mindedness. This is not exactly the same thing as the observing
ego, however. The observing ego is neither a necessary nor a suffIcient
component of psychological mindedness. However, a main trunk of the
therapeutic alliance does attach to the ego structure via the observing ego.
The observing ego allows the formation of a true, useful therapeutic alliance.
84 Psychosis and Near Psychosis

Agreement about the reality experience of the doctor, the patient's

symptoms, and the treatment setting permits treatment for change. A first
order of business, therefore, is to free the observing ego from its
condensations and/or dissociations. A dissociated observing ego is an easier
treatment situation than an observing ego that is captured by the near
psychotic condensation. In either case, the analyst attempts to help the
patient free the observing ego.

The characteristics of observing ego in near psychotic patients are:

1. May be part of near psychotic structure or separate; if separate, always

suspended and usually dissociated.

2. Suspension or capture of part of the observing ego by primitive defenses

(at one content point in the pseudo delusional or at a broad thematic line
as in attitude and then expressed directly in behavior in the behavioral
type of near psychotic, the borderline).

3. When blocked, the capture blocks insight and access to the near psychotic
area. This is the defensive function of the capture of observing ego.

Reality Experience, Emotional Experience and

Their Relationship
In near psychotic states, there is a condensation capture of part of reality
experience by part of emotional experience in the preconscious. This
condensation is then dissociated.
Because reality testing is suspended, because there is a condensation
between reality and fantasy, because this fantasy is just out of awareness, and
because this condensation affects reality experience, there is a specific
mental experience of near psychosis. The experience is akin to the uncanny
(Freud, 1919) or deja vu. These experiences, while of different structure, also
involve momentary conscious uncertainty about reality experience. The most
common near psychotic structure involves only specific condensation points
of affect content. Only emotionally relevant reality experience is captured.
Some very ill near psychotic patients, however, have attitude propensities to
near psychotic condensations along broad thematic areas, of which the
broadest is mood. In these patients, transient near psychotic condensations
may occur whenever reality content evokes and intensifies mood-congruent
affect.
Thus, the regulation problem of the relationship between reality
experience and emotional experience may be broad or narrow, intermittent
or constant.
3. Near Psychosis 85

The relationship between reality experience and emotional experience in

near psychosis is the relationship of (1) the captured reality experience to
emotional experience, and (2) the resulting dissociated and incompletely
repressed condensation to the rest of mental life, especially to the totality
of conscious reality experience. Many areas and aspects of conscious
autonomous ego function may be intact, more so in the pseudo-delusional
than in the behavioral (borderline) type. In addition, each patient varies and
each illness varies. The near psychotic condensation is specific, fixed, intense,
dominating, and has the quality of reality experience. This condensation is
usually in a dissociated relationship with the rest of mental life, but the
condensation affects conscious reality experience in affect, quality of
experience, and nuance of ideas without capturing reality testing.
The point is that the relationship between reality experience and
emotional experience is no longer strongly organized by reality-oriented
secondary process. Instead, the relationship is emotionally oriented and
primary process-organized at specific points of affect laden ideas or along a
broad front of mood.
I will now describe the relationship of reality experience to emotional
experience within the near psychotic condensation. Intense affects are
preconscious and are condensed with reality experience. What is felt, is felt
to be almost real. At the same time that what is felt is felt to be almost real,
it is also felt as feelings. The near psychotic experience is of both feelings
and reality at the same time. The major boundary crossing is between
preconscious reality experience and preconscious emotional experience. I will
now describe other ego problems and how they affect the near psychotic
condensation.

Mental Experience and Behavior

This brings us to a boundary between mental experience, especially between

affect and behavior, i.e., that separates thoughts and feelings from action.
This boundary is strained in all near psychotic states but is severely damaged
in the behavioral borderline type. Borderline patients are those patients with
near psychotic behavioral actions. They act out their reality experience-emo-
tional experience condensations directly into the environment in reality. This
is usually the result of a projection of the near psychotic condensation. They
are not, however, projecting onto the object in reality. The inside-outside
boundary is intact. They are projecting onto their own preconscious real
mental object or real self and then behaving in accordance. Their ability at
the same time to perceive an accurate object or self in reality is intact.
In the pseudo-delusional form of this illness group, there are various
projections onto the preconscious experience of the real object or real self,
but they are not acted upon. This makes an outpatient treatment more
tempting and, potentially, more possible. However, it must be realized that
86 Psychosis and Near Psychosis

even in the pseudo-delusional, boundaries are under strain. Affect

responsiveness to reality interventions can be hair-trigger, and the behavior
boundary can be breached abruptly and massively in the transference.
Treating these patients is a most interesting experience requiring the
greatest concentration on the details of structure that will determine the
technique of therapy (see chapter 8).
Except for the behavior boundary, the structure, location and quality of
near psychotic experience are the same for both the borderline and the
pseudo-delusional. The mental experience of near psychotic behavior is
specific in its structure. The structure is identical to the structure of near
psychotic ideas except for the affect-behavioral and the more general
fantasy-behavioral boundary problem.

Integrating Capacity
The ability of the near psychotic patient to integrate mental experience is
severely impaired. The impairment takes place at the level of autonomous
ego functioning, just as it takes place in defensive structures. The
impairment involves an inability to integrate near psychotic experience with
reality experience but also with emotional experience and with other areas
of personality functioning.
The ego should normally be able to synthesize reality experience,
emotional experience, conscious experience, preconscious experience,
primary process, and secondary process in an even-flowing, integrated, and
sublimated mental life.
lt is this overall synthetic function that is damaged in near psychosis. The
synthetic function (Nunberg, 1931) is a compound ego function (Bellak et
aI., 1973) or superordinate ego function (Hartmann, 1939; Blanck and
Blanck, 1986) and is badly distorted by the ego problems already listed.
The exact nature of the integrative disturbance has been variously
described. The inability to integrate emotional life has usually been focused
on (identifications: Stone, 1986; Searles, 1986; object relations based on
affect: Kernberg, 1975).
The inability to integrate emotional experience or object relations
experiences occurs not only in near psychosis, but also in various illnesses
and in nonillness states as an ego variation. The specific feature of near
psychosis is the autonomous ego integration failures in preconscious reality
experience and not just the lack of defensive integration in emotional
experience. Autonomous ego difficulties are crucially involved. The most
severe aspects are the integration problems where emotional experience
3. Near Psychosis 87

Table 3.1
Autonomous ego function in near psychosis (partial list)

I. Disrupted:

A Boundaries

1. Between inside emotional experience and inside reality experience

(merged by condensation at limited points in the preconscious)
2. Between unconscious and preconscious (show increased porosity)
3. Between conscious reality experience and preconscious near
psychotic condensation in near psychotic area (show decreased
porosity)
4. Between conscious reality experience and preconscious affect
(show increased porosity) and between conscious reality and
preconscious content (show decreased porosity)
5. Between primary and secondary process in the preconscious (show
increased porosity, and often this problem extends into
consciousness)
6. Between affects in preconscious (show increased porosity)
7. Between affect and mood (show increased porosity)
8. Between affect and concept (show increased porosity)
9. Between real Object and Object representation or between real self
and self-representation (show increased porosity)

B. Integrations

1. Integration failure between reality experience and emotional

experience at a particular point in the preconscious
2. Dissociative lack of integration of the resulting condensation from
conscious reality experience, preconscious reality experience and
preconscious emotional experience (in those preconscious areas
not captured by the near psychotic experience)
3. Lack of integration of affects and their associated ideational
contents [dissociations in primary process and lack of secondary
process integration (secondary process) of affect with ideas]

C. Observing ego

1. May be captured by primitive defenses and sometimes condensed

with near psychotic structure
88 Psychosis and Near Psychosis

Table 3.1 continued

II. Not disrupted
A. Reality testing
Suspended in consciousness and not part of near psychotic structure
B. Boundary between inside and outside

intersects with reality experience. Near psychotic structure is characterized

by the location, composition, amd dissociation of this difficulty. The main
feature of near psychotic structure is the particular dissociated preconscious
condensation experience that results. This condensation lies unintegrated in
near consciousness. The characteristic lack of integration is the dissociation
of this condensation. The characteristic dissociation is a vertical and
horizontal dissociation. The near psychotic horizontal dissociation
(repression) is a partial repression into the preconscious of the near
psychotic condensation. There is a faulty open channel from the unconscious
into this preconscious condensation, but little or no interChange between
conscious reality experience and the condensation. Instead, current reality
provokers bypass the condensation and evoke affect and unconscious primary
process contents, which then evoke and energize the preconscious
condensation and spill over into conscious reality experience. The near
psychotic experience is usually vertically dissociated from other aspects of
preconscious reality and emotional experience, and horizontally dissociated
from conscious reality experience. The near psychotic condensation is,
therefore, isolated, both vertically and horizontally.
The vertically dissociated near psychotic preconscious experience exists
alongside other preconscious and conscious experience but is not changed
by these other experiences. The separation extends along content and affect
congruent lines down into upper layers of the unconscious and up into lower
layers of consciousness. The extent to which the vertical dissociation extends
into consciousness does vary. The dissociation has mediating autonomous
ego deficits, just as it has mediating defense mechanisms.
The dissociated area may have affect that has opposite valence, but the
lack of integration may involve a content area with layered or even
integrated affect. The latter is more true of the pseudo-delusional type. In
either case, the near psychotic condensation is dissociated with the widest
and most rigidly fixed aspects of that dissociation located in the
preconscious.
The lack of integration in near psychosis of emotional experience and
reality experience takes its special form because of both the condensation
and its dissociation. The dissociation is not between reality experience and
emotional experience but between the focal preconscious condensed reality
experience-emotional experience and everything else.
3. Near Psychosis 89

What ego problems mediate vertical dissociations?

1. Lack of secondary process synthetic integration, alone or in combination

with
2. Failures of generalization and application,
3. Failure of word presentations to contain and organize affect,
4. Failures of affect modulation (causing unintegratable intensities),
5. Failures of primary process-secondary process boundary,
6. Failures of reality experience-emotional experience boundary and
integration,
7. Enabling character defenses.

Object Relations

The pathognomonic feature of near psychotic autonomous ego problems in

the area of Object relations is the loss of the boundary in the preconscious
between the reality-experienced real object and the representation of
emotional experience in the Object representation, or between the real self
and self-representation, or between the self-representation and the real
object. Condensations take place between these realms. The two realms are
the emotional experience and the reality experience of self or Objects. Real
self- or real Object experiences are always involved. The near psychotic
experience is the mental experience of this preconscious Object relations
condensation.
Usually, the condensation preconsciously involves real Object with Object
representation or real self with self-representation. If the real object/object
representation condensation is also suffering a projection from the self-
representation, it is usually a more deeply unconscious projection. The
patient may experience the affect simultaneously in the real Object, the
Object representation, and the real self. Various combinations of these
possibilities commonly occur.
Projection of affect from self-representation to Object representation
without the conscious experience of affect in the real self is the neurotic
phenomenon. In borderline states, the preconscious projections and
condensations always involve the real self- or real object experience.
Autonomous apparatuses of boundary determine what aspect of object
relations is condensed and where and at what level the condensation occurs.
AIl near psychotic object relations condensations involve an aspect of the
reality-experienced Object relation condensed with an aspect of the
emotionally experienced Object relation in the preconscious. 2
Other autonomous ego problems often found in near psychotic states,
such as decreased repression barriers, decreased affect intensity modulation,
decreased affect spread regulation, and increased recruitment of affect-
associated ideational contents, mean that intense and undiluted affects and
90 Psychosis and Near Psychosis

contents will appear in preconscious object relations, making them extreme,

polarized, whole-object relations with clear story lines. This means that at
the preconscious level, one does not have just preconscious mechanisms or
processes with contents that are more deeply repressed as in the neurotic,
but processes and mechanisms that are linked to content at the same level
of consciousness. It was Schafer (1968) who pointed out that defense
mechanisms have an emotional content. In near psychosis defensive
mechanisms are linked to clear Object relations scenarios in the
preconscious. Instead of an emotion being projected, an entire self or Object
image with affect and content is projected. For this reason, object relations
in near psychosis are spoken of as defenses, and defense mechanisms are
filled with dramatic object relations. In near psychosis, the two concepts
become one because of the changes that occur in the preconscious level of
near psychotic mental life.
American ego psychologists tend to describe defensive functioning of
processes in emotional experience, whereas British object relations theorists
and their American relatives tend to describe Object nondefensive as well as
defensive object relations in emotional experience. Neither describes
autonomous ego functions well or extensively except for the American,
Bellak (Bellak et aI., 1973).
Typical near psychotic defenses such as denial of fact or projective
identification are often described in Object relations terms when describing
very ill patients. However, the mechanism for emotional negation or
neurotic projection is inadequate to describe the sicker forms where reality
experience is captured and Object relations content is close to consciousness
and to manifest content. The usual object relations description of near
psychosis fails to distinguish the crucial role of the capture of real Object or
real self-experience.
Defenses are mechanisms. Object relations are contents. Both deal with
affects. These affects are transformed by defenses, disguised by defenses, and
expressed in defenses. The defense mechanism itself has an emotional
content and experience. All of these phenomena have object relations
contents condensed at the preconscious level in near psychosis.
The point is that as the boundary between conscious and unconscious and
also between real and emotional changes, the boundary between Object
relations elements changes. The key to different Object relations experiences
is the autonomous ego boundaries.
For example, real object introjection may describe a phase of normal
growth and development. It is abnormal, however, when there is an
especially porous boundary resulting in affect flooding, and/or if affect goes
back and forth and is poorly localized, and/or if the real self or real Object
is then captured. Therefore all object relations experiences and hence
descriptions are defined by aspects of apparatus ego function.
Because these apparatuses can be changed by psychotropic medication, we
see that they do have a level of autonomy from the dynamic content of
3. Near Psychosis 91

object relations even as they are affected by them, and for this reason they
are also responsive to psychotherapy. One can see this most dramatically
when medication reduces a psychotic projection to a borderline projection
and together with the help of psychotherapy reduces that to a neurotic
projection without ever changing the content theme of the projection!
Table 3.5 (see p. 110) shows that the key to different object relations
experiences is the ego boundaries between elements, especially between
reality experience and emotional experience and between levels of
consciousness. The argument is over whether the boundary disturbances are
caused by the object relations or, as I say, the object relations disturbance
is also caused by the autonomous ego boundary disturbance in psychotic and
many near psychotic illnesses.

Day Residues

Because near psychosis captures reality experience, we are interested in what

reality experiences are captured and why. I have been using the term day
residue as analogous to precipitating event or organizing event: a reality
event, with its sequences and contexts, that is meaningful and therefore is a
reality evoker of affect and of symbol. Because there are propensities to
structure that are developmental and biological, it is not quite accurate to
call a reality trigger a cause, necessary and sufficient. But the day residue is
a nidus, and while not sufficient, it may be necessary. Perhaps it is better to
say that we need to look at how what happened becomes organized in the
psychotic or near psychotic structure. We are interested, then, in the process
organizing the day residue into the symbolic transformations of near
psychotic structure.
In the near psychotic patient the day residue object or event is in the
same preconscious layer as the symbolic transformations, or just below. It is
part of the near psychotic condensation. It may also be intact and
dissociated. Sequence and context are also usually captured.
There is a condensation summation experience between the day residue,
the symbolically altered day residue, and emotional experience that is intense
and overwhelms reality experience in the preconscious. A therapist can find
out what in reality is upsetting or triggering such a patient fairly soon after
exploring the emotional material, because the point of condensation between
reality experience and emotional experience is at the day residue point. This
point is almost conscious and has intense affect which is conscious and
marks the available edge of near psychotic ideational content. The
condensation is primary process. In this sense, it is like a temper tantrum of
a small child who is not making logical sense but who, after being comforted
and listened to, can finally calm down enough to tell you what happened.
The day residue in near psychosis, because it is significant in reality as
well as emotionally significant, like the day residue in psychosis or the day
92 Psychosis and Near Psychosis

residue in traumatic dreams, is a reality bridge between fact and fantasy,

present and past, primary process and secondary process, and conscious and
unconscious. It symbolically represents the emotional conflicts that emerge
disguised and expressed in the primary process alterations of reality that
occur. In near psychosis, all of this is primary processed at the preconscious
level.
The day residue in near psychosis can be an event in reality that seems
dramatic or minor, but near psychotic day residues are never minor to the
patient. They are events in reality that trigger emotional experience because
they are similar to or evoke the same emotional experience as genetic events
in the past and often because they are real traumas and deprivations in the
present.
The conscious percept experience in near psychosis tends to be the affect
significance of the percept rather than an altered percept. A significant
displacement of emotional experience onto reality experience is involved,
especially of genetic emotional experience onto present, reality, day residue
experience.
Because the day residue Object or event is part of the near psychotic
condensation, the contamination of reality experience tends to be quite
significant. This is as significant as in psychosis, except that in near psychosis
the contamination of the day residue tends to be in the preconscious, is
more fluid, and does not fully contaminate conscious reality experience.
Thus, we see that there are differences between dreams, psychosis, and
near psychosis in the location of the day residue and its symbolic alterations
but similarities in the primary processing of reality experiences. The day
residue experience in near psychosis is condensed with emotional experience
in the preconscious, but in addition, there may be intact day residue
dissociated. If this is so, the dissociation is either conscious but disavowed,
or preconscious and denied. Many times, however, there is no intact
dissociated day residue of secondary process and it must be disentangled by
interpretation from the primary process condensation location in which it
is trapped.
Sequence and context in the day residue experience, unlike sequence and
context in the psychoses, tends to be captured by the condensation in the
preconscious and not by repression. This can be a key to interpretive
leverage in disentangling the day residue event or object from the primary
process near psychotic condensation. Also helpful is that the sequence and
context are usually less rigidly captured than the day residue even or object.

Thing Presentation

The near psychotic condensation takes thing presentation form. Near

perceptual experiences, alterations, significances, and percept-affect
organized according to primary processes convey concept. In near psychosis,
3. Near Psychosis 93

this is in the location of near consciousness. Thus, we have a thing

presentation form, content, and experience of emotion fIXed and partially
repressed in the preconscious, influencing but unavailable to conscious word
presentations and secondary processes. Aspects of conscious reality
experience will be actively contaminated by intense emotional alterations of
reality with perceptual qualities. This experience will be almost available to
consciousness and will strongly influence conscious decision making but will
be unavailable to the secondary process logic of conscious reality experience
because of preconscious location and dissociation. The influence of the
preconscious thing presentation and its processes will form its own
motivating system because it seems almost real, has intense affect and
validity, and so requires discharge. It will also influence the selection and
organization of new reality experience. This accounts for the maladaptation
of near psychotic states.
Because of the thing presentation phenomenon, the preconscious near
psychotic idea is not a concept but a concrete representation. The near
psychotic behavior is not a response that is adaptive to external reality
stimuli but is a concrete enactment of, and response to, this thing
presentation. The near psychotic attitude or affect is the behavior or idea
encoded in these preconscious thing presentations. Psychoanalytic treatment
of near psychosis is the understanding and treatment of these thing
presentations, whether in behavior, idea, or only in attitude.
All thing presentation phenomena involve affect-determined percepts and
primary process organization. All thing presentation phenomena borrow
from reality experience and have the perceptual qualities of those reality
experiences. Only some thing presentation phenomena, however, occur in
reality experience in near consciousness and are vertically dissociated from
the rest of mental life. These are near psychotic thing presentations. This is
the form of experience the near psychotic condensation takes.
When reality experience-emotional experience condensations are
expressed in a thing presentation in near consciousness, emotions will be
concrete, almost perceptual, and experienced as almost real. Near psychotic
thing presentations protrude their intense reality, perceptual, affect
experience qualities into consciousness.
The thing presentation in near psychosis tends to be rigidly fIxed,
stereotyped, and repetitive in content and affect. It is vertically dissociated
in the preconscious and is therefore unchanged by other preconscious
experience, unavailable to creative play, and automatically intensified by
triggering day residues. Because the thing presentation is preconscious, it
may be more influenced by affect intensifIcation, mood, and mood-congruent
provocative reality events.
The preconscious thing presentation tends to influence consciousness not
only because it has perceptual qualities but also because it does not totally
contain the affect. This echo of affect in consciousness adds validity to the
conscious experience, which then reinforces the preconscious ideas. Also, the
94 Psychosis and Near Psychosis

conscious translating mechanism between primary and secondary process,

thing presentation and word presentation, affect and concept, is either
overwhelmed, damaged, or both. Symbolic thinking is limited in the near
delusional area to preconscious concrete pictorial thing presentation
experience.
Rigid, fixed, porous, preconscious thing presentations are the mental
experience at the basis of all near psychotic phenomena. Object relations, for
instance, in near psychosis take a concrete thing presentation form of
preconscious perceptual reality. Their use as emotional symbols is
stereotyped, repetitive, dissociated, with a fIxed relationship to day residue
triggers.

Thing Presentation Quality

Crucial to psychotic and near psychotic experience is the quality of the
experience. This quality is a mixture of emotional and reality experience,
with a perceptual quality of reality experience dominating. In near psychosis,
this is just out of awareness but pushing into consciousness. This
affect-percept quality charges ideas or behavior or attitudes with intensity
and a near reality veracity. The near reality quality of the experience is its
own motivation to actualize in reality and to gain satisfaction in reality. This
can occur without the content or process of the condensation being fully
conscious.
When reality quality energizes affect, the motto is "I feel, therefore my
view of reality must be true." When reality quality infIltrates ideas, the motto
is "I know it is so, therefore my view of reality must be true." When reality
quality infiltrates behavior, the motto is "I took action, therefore my view of
reality must be true."
The quality of the thing presentation in near psychosis is the quality of
the affect condensed preconsciously with perceptual quality. The
condensation in the preconscious is between affect and percept, and only
secondarily with the idea.
This causes a shift in the experience of validity. Validity is heavily
influenced by the thing presentation experience at the expense of other
validating mental experience, because both the quality of perceptual reality
and the quality of affect are focused together. It is this quality of reality and
validity in the preconscious that gives the near psychotic experience its
particular and peculiar essence. 3
Near psychosis is not a strong memory or imagination or daydream.
Eidetic people have very strong memories and often imagination experiences
that may be conscious, perceptual sense experiences. These states are not
near psychotic because they do not have near psychotic condensation
structure, location, and influence. They occur in an intermediate area
3. Near Psychosis 95

between reality experience and emotional experience. They are often reality
memory traces uncondensed with present reality experience, although
perhaps triggered by present reality day residues.

Experiences That May Seem to Be Near Psychosis

but That Do Not Have Near Psychotic Structure
I. Eidetic-thing presentation content and quality intensely and fully
conscious but experienced in a conscious zone intermediate between
reality experience and emotional experience. 4 It is memory or imagination
with strong perceptual qualities about which reality testing and observing
ego are intact.

II. Imagination-thing presentation content usually not conscious, but if

so, reality experience may be borrowed but not captured; thing
presentation quality experience, if any, is in superordinate emotional
experience or intermediate ego.

III. Uncanny-reality quality intense due to an overlap of preconscious

emotional experience and memory with the situation in reality; takes
place in emotional experience; no condensation capture of reality
experience; the reality quality is from the conscious experience of the
thing in reality, from reality properties of memory of a real event in
the past and only secondarily from overlapping emotional experience.
There is no preconscious condensed thing presentation.

IV. Trauma and "flashbacks"-reality experience triggers a "flashback" of

eidetic memory experience of trauma which overlaps with present day
reality experience; no true condensation occurs; intense affect charges
the traumatic memory but does not lead to near psychotic
condensation, although the experience may strongly resemble near
psychotic condensation. Some early traumas do lead to near psychotic
condensations.

Defenses
The unique feature of near psychotic defenses is their capture of
preconscious reality experience. 5 The defensive capture is organized
according to primary process rules. Defenses in psychosis and near psychosis
function to avoid reality-experienced evidential and cognitive-logical
confrontation against deeper layers of conflicted affect and content. In near
psychosis, deeper and/or dissociated layers of emotional experience are
% Psychosis and Near Psychosis

protected by certain aspects of captured reality experiences. The defensive

capture of reality may occur through intensity that overwhelms, as in chronic
childhood trauma or manic-depressive illness, or through direct boundary
damage, as in schizophrenia or attention deficit disorders.
Near psychotic defenses tend to be quite rigid, inflexible and maladaptive.
One reason is that defenses operate against aspects of reality functioning
and therefore must maintain a rigid stance because the potential
confrontational input of reality may be fairly constant. The second reason is
that the intensity of affect in many of the near psychotic illnesses is great
and constantly pressing, so that defenses must be maintained continuously
and inflexibly. Third, certain near psychotic defenses, for instance in states
of depression, involve intense and angry superego contents and functions
condensed with ego defensive operations, and the intensities and rigidities,
therefore, summate (cf. Coen, 1988). However, there are some more
plastically organized near psychotic patients whose defenses are not rigidly
fixed in content or in intensity of affect. But these defenses also operate
continuously to change reality experience, especially interpersonal social
experience, and internal psychic conflict.
Defenses in near psychosis are part of the near psychotic condensation.
They involve reality experience, emotional experience, observing ego content,
reality testing content but not processes, mediating defenses of vertical
dissociations, and horizontal defenses of repression across a broad front of
basic personality functioning. These condensations occur preconsciously, and
so the integration characteristics of the primary process/secondary process
preconscious determine form. The summation of these different areas, with
their contents, affects, and autonomous ego captures, makes near psychotic
experience seem chaotic. However, this seeming chaos is in no sense
random. There are specific and stable autonomous ego problems, specific
and stable character attitudes and defenses, and stable themes and conflicts,
with limited numbers of condensation points.
The degree to which there is a vertical dissociation between this near
psychotic condensation and the rest of personality function varies from little
and fluid in the behavioral borderline patient to large, rigid, and fixed in the
near delusional. There is always, in both types, a large vertical dissociation
from intact autonomous ego functions. In the near delusional patient, a near
psychotic condensation may involve one interpersonal relationship and
content area and be dissociated from the remainder of personality
functioning and associated conscious cognitive functioning. There are two
separate areas of reality testing content and two separate areas of observing
ego function. One relates to the near psychotic condensation and the other
relates to the rest of mental functioning. As in the psychotic patient,
mediating the vertical dissociation are defense mechanisms that are often
basic to the personality structure of the patient. The difference between
these mediating defenses of vertical dissociations in near psychotic patients
and those of psychotic patients is that the enabling defenses in the near
3. Near Psychosis 97

psychotic are part of the near psychotic condensation. This may make initial
confrontation and exploration of the near psychotic content more difficult,
but once entry into the defensive system has been achieved, progress may be
extremely rapid because it allows immediate entry into the near psychotic
condensation.
An effort has been made in the analytic literature to describe the peculiar
and particular characteristics of near psychotic defenses. Words like
primitive and splitting are often used. There are various definitions of these
phenomena. The point, for me, is that all near psychotic defenses capture or
alter reality experience in the preconscious and press into the conscious
experience of reality. There are various dissociative mechanisms involved in
maintaining and organizing this capture. I will use primitive to mean capture
of reality experience. I will limit splitting to mean a particular type of
dissociation based on affect valence. 6 Splitting is a lack of integration in
emotional experience. In near psychosis this splitting is only a first step
toward a second step which captures an aspect of reality experience. The
usual second step is a projection onto the real object or the real self. Not
all near psychotic defenses involve splitting. All near psychotic defenses,
however, are primitive in that they capture part of reality experience (cf.
Willick, 1983). These defenses always function to isolate the near psychotic
condensation from the remainder of reality experience, and sometimes from
other aspects of personality functioning and defense. Because defenses in
near psychosis involve the capture of reality experience, they have a different
function and target than in the neuroses. The defenses in near psychoses
operate against aspects of reality experience by primary processing aspects
of reality experience as part of a condensation structure.
The most common ways reality experience can be defensively affected are
through projection or denial. I will describe both for near psychotic states.
Before I do so, I need to say something about defense content themes.
Defense content themes tend to be more homogeneous in near psychotic
states. Even if they are mixtures of themes, there are limited numbers of
themes in the mixture. Thus, thematic content is characteristic of each
patient and each category of near psychotic character disorder; indeed, all
character disorders have characteristic themes. These themes express
themselves especially in behavior and attitude. For this reason an archaic
term for these disorders is behavior neurosis. I prefer the term attitude
neurosis, because the behavior is an expression of the underlying attitude
that forms the premise for the behavioral action, and because there are
many patients with near psychotic attitudes who do not go on to enact in
behavior (see Compton, 1987).
98 Psychosis and Near Psychosis

Projective Identification
When projection involves reality experience alterations, it is called projective
identification. It is based on three autonomous ego problems. One is the
problem with reality testing, which is either suspended or dissociated. The
second is the lack of ability to repress the intensity and associated content
of strong emotions. The third, and the most important, is the projection
onto reality experience, usually onto the real object from the object
representation, or onto the real self from the self-representation. Projective
identification describes a level of mental organization which permits a
certain type of capture of reality experience by emotion. Neurotic projection
involves an unconscious feeling in the self-experience projected onto the
preconscious emotional experience of self- or Object representation but not
onto the real self or real Object. A neurotic statement reflecting this fact is
"Are you angry at me? I worry you are angry at me." By contrast, sicker
patients project onto the reality experience. These patients are fairly certain
that the person is angry at them. In addition, because of repression
incompleteness and lack of integration, it is not just a feeling that is
projected, but also an entire Object relationship. The projection contains not
just a feeling but also its associated ideational contents. The patient feels the
other person really is angry, and also knows why the person is angry and
how the person feels about the patient because of the anger.
This merger onto reality experience in near psychosis occurs
preconsciously. The condensation is preconscious. Deeper layers of affect
and content are unconscious. The resulting feeling and idea may be
conscious.
I have discussed what is projected and where the projection is to. Where
is the projection from? It is either from the unconscious Object
representation to the preconscious real object or from the unconscious self-
representation to the preconscious real self. If the projection involves self-
and Object representations in the projection, the projection is from self-
representation to the preconscious real object or from the Object
representation to the preconscious real self.
Projective identifications involving projections to the experience of the
real self are very important in near psychotic depressions, manias, and
psychosomatic illness. They are often missed in work with depressed patients
(see chapters 5, 7, and 8).
In summary, projective identification is a term that describes a particular
mental mechanism in which what is projected, and where it is projected to,
differs from neurotic projection. In projective identification, a whole self or
whole Object image from unconscious emotional experience is projected onto
the preconscious real self or real Object.
3. Near Psychosis 99

Why is the mechanism called projective identification? What is the

identification component? Learned authors have discussed this issue for
years (Kernberg, 1975; Meissner, 1980; Ogden, 1982; Porder, 1987; Sandler,
1988; Steiner, 1989). Each one has a different explanation. Klein, the
originator of the term, never clarified this. I do not think she felt she had to,
because she believed in an in-out/in-out process of object relations
structure building. What was in went out, and what was out went in at the
schizoid level of development. Some authors describe this phenomenon in
Freud's term of primary identification, which hypothetically occurs in infants
as an internalization before "self and object" are differentiated. It is unclear
whether this ever happens at the conscious level (see Stern, 1985). It is
usually unclear whether the psychoanalytic literature means conscious,
unconscious, or both, or cognitive, affective, or both. In any case, Freud
meant simultaneous and undifferentiated, whereas Klein meant sequential.
My description is that the projected emotion is felt also in the
preconscious real self but is felt to be in response. The patient experiences
his or her anger in his or her real self-experience as being caused by the
anger in the real object. The patient therefore experiences preconsciously a
change in his or her real self related to a felt change in the real object. This
is identification (Sandler and Rosenblatt, 1962; Schafer, 1968). The fact that
the real object has suffered a projection is preconscious.
The same holds if the projective identification involves projection to the
self-experience only. The patient feels bad about himself or herself in
response to a projection of the way he or she fears he or she really is. See
Table 3.2.
In projective identification, therefore, the emotion is projected from the
preconscious self-representation but felt in the preconscious real self at the

Table 3.2 Projective Identification

Location of projection Preconscious

mechanism

Target of projection Reality experience

(preconscious real object or
preconscious real self)

Origination of projected Emotional experience; self

feelings representation or Object
representation, or both

Identification component Preconscious change in real

self in response to the
projection
100 Psychosis and Near Psychosis

same time. The projected emotion can be to either the real Object or the
real self. The emotion can be any emotion from anger, to contempt, to
eroticism. The ideational component is usually not identical in self and
object. Thus, in the adult, the phenomenon is not the same as so-called
primary identification. The adult phenomenon resembles a condensation.

Denial

Because very ill patients may seem to ignore reality, they are often said to
practice denial. However, denial means not ignoring or avoiding reality, but
an active intrapsychic process of denying an aspect of experienced reality.
Healthier patients may deny aspects of their emotional experience but not
aspects of their real-world experience. Sicker patients actively deny aspects
of their own experienced factual reality. Denial affects the experience of
things in reality, the experience of the real Object or the real self. The
experience of reality sequence or context is also usually affected.
Denial in near psychosis refers to a mental state in which information
from reality is received and stored in reality experience of the conscious and
preconscious but is dissociated from the rest of reality experience and from
conscious emotional experience. It is a type of dissociation. (For a beginning
discussion of this see Freud, 1925.)

Symbolic Alterations of Reality

Symbolic alterations of reality are condensations that capture and use
aspects of reality experience to symbolically represent an emotional
experience. The reality which is captured involves present day experiences
akin to the day residue concept in psychoanalysis and the precipitating event
concept in general psychiatry. The present reality day residue is emotionally
elaborated and altered, condensed with the past, experienced as real in the
present, and used symbolically but not experienced symbolically. A symbolic
alteration of reality is a plastic representation of reality.
In creativity, the symbolic alteration of reality is experienced emotionally
or experienced in an intermediate zone (Winnicou, 1953, 1971). In creativity,
the ego can use the symbolic alteration. The use is conscious and under the
control of secondary processes (see Arieti, 1976). In psychosis, the symbolic
alteration is in conscious reality experience and not under conscious control.
In near psychosis, the symbolic alteration of reality is in preconscious reality
experience and is not under conscious control.
The symbolic alteration in near psychosis occurs in preconscious reality
experience and not just in emotional experience or in the transitional area.
This means that the symbolic processes in near psychosis not only capture
3. Near Psychosis 101

reality experience but also are not under control of conscious, creative,
logical, symbolizing ego processes. The symbol processes take over an area
of preconscious reality experience, dominate and control real experiences in
that area, alter reality experience via primary process mechanisms, and
borrow reality experience qualities of perception to form a thing
presentation. The resulting thing presentation symbol is not experienced as
a symbol but as a concrete near reality. See Table 3.3.
Concrete means not experienced as abstract, truncated in concept, and
having few referents in the immediate associations. Deeper, richer
relationships and variations on the symbolic theme are repressed in the
unconscious and/or dissociated in the preconscious, often in character
derivatives like attitude and behavior.
The day residue has a rigidly fIxed and limited position at the center of
the symbolic alteration, with a fixed primary process relationship to
emotional experience in the specifIc condensation mechanisms and defense
mechanisms used. The symbol is horizontally and vertically dissociated from
processes in the ego that might translate and use the symbol. The location
in the preconscious horizontally dissociates the core of the condensation
from conscious reality processes. Translating mechanisms of the ego are thus
cut off from the symbolic alteration of reality. In addition, conscious
translating mechanisms of the ego may be flooded or broken. This varies
according to illness.
The structure of all thing presentation symbols is composed of perceptual
reality, but where this percept is experienced, how it is controlled, its
plasticity in relationship to the emotional aspects evoked by the day residue,
its relationship to the rest of emotional experience, whether it is open to
secondary process use and variation, and whether it can be translated into
word presentations, all determine whether the resultant thing presentation
symbol is a manifestation of illness.
All thing presentations use reality experience for their formal elements of
content. All thing presentation symbols have reality experience qualities. All
thing presentations alter formal elements of reality-experienced percept
according to primary process rules. But only in mental illness does the thing
presentation symbolically alter reality experience with a dissociated or rigidly
fixed relationship to emotional experience and to reality experience, all
taking place within reality experience and uncontrolled and unavailable to
secondary process word presentations.
Thing presentation experience is the experiential aspect of primary
process. The term primary process refers to formal, organizational aspects.
Symbolic alteration of reality refers to the use primary process makes of
reality, focusing on the ways reality is altered. Symbolic alterations of reality
are metaphorical and emotional uses of reality experience.
Are all psychoanalytic symbols thing presentations? No, thing presentation
is a type of mental experience. Psychoanalytic symbols are a primary process
102 Psychosis and Near Psychosis

Table 3.3
Symbolic alterations of reality in psychosis and near psychosis

A Symbolic alterations of reality in psychosis

1. Location: (of thing Conscious reality experience

presentation condensation
of reality experience with
emotional experience.)

2. Quality Reality-perceptual

3. Organization Usually primary process; because

of location, may be secondary
process

4. Stnlctural location of the Symbolic alteration of day

day residue residue altered and condensed in
conscious reality experience and
may also be unaltered in
dissociated conscious or
preconscious reality experience

B. Symbolic alterations of reality in near psychoSis

1. Location (of thing Preconscious reality experience

presentation condensation)

2. Quality Reality-perceptual

3. Organization Always primary process

4. Structural location of the Symbolic representation of day

day residue residue from conscious reality
experience altered and
condensed in the preconscious
(and may be also unaltered and
dissociated in conscious or
preconscious reality experience)
3. Near Psychosis 103

C. Symbolic alterations of reality in psycho neurosis

1. Location: (of thing Emotional experience

presentation condensation unconscious
of reality experience with
emotional experience.)

2. Quality Emotional experience

3. Organization Primary process in unconscious,

much secondary elaboration in
conscious

4. Day residue From minor displaced conscious

or preconscious reality
experience and from major
unconscious emotional
experience

D. Symbolic alterations of reality in creativity

1. Location: (of thing Conscious and/or preconscious

presentation) and/or unconscious; if conscious
or preconscious, then third space
and not capturing reality
experience

2. Quality Emotional experience or thing

presentation quality experience

3. Organization Primary process and secondary

process

4. Strncture Flexible relation to day residue;

flexible use of symbol;
translating mechanisms intact
and/or not dissociated or
avoided

form of emotional metaphOr. Thing presentations are a specific

affect-percept symbol experience of metaphor.
104 Psychosis and Near Psychosis

Much, if not most, of human mental life is symbolic. Only a minority of

these symbols are consciously and preconsciously experienced as thing
presentations. Only in psychosis or near psychosis do these symbolic thing
presentations alter and dominate the conscious control of reality experience.
In psychosis and near psychosiS, as a thing presentation experience
emerges, the details of the symbolic alterations of reality that are involved
are charged with affect. The appearance of these affect-laden details is a
surprise to the patient, and their meaning is unknown to the patient because
of the dissociations and because translating mechanisms are broken.
The exact and complex relationship between symbols, thing presentations,
and symbolic alterations of reality will be the topic of a future work.
Understanding symbol experience and construction in near psychotic
patients will enable the psychoanalyst to help the patient make the symbolic
alteration of reality fully conscious and to translate the condensations of
affect, ideas, and perceptual experiences into words.

Toward a Psychoanalytic Theory of Action

One problem standing in the way of a psychoanalytic theory of action is to
equate behavioral action with pathology.
The therapist goes on vacation. His woman patient takes her cat and kills
it by putting it in the refrigerator. After years of treatment, she makes a
sculpture of a dying, screaming cat at a time of separation from the
therapist. In a similar example, a therapist goes away and his male patient,
while hunting, "accidentally" loses his dog. At the same time, the patient, a
writer, is writing a story about a lonely and abandoned dog. Of these four
described actions, which is pathological? Which is sublimation? If the
sculptress had only sculpted, would that have been sublimation? If the writer
had only written and not hunted, would he have been free of pathology?
These questions, of course, cannot be answered without an understanding of
the patient's mental experience of all these actions and knowledge about the
relationship of the experience of these actions to other ego functions, such
as reality testing and the integrative-regulation ego function that negotiates
the relationship of reality to fantasy. That there are dynamic, even conflicted
feelings expressed in actions is true regardless of the level of ego function.
Both patients felt rage and abandonment, both patients experienced
emotional abandonment by one or both parents, both experienced the
therapist as cold and themselves as lost and helpless victims. All four forms
of behavioral enactment reversed the passive-active equation. But the actions
fell along very different points of the ego pathology spectrum. Enactment
occurs in normal, neurosis, near psychosis, and psychosis, although the
clearest examples usually are in near psychotic behavioral borderlines where
behavioral action is a wide-open channel of personality serving defense-
discharge functions in a system which is stimulated by present day events.
3. Near Psychosis 105

The problem of action, therefore, and its relationship to pathology is a

separate question from the question of action itself. Pathology and its
categories can only aid a psychoanalytic theory of pathological action. It may
be that psychoanalysis should confine itself to this. However, analysis also
deals with behaviors that are dynamically meaningful but not particularly
pathological. Every analyst, including Freud, has dealt with the
psychopathology of everyday life. This includes the psychodynamics of
normal behavior.
If psychopathology cannot enlighten us about action, can we as analysts
say anything about action in general? Can we say anything about the
experience of action, per se? Psychoanalysis has traditionally tried to do this
by describing the dynamic features of behavior. Certain analysts in particular
have focused on the emotional and ideational content expressed in behavior
(Reich, 1925; Kernberg, 1975).
But understanding that behavior has specific meaning does not distinguish
action from other mental products which also contain dynamic content
expressions. The question then arises whether there are characteristic
structural or organizational features of action that distinguish action from
other mental products which also symbolically mediate the dynamic
unconscious. Is action different? Is action a unique mental product? If so,
and if this can be described, we then might reapproach the issue of why
behavior seems to be a chosen modality for some patients and why behavior
is pathological in some patients.
Psychoanalysis should start by describing the inner experience of action.
Is the experience of action different from the experience of fantasy? I will
discuss only dynamic, symbolic action, where dynamic, conflicted feelings are
expressed in behavioral action and where the present day initiator of the
action is also symbolic-a day residue. Present behaviors are symbolic
expressions of the present unconscious, the unconscious genetic past, and
the affect of both. The present day initiator's power to evoke is partly based
on emotional associations to the perception of reality. Reality perceptions
evoke partly because they symbolize. Freud (1900) considers the
characteristics of objects that enable them to symbolize, i.e., to be evocative,
especially of affect. Some patients use characteristics of the Object for symbol
experience more than others. Patients with psychotic and near psychotic ego
structure often tend to do so. So do cultural products. So, too, does action.
How does the experience of action differ from the experience of fantasy?
What is the symbolic form of this experience? What role do reality, percept
and behavior play?
Action is a way of experiencing externally. Some people only consciously
register something when they do something. As a patient said, "I do it; then
it crosses my mind." The inside experience is made more available through
an experience of outside.
Now the question psychoanalysis could profitably explore is: what is the
106 Psychosis and Near Psychosis

internal experience of the external something? The experience seems to be

the experience of a particular kind of condensation in which the symbol
elements of percept, affect and concept condense with behavior. Action is
a term used to express this special type of symbol condensation.
It would be helpful if we could describe the exact relationship between
percept, affect, concept, and behavior inherent in all dynamic action. Since
many mental products show, in their symbolic form, a condensation of
percept, affect, and concept, what is the specific arrangement of these three
components when behavior is condensed with them? This may then help us
understand the pleasure of behavior.
The crucial factor in the relationship of these elements is that behavior
occurs in the real world and in reality-recording and reality-experiencing
capacities of the mind. Action takes place in reality experience, not fantasy.
Action is an attempt to Change, or respond to imagined change, in the
perceptual feedback of reality experience. The attempt to do this often
externalizes the internal causal experience of affect and of wished-for or
feared percept and ascribes them or experiences them as part of the external
target of the behavioral action. But the reality-experienced target of dynamic
behavioral action is a day residue that has symbolic, emotional, fantasy
significance. Action is that dynamic mental product which attempts to
change the day residue (cf. Sandler, 1990). Action does this, not just in
fantasy, but in reality experience. Action attempts to change the actual
Object (object in reality or self in reality) and/or the experience of the actual
object (real object or real self), even though the actual Object is also a
symbolic day residue Object.
In action, the affect tends to follow the perception of the alteration in the
day residue rather than be experienced together with the concept. In
dynamiC action, there is an attempt by behavior to change the perceptual
aspect of the day residue symbol while the inherent concept, in the patient,
is maintained unchanged. This is in marked contradistinction to other
dynamic mental products in which the concept is more flexibly available to
the fantasy wish-defense compromise system and the concept and affect are
together. In action, the affect goes along with behavior and the perceptual
change brought about by behavior. Action is primarily a percept-affect
experience rather than a concept-affect experience. Action uses behavior to
experience affect together with behavior and behavior's effect on the
perceptual reality of the day residue.
Psychotic patients change the day residue by changing their own percept.
Borderline patients use behavior to provoke the day residue initiator to
change. Borderline action involves a preconscious condensation between
affect emotional experience and day residue reality experience with
perceptual thing presentation qualities in the preconscious, pushing into the
conscious. This condensation trans modally changes affect experience to
percept quality experience, thereby affectively charging the day residue
percept. It is this quality added to the day residue which tempts one to
3. Near Psychosis 107

action. The condensation is then enacted across a porous affect-behavioral

boundary. Neurotics do this in highly disguised, more indirect behaviors and
avoidances. Normal action attempts mastery of the environment.
Pathological behavior is when the behavioral response to the day residue is
rigidly stereotyped in behavior, affect, and attitude. The stereotypy is based
on the genetic day residues and their resulting affect experiences rather than
on the reality characteristics of the present day.

Motivation for Symbolic Action

Three categories of motivation for all action are the experiential motive, the
defensive motive, and mastery. The experiential motive operates when
symbolic action expresses a particular condensation of affect with the Object
in reality and real object experience. This feels different. Why? Fantasy
discharge may be inadequate for certain types of affect experience. Some
experience may not be fully translated into word presentations without risk
of reduction. Translating behavior into words may cause a reduction of the
complexity of the condensation by separating and changing affect contents,
qualities, intensities, and domains. Behavior may therefore allow experience
of complex primary process emotional qualities. The complexity, intensity,
and particular quality of mixture in the conflict may only be possible to
experience through the perceptual and bodily experience of behavior. "I do
it, then 1 feel it." Some people can only experience an attempt to integrate
their affect in this way. Regardless of the level of ego pathology, some
people can only feel, or best feel, when they see their feelings in action. This
is an ego characteristic.
The experiential motive for action involves not only the resistance to the
reduction of affect complexity but also the resistance to change in affect
quality due to a change in affect modality. Stern (1985) describes transmodal
development and the resulting symbol formation. Affect does not feel the
same when the modality of the affect experience changes to word
presentations, because affect quality partly depends on the modality of
experience. Loewald (1988) alludes to this in his discussion of "stickiness of
the libido" (Freud). Action is different from fantasy because action is a
different mode. Affects experienced in action feel different from affect felt
in fantasy. "I do it, then 1 feel it in the way 1 want to feel it."
Second, there are dynamic defensive motivations. Sometimes affect is
placed into reality experience because the affect is frightening. Placing the
affect into reality experience may enable the discharge of conflicted affect
without mobilizing terrifying ego defenses and associated early superego
affects such as shame. Behavior may enable the experience of affect through
a separate physical, bodily, and perceptual channel. This may allow the affect
to escape from repression without the concept escaping. The behavior is
then often further dissociated from the conscious observing ego. Placing the
108 Psychosis and Near Psychosis

affect in present day reality experience while discharging it is a way of

producing a defensive derivative. The present day reality experience may
mimic the genetic past closely but is not the genetic past. The affect's
reappearance in the behavioral enactment and in the behavioral response
gives the patient a chance to fight and/or indulge the derivative reality
instead of the genetic reality. Therefore, the behavior may bypass ego
defensive and superego injunctions.
This derivative present day reality experience also carries with it a way of
justifying. The behavioral counterreaction that is made by reality justifies the
initial behavior even though the response is later in time; just as passive has
become active, so, too, does the later become justification for the earlier.
This is particularly true of borderline patients. Action is used in this way to
validate fantasy.
The motives for action also include various mastery motives for the wish
to change the day residue. These motives are on a continuum of pathology
from adaptation and conflict mastery to omnipotent, primary process control
to delusional grandiosity. All along that axis will be found those people
whose stubbornness, will, and perseverance lead them to insist on dealing
with the real world. Freud discussed the pathology of these characters in
"Observations on Transference Love" (1914) when he talked about certain
stubborn women who attempt to enact the erotic transference and are
therefore unanalyzable. But analysts deal with mental conflicts so that
patients might be able to regain the growth element not only in their ego
but also in the reality of their lives (Diamond, 1988). This experience is
pleasurable. Hartmann (1939), Jacobson (1964), and Schafer (1968) discuss
mastery pleasures of the ego.
Because of the importance of reality experience to action behavior, it is
no wonder that enactments often find their genetic origin in traumatic
behaviors that were inflicted in reality upon the patient. Freud's first theory
expressed this. It is no wonder that we also believe that the earlier such
trauma is inflicted, i.e., preverbally, the more likely it will be to have only a
behavioral form of expression, because that was the only form of
communication at the time of the trauma. The concept of trauma ties in
psychogenetics, phenomenology, psychological organization, and adaptive
style. Questions of reality trauma often arise in treating psychotic or near
psychotic patients (Fliess, 1973). Issues of reality trauma also frequently arise
in the study of group behavior and the resultant cultural product (Marcus,
in press). But trauma is not the only route to action. There is the factor of
the intensity of affect, which may make it difficult to change modalities and
provide a cause for "stickiness of the libido" (cf. McElroy et aI., 1992). There
is the factor of how completely language function has developed and how
available it is to affect containment, integration and expression. There is also
the issue of the ego barrier between affect and behavior. This barrier has an
autonomous capacity that develops to various degrees in different people.
Action is different from fantasy in symbol structure, modality of
3. Near Psychosis 109

Table 3.4 Summary of all near psychotic structure

Always

1. Real object and object representation or real self and self-

representation are condensed in the preconscious
2. Heavily infiltrated by primary process
3. Day residue may be displaced or may be undisplaced but in either case
is condensed in the preconscious with emotional experience. Day
residue sequence and context follow the location of the day residue
4. Thing presentation quality is strong in the preconscious and passes
into conscious experience
5. Preconscious defensive maneuvers condense with preconscious reality
experience
6. Reality testing content is influenced by the near psychotic
condensation but not reality testing processes; reality testing processes
are dissociated from the near psychotic condensation
7. Observing ego is frequently captured by mediating defenses of vertical
dissociation between the near psychotic condensation and the
remainder of autonomous ego functions

Usually

1. Vertically dissociated from the rest of reality experience and sometimes

from the rest of personality experience
2. Enabling defenses surround vertical dissociations and are part of the
structure of near psychotic condensations

The form the near psychotic material takes depends on:

1. How the particular illness disrupts the ego

2. The cognitive and emotional organizational level reached before the
near psychotic illness

The content depends on:

1. The content of past and present emotional and reality experiences

2. The content of psychological conflicts in and between the two areas
110 Psychosis and Near Psychosis

Table 3.5 Some object relations and ego boundary functions

1. Real self-projections

A. Real self projected to self-representation

1. Normal: role acquisition; no flxed condensation

2. Neurotic: conflicted identifications with and evocations by real
self-experience; an unconscious identification process
3. Near psychotic: identification condensations in the preconscious
(severe physical illness in childhood, severe childhood trauma,
severe behavioral disturbances which proceed to identification)
4. Psychotic: conscious fusion states; in-out boundary damage;
(organic mental syndrome, acute schizophrenia, extreme mania)

B. Real self projected to object representation

1. Normal: growth and development; evolution of psychic change in

life course; alterations of emotional view of others based on self
in reality and real self changes
2. Neurotic: unChanging relationship due to growth and development
conflicts (oedipal and preoedipal)
3. Near psychotic: condensation in preconscious (may be in defensive
relationship to a fixed, unchanging, unconscious object
representation as in the ideal object of near psychotic narcissistic
disorders)
4. Psychotic: conscious condensations with idealized or debased
object representation as in manic grandiosity or psychotic
depression

C. Real self projected to real object

1. Normal: reality interchange; no condensation; based on self in

reality and object in reality interactions
2. Neurotic: same as above except there are unconscious emotional
conflicts about this interchange
3. Near psychotic: preconscious condensed interchanges of affect
between real self- and real object
4. Psychotic: fusion across damaged in-out boundary; self in reality
and object in reality confusion with resultant real self and real
object confusion, of which real self projections to real object are
a manifestation (in dyslexias there may be conscious or subliminal
interchanges, but no fixed condensation and accurate secondary
process sorting can occur when attention is focused)
3. Near Psychosis 111

II. Real self introjections

A. Real self introjections from the self-representation

1. Normal: an aspect of normal learning or growth and development;

part of role acquisition (trial learning, aspirations, role fantasies)
2. Neurotic: unconscious conflicts and condensations where self-
representation conflicts with real self (viz., assumption of authority
role in real life)
3. Near psychotic: condensations in the preconscious (condensations
in hypomania with ideal self and real self; near psychotic
depressions with condensation of debased self-representations with
real self)
4. Psychotic: conscious condensations (viz., mania: conscious
condensations with ideal aspect of self-representations and real
self or psychotic depressive condensations with debased self-
representations)

B. Real self introjections from object representation

1. Normal: an aspect of normal role acquisition; a type of

identification; no conscious condensation
2. Neurotic: unconscious conflict (viz., conflict over assumption of
initiate role)
3. Near psychosis: condensation in preconscious (viz., severe sado-
masochistic or paranoid characters; near psychotic depressions; an
aspect of the second phase of projective identification)
4. Delusional identification: paranoid schizophrenia; some severe
chronic manias; conscious aspect of some delusional depressions

C. Real self introjections from the real object

1. Normal: a type of identification as in the representation of role

acquisition experiences
2. Neurotic: unconscious, conflicted identifications (viz., narcissistic
fantasies of grandiosity or debasement)
3. Near psychotic: condensations in the preconscious as in pseudo-
delusional narcissistic fantasies of grandiosity or depressive
debasement
4. Psychotic: conscious condensations with losses of reality testing as
112 Psychosis and Near Psychosis

Table 3.5 continued

in or psychotic depression, fusion states in acute schizophrenia,
organic mental syndrome, or mania

III. Real object projections

A. Real object projected to object representation

1. Normal: social learning

2. Neurotic: unconscious, conflicted traumatic experiences
3. Near psychotic: preconscious condensations (viz., severe trauma;
introjective contaminations of real Object as in affective illness)
4. Psychotic: an aspect of psychotic fusion states or of grandiose
delusions or of psychotic depression after real Object has been
contaminated with projections and then reintrojected

B. Real object projected to self-representation

1. Normal: learning; romantic love (a type of identification where the

intense focus of experience is in the real Object)
2. Neurotic: unconscious condensation; intense, conflicted
3. Near psychotic: condensation in preconscious (viz., near psychotiC
narcissistic condensations of real Object, real self, and self-
representation); see Kernberg (1975)
4. Psychotic: condensations in consciousness (psychotic grandiosity;
some sChizophrenic delusions)

C. Real object projected to real self

1. Normal: encoding of normal social role interchanges; no

condensations; conscious and preconscious
2. Neurotic: unconscious condensation fantasies expressing yearnings
and fears for similarities and special relationships
3. Near psychotic: condensations in preconscious (near psychotic
depressions with reality disappOintment in previously idealized
objects) (without condensation and preconscious subliminally in
some organic brain syndromes with porous in-out boundary)
4. Psychotic: psychotic condensations and/or fusions (mania, paranoid
schizophrenia)
IV. Real object introjections from Object representation

A. Real object introjected from the Object representation

1. Normal: a type of relationship and identification with real Objects

in social interactions or growth and development; the shaping and
changing of the Object aspect of identifications. No condensation
3. Near Psychosis 113

2. Neurotic: unconscious condensations expressing strong wishes and

fears about the real object
3. Near psychotic: condensation in the preconscious (viz., aspect of
projective identification in depressions and manias)
4. Psychotic: condensations in consciousness (psychotic depression,
psychotic mania, schizophrenia)

B. Real object introjections from the self-representation

1. Normal: in social role performance

2. Neurotic: unconscious, conflicted emotional of contamination of
real object
3. Near psychotic: preconscious condensations as in affect captures
of manic-depressive illness
4. Psychotic: conscious condensations as in psychotic mania or
depression

C. Real object introjections from the real self

1. Normal: an aspect of social learning/growth and development

2. Neurotic: unconscious, conflicted condensations
3. Near psychotic: preconscious condensations as in some near
psychotic affective illnesses
4. Psychotic: as an aspect of conscious fusion states

experience, and affect quality. There is a different sense of mastery, i.e., of

adaptation to reality. There are different defensive opportunities, i.e., of
adaptation to one's own emotions. Action provides a different experience of
satisfaction. Action~ometimes, we call it achievement!

Notes

1. The issue of reality testing alterations in near psychotic states is even

more complex than in the psychoses, because in some ways reality testing
function seems damaged, but in some ways it seems intact. Kernberg
(1977) has been articulately insistent on the existence of a specific
alteration in reality testing function in borderline patients, and it is part
of his definition of borderline states. Following Frosch (1964), Kernberg
(1975) describes alterations in reality experience but not in reality testing.
In his structural interview paper Kernberg (1977) describes a quite
114 Psychosis and Near Psychosis

different idea of reality testing suspended but not lost, and therefore
available when confronted in a psychiatric interview.
I agree that this is the striking and definitional issue. The other issue
of alterations in reality experience is not definitional, being variably true
of near psychotic states and nonborderline states. For a description of
alterations in reality relations, (which I do not think is definitional) see
Kernberg, (1980), p. 15. (See also chapter 1, n4.)
The issue of reality testing in near psychotic states gets further
confused because of the longstanding description of "mini psychotic
episodes." These are acute exacerbations of the illness in which either
intense behavior or an intense idea seems to lose reality testing altogether
for a period of hours to days. My own experience is that patients who
truly lose reality testing even for hours or days often have a concurrent
Axis I diagnosis in DSM-III-R, i.e., a major affective illness,
schizophrenia, or organic brain syndrome. Usually, the issue in such
patients is affective illness. A search for associated signs and symptoms of
these illnesses is almost always fruitful. Many of these patients are,
however, not delusional at all, but only intensely pseudo-delusional. This
can be demonstrated even at the time by a persistent and accurately
targeted mental status examination during the psychiatric interview. In
conclusion, my own experience has been that patients with "mini psychotic
episodes" are either psychotic or not psychotic. If they are psychotic they
have some psychotic illness. If they are not psychotic, then all they have
is an exacerbation of their near psychotic state. In either case, the term
"mini psychotic episode" is a misnomer and may be dangerously
misleading because it encourages complacency of differential diagnosis
both of level and of illness type. However, even I admit that there are
some patients who, while intensely in an exacerbated state, seem to be
frankly delusional, and it is impossible for a brief period of time to be
sure whether they are psychotic or only near psychotic. I used to believe
that until proven, they were not. My clinical experience over the last 20
years has taught me the error of this more heuristically pure assumption.
Most of the patients I was not sure about have turned out to have a
psychotic illness in addition to their near psychotic illness.

2. This whole area is historically murky. Klein (1940) did distinguish reality
from Object relations fantasies. She used the term actual object for the
object in reality and maybe for reality experience, although she tended to
ignore this last distinction. More importantly, she felt she was writing
about unconscious Object relations fantasies. Kernberg and Jacobson tend
to blur these distinctions. Also, they all imply that object relations
fantasies determine psychic structure, its boundaries, and autonomous
apparatuses.
But the use of Object relations to define near psychotic states has other
problems. Object relations theory alone deals poorly, even descriptively,
3. Near Psychosis 115

with some characteristic near psychotic ego problems, such as:

1. Nonbehavioral near psychosis;

2. Reality testing alterations;
3. Near psychotic symbol experience: relationship of symbol to
reality experience;
4. Condensations with observing ego;
5. Relationship of defense to near psychotic symbol;
6. Distinguishing characteristics of near psychotic Object relations
structure in those who do not show marked affect splitting.

All these aspects are better described in terms of mediating

autonomous ego dysfunctions, especially autonomous ego function.
In addition, Object relations do not deal with different illness etiologies
for the near psychotic state. Object relations theory usually implies that
the etiology is either inborn aggression or interpersonal experiences that
shape internal Object relations, or both. Yet we know that head trauma
in the adult can produce a borderline patient.
It is important to realize that the organization and experience of Object
relations is an ego function.

3. It may seem paradoxical to describe a preconscious thing presentation and

percept when there is no conscious sensorial event. Why not just say that
although there is no conscious perceptual event, there is a condensation
of percept qualities with affect qualities, including especially feelings of
perceptual veracity and validity. If this seems clearer, it is fine with me.
It is a bit inaccurate and a bit reductionist, however, because:

A. Many near psychotic patients describe more than this. They

describe a perceptual experience without being able to describe an
actual sensorial event. It is this psychopathological paradox that
must be described.

B. In any case, it is the capture of reality experience in the

preconscious that is crucial. Patients feel that something almost
really did happen! This preconscious perceptual something is
constantly leaking out into illusions, pseudo-hallucinations,
dreams, and behavioral responses.

c. Perhaps what we are talking about is a subcortical percept/sensory

event. This may be why such patients feel they see or hear the
percept. Subcortical limbic-hypothalamic areas may be capable of
perceptual/sensory phenomena as well as affect phenomena (Le
Doux, 1989). The cortex, especially conscious mental functioning,
is better able to separate percept from affect. Remember that
116 Psychosis and Near Psychosis

Freud's original concept of thing presentation was a neurological

one, based on his understanding of the neurology of percept. He
believed this to be different from the neurology of words. (For a
review of Freud's word presentation neurology see Ojemann and
Mateer, 1979).

4. Winnicott (1953, 1971) was the first analyst to describe the intermediate
zone of experience between reality and fantasy. His contribution to this
area of play, imagination, creativity and hence art and culture (see Kuhns,
1983) and also to development (see Grolnick, 1990) cannot be
overes tima ted.

5. For many analysts, defenses define illness, especially in sicker patients.

They disagree, however, about which defenses define which illnesses and
also what definitions to use of different defenses.
Kernberg (1975), especially, uses the organization of defenses around
splitting of affect as definitional. This use dates back to Klein, for whom
splitting was an unconscious defense. Reich and Freud likewise felt
defenses were important in sicker patients but used a descriptive model
of dissociation which also included consciousness.
I agree with everyone, more particularly with Freud and Reich. I see
sicker patients as usually having dissociation defenses which mayor may
not be based on affect valence. The main issue, however, is whether those
defenses capture reality experiences and where they do so (in what areas
of mental functioning). Autonomous ego is always involved, especially
boundaries between unconscious and preconscious, conscious and
preconscious, reality experience and emotional experience. The result is
a particular condensation experience not previously described in the
literature in which defenses of different possible types play a role,
together with boundary disturbance. The etiology varies from illness to
illness in the exact relationship between defenses and autonomous ego
boundaries.

6. For the history of the term splitting see chapter 2, nl. The point for this
chapter is that Kernberg (1975) has used the Kleinian splitting concept
as a crucial aspect of his descriptive definition of borderline states. He is
not always clear whether he means conscious, preconscious, or
unconscious. Also, the term splitting does not describe the peculiar
relationship of the defenses to reality experience. Finally, some near
psychotic patients do not split, they dissociate. That is to say, some near
psychotic patients have an integrated affective area which almost captures
an area of conscious reality experience and is separated from the
remainder of the ego's experience and functions.
4
Mental Status Examination

General Principles
The mental status examination is an interview method psychiatrists use to
gather and organize their observations about the patient's mental function-
ing. The mental status examination grows out of the general psychiatric
tradition of noting mental signs and symptoms of psychiatric and
neurological illness. Psychoanalysis adds observations about emotionally
dynamic mental contents of ideas and affects. Psychoanalysis focuses
especially on the process of this material as it reveals itself in sequential
associations and in patients' fantasies about the interviewer. Some
psychoanalysts, like general psychiatrists, also observe aspects of the mental
organization of this process, called structure, that might reflect severity of
illness or even illness type (Reich, 1945; Jacobson, 1971; Bellak et aI., 1973;
Kernberg, 1975). Some have written about the relationship between
symptoms, structure, transference, and dynamics (MacKinnon and Michaels,
1971; Kernberg, 1975). I follow this latter tradition because the structural
road map is so important in diagnosis and treatment of psychotic and near
psychotic conditions. I include, therefore, as part of the mental status
examination, the careful assessment of certain ego functions damaged in
psychosis and near psychosis. This damage leads to the characteristic mental
manifestations of these illnesses and their dynamics.
The mental status examination generates a series of evolving hypotheses.
This is because the data on which the hypotheses are based are continuously
evolving as new information is continuously elicited. The functional
organization of the mind should not be a rigidly fixed property. Therefore,
new information is regularly emerging and questions lead to constantly
deepening factual and emotional information.
The examiner affects the mental status examination by having an impact
on the mental experience of the patient. That the observer affects the results
is both a problem and an opportunity, because it allows the observer,

117
118 Psychosis and Near Psychosis

through the interaction of the examination, to understand more carefully

with the patient the active, present functioning of mental experience. The
mechanisms, contents, organizations, behaviors, and feelings elicited during
the examination can also help emotionally inform historical information. In
addition, there is the opportunity to understand through the observer's own
experience.
The mental status examination interview, therefore, includes information,
observations, hypothetical constructs, verifications, and nonverifications
about the patient and also observations of the examiner's own feelings.
The content of mental life, the organization of mental life, and the
interaction between content and organization are to be carefully described.
The mental status examination is designed to elicit information about
signs and symptoms of illnesses, unconscious thoughts and feelings, and
mental organization. An illnesses is a particular collection of signs and
symptoms that together bespeak a common etiology, a common response to
treatment, and a common prognosis. General psychiatrists call the signs and
symptoms of these illness categories the study of psychopathology.
The psychonanalyst looks to the additional category of unconscious ideas
and feelings. The diagnostic categories and treatment modality of analytic
psychiatry are this unconscious material. Psychoananlysts call this
psychological content psychodynamics.
A third mental category is also crucial to those analytic psychiatrists who
treat very ill patients. This category is the organization of all mental
functioning. It includes the organization that autonomous ego problems
impose on psychological content. Autonomous ego organization should be
relatively stable, relatively autonomous from breakdown due to psychological
conflict, and relatively adaptive to both reality experience and emotional
experience. Especially important is the ability stably and appropriately to
regulate the relationship between the two areas. Autonomous ego
apparatuses and functions are particularly important in very ill patients
because it is these functions that are characteristically damaged in psychotic
and near psychotic illness.
The mental status examination in psychosis and near psychosis involves
the careful examination and exact description of ego functions. This chapter
will focus especially on aspects of ego structure that define psychosis and
near psychosis.
However, the mental status examination involves only one slice in time.
It is a synchronic analysis making diachronic hypotheses. The phenomenon
of relatively stable structure allows this deduction. Illnesses do change
structure, but in characteristic illness-specific ways and at characteristic rates.
Acute illnesses abruptly change mental structure. Chronic illnesses more
gradually and persistently change mental structure. Normal development and
psychotherapy also change mental structure. The understanding of normal
development, of normal mental structure compared to the highly abnormal
4. Mental Status Examination 119

psychotic and near psychotic states, enables us to describe and categorize the
general stabilities of illness structures.
In addition, stable organizational rules and structured content experiences
should normally vary between different levels of awareness. It may be highly
pathological for one level of organization to invade another's level. Both
because some aspects remain out of awareness and because of the nonverbal
qualities of the experience, the patient cannot usually give a clear description
of these contents and relations. The analyst helps to elicit the full story,
some aspects of which are not fully conscious. Then the content and
integrated picture will be transcribable into words and describable to the
patient.

Technique of Mental Status Examination

The mental status examination is an active inquiry with patients about their
mental experience. The experience of reality, the experience of emotions,
conscious and unconscious, and the organizational relationship of this
information over the course of development are described. The examiner's
task is to facilitate the telling, to evaluate the data for diagnosis and
treatment, and in sicker patients, to help integrate experience.
The techniques involve:

1. Observation;
2. Active inquiry (confrontating of the pathology, not of the patient);
3. Beginning interpretation (perhaps better described as hypothetical,
interpretive descriptions).

Observation
Observation alone produces much information. The verbal stream of ideas,
its organization, the emotional theme stated or implied, the affective display,
interpersonal behavior, the sequence and proximity relationship of all of
these to each other, and the doctor's own experience of the patient are all
observable. The physician uses both secondary and primary processes in
collecting, searching for, and organizing hypotheses about observations and
their integration.
The observation required is a special type of observation. It is an active,
empathic, integrative, observational experience. This empathic experience is
in the examiner. It is both logical and emotional. It is an attempt
em pathetically to experience the patient's mental life. Psychotic and near
psychotic patients require special capacities of their empathic interviewers.
120 Psychosis and Near Psychosis

Active Questioning

I prefer the term active questioning to the more standard term confrontation,
because confrontation often implies, especially to the beginner, an aggressive
stance or attitude. There is a proper but complex use of countertransference
aggression and mastery aggression in the interaction with very ill patients,
but it is best to separate the issue of aggression from the technique of the
interview, and I do so by changing the term to active questioning.
The active questioning is of reality experience, emotional experience, and
especially, their relationship to each other.
Active questioning asks for more data, a different kind of data, a
comparison of data, or an elaboration of data. Active questioning calls the
patient's attention to a paradoxical or absent step of logic or emotion.
Active questioning is focused on a particular area of interest to the examiner
who sees that area as crucial to the evolving story. Active questioning often
challenges defenses because dissociations of mental organization may cause
absent data or paradoxical data. More importantly, integrative capacity and
therefore level of illness may be unknown until challenged (see Kernberg,
1977; cf. Stone, 1980).
Knowing what and when to engage and question depends on the evolving
story of facts and emotions, and on the analyst's knowledge of dissociative
processes, secondary processing of day residues, and primary processing of
fantasies. The examiner must also be familiar with illnesses and their
characteristic effects on mental organization, agency experiences and their
likely conflicts, and development with its emotional phases, life task phases,
and resultant important influences on day residues. Clearly, the more the
analyst knows about these areas, the more effective the interview will be.
Timing in the interview is important and is a matter of clinical judgment.
The more practice the examiner has, the better he or she will be able to
conduct the interview rapidly, accurately, and tactfully.

Illterpretive Descriptions

Emotional primary process experiences may be elicited along with or instead

of secondary process. These experiences are both crucial aspects of, and
defenses against, deeper layers of the evolving story. In the very ill, these
defenses may maintain vertical dissociations, block observing ego, and
overwhelm verbal, conceptual capacity. The analytic therapist must therefore
be prepared to interpretively describe these ego problems, their resulting
primary process reactions, their defensive functions, and their effect on
4. Mental Status Examination 121

mental organization as well as latent dynamics. The analyst points out these
reactions, helps the patient describe the mediated feelings verbally, and
describes the relationship to the patient's full story of reality-experienced day
residues. The interview may strengthen integrative, secondary process and
enable the release of new factual and emotional information and their
relationship.
As one explores the relationship of reality experience to emotional
experience, the patient may reorganize the relationship via secondary process
and word presentations. As a result, an effective mental status interview
becomes a treatment process. The patient translates thing presentation
experiences with their reality quality into verbal, conceptual reports of
emotional experiences. Interpretive descriptions express in words the
relationship of feelings to reality in a way that describes how the patient is
experiencing the relationship, the role of reality day residues, blocks to a
more complete integration, and some hypotheses about the motivational
conflicts and illness deficits that have produced the resultant patient
experience.

Examination of Ego Functions

I will now describe the mental status examination of those aspects of ego
function crucial to the organization of psychosis and near psychosis.

The ego functions I will discuss are the following:

Boundaries
In-out
Between Object relations
Between levels of awareness
Between primary process and secondary process
Between affects
Between affect and mood
Reality testing
Observing ego
Day residue experiencing capacity and location
Modulating capacity
Integrating capacity
Defenses as they intersect with reality ego
Symbolizing function: thing presentation, thing presentation quality, and
symbolic alterations of reality
122 Psychosis and Near Psychosis

Boundaries

The boundary between outside and inside is easily observed in the mental
status examination. Patients with this difficulty will incorporate their
environment into their self reports. The environment may include the
examiner. For example, an examiner reached down to scratch his leg and the
patient asked, "Why are you scratching my leg?" A more subtle example,
which involves emotion, is the hospitalized patient who cries when another
patient is crying. The patient may not be able to say why he is crying, and
the diagnosis therefore depends on the observation of the external event.

Object Relations

Object relations refers to the patient's unconscious and preconscious

experience of himself or herself in relationship to his or her feelings about
other people in his or her life. The term includes present, past, and future.
The term is used to include the experience of the reality of the other person,
the emotional experience (fantasies) of the other person, the characteristic
phase of development in which those emotional experiences (fantasies) are
first organized, the characteristic organization in specific character types, and
the characteristic distortions of different illnesses (cf. Sandler, 1991).
The main points for the mental status examination of the very ill patient
are (1) whether or not the patient distinguishes between the experience of
the real Object and the emotional experience of the emotional Object;
likewise, whether the patient experiences himself or herself in reality as
distinct from the emotional experience of himself or herself; (2) the
characteristic emotional themes that organize the experience of the patient's
self and others; (3) the characteristic distortions the various illnesses impose
upon the organization and themes of these relationships.
Object relations experiences are often the most difficult to describe. This
is because very ill patients have great distortions in these relationships,
which obfuscate coherent narrative. The Object relations experiences may be
intensely infiltrated with emotion that blurs the causality and plot. The
experience may suffer boundary problems that merge aspects of the entirety.
The content may be extreme, exaggerated, or bizarre. Crucial aspects may be
dissociated vertically and either not reported or reported in a paradoxical or
unintegrated way. The Objects may be fragmented. They may be projected or
denied.
However, the same three mental status examination methods apply.
Carefully observe the reports of the relationship with other people and
feelings about them. Inquire about those aspects that are not clear. Confront
4. Mental Status Examination 123

any lack of coherence, lack of integration, lack of day residue, or

precipitating event reports. Descriptively interpret the distortions and
resistances to questions about those experiences. Listen for associations
revealing preconscious emotional themes and contents.
With these techniques, a fuller object relations story emerges, often
dramatically, and usually in the first interview. The story can then be
categorized according to its dominant thematic content and dynamic
defensive processes. This describes character type. The distortions of
organization due to autonomous ego dysfunction describe levels of illness as
in neurosis, near psychosis, or psychosis.
During the mental status examination, the examiner is experienced by the
patient as an Object. Particularly in the sicker illness states, the reality of the
examination becomes captured by the patient's emotional object world with
its illness condensations. Subtle and not so subtle signals of how the patient
is experiencing the physician are the most crucial and validated data about
object relations. This transference component of the interview can be subtle
in the neurotic, outrageously obvious in the borderline, and rigidly fixed and
concretely encoded in the psychotic. Therefore, the examiner gains important
information about the level of ego functioning. Because the interview
explores intense emotions in the patient's object world, defenses that
mediate that intensity will come into play. This gives one the best
opportunity to observe, describe, and interpret defenses.

Boundaries in Object Relations Experiences

The most common failures in an Object relations boundary are either

between the real object and the Object representation or between the real
self and the self-representation. Real object refers to the inner, mental
experience of the Object in reality. The boundary, therefore, is a higher-level
boundary than the boundary between inside and outside, because the real
Object experience has already been contained as an inside mental one.
The condensation of real object with object representation may be easy
to observe when the content is phantasmagoric. It is more difficult to
observe when the content is either commonplace or involves projected
condensations of motivation or affect. The transference can help enormously
if and when the patient turns these mechanisms onto the examiner.
Fortunately, because of this particular boundary problem in very ill patients,
it is not long in the interview before this phenomenon does occur. Often this
happens instantaneously or even before the patient walks in the door. This
is especially true of near psychotic patients. When this happens, the
examiner can compare what he did with what he is reported as doing, and
what he felt with what the patient believes he felt. Because the examiner is
the day residue, the translation of the patient's symbolic alteration of the
124 Psychosis and Near Psychosis

examiner is more readily available to the examiner. This can then be

described to the patient.
The examination is more difficult when real self-experiences are
condensed with emotional self-representations, either consciously and
manifestly, as in psychosis, or preconsciously and latently, as in near
psychosis. The examiner must be aware of the possibility of condensation in
this area and listen for the affect intensities, thing presentation qualities,
primary process logic, and sense of conviction that are a part of such
condensations. Active questioning from a variety of perspectives may be
needed. The more logical, the more affect-muted, and the more appropriate
to reported day residues such condensations are, the harder it is for the
examiner to recognize them.
The boundary between self-representations and Object representations
mediates pure emotional experience condensations, which are not unique to
psychotic and near psychotic states. The phenomenon is usually examined
through derivatives in latent content.
Projective identification is most reliably observed in the transference. If
it is dangerous to allow this, the mechanism can be identified by active
inquiry when the examiner hears an object report filled with emotion that
the patient also feels or demonstrates, especially with thing presentation
quality and primary process organization. Active questioning about the day
residue reality experience and about secondary process causal events and
sequences will highlight the emotional component of the condensation and
reveal the existence of the condensation mechanism and associated status of
relevant observing ego and reality testing capacities.
It is particularly in the area of Object relations that skill, timing, and
experience payoff. The information elicited is extremely enlightening about
ego organization, mental contlict, illness category, personality category,
transference, and countertransference.

Boundaries Between Levels of Awareness

It is extremely important for the analytic psychiatrist to remember different

organizations in different levels of awareness. The organization rules and the
content experiences should vary between levels. This is the normal
organization. It may be highly pathological for one level's organization to
invade another level.
Because aspects of psychosis and near psychosis remain out of awareness
and because of the nonverbal qualities of the psychotic and the near
psychotic experience, the patient cannot give a clear or full description of
these relations and contents (Freud, 1893-95). The therapist must help by
eliciting the full story, some aspects of which are not fully conscious. Then
the content and integrated relations will be describable to the patient and
translatable into words.
4. Mental Status Examination 125

Material of which the patient is fully aware is called conscious material

and is given in the historical anamnesis and report of present signs,
symptoms, and experiences. Preconscious levels of awareness are those levels
that the patient can lead into through introspective attention focusing.
Deeper layers of the preconscious are reached by letting the mind wander
in an uninhibited and speculative way. This can enable a free mental stream
called free association that leads deeper into unconscious fantasies. The
organization rules at this level of mental experience change to the less
logical rules of thinking and feeling called primary process. The easily
available example is dreams.
The deepest layers of awareness are called unconscious and they are
reached through hypothetical constructs. One gathers evidence for these
hypotheses in the conscious and preconscious levels. The verification of
these hypotheses is in the patient's new affective, memory, and fantasy
experiences, in evolution of the fantasy story line, and in transference and
countertransference experiences. Together these verifications enable the
predictions and retrodictions of psychological, behavioral, and historical
material. Some of the most important early verifications of these hypotheses
are found in the ongoing transference and countertransference relationship
of treatment, including the initial interview and mental status examination.
Some very ill patients give a constant stream of associations instead of a
logical story. This stream is called loose associations to distinguish it from
free associations. Loose associations are not free. Their occurrence is
uncontrollable or poorly controllable. Their content is rigid, repetitive, and
often tangential and superficial, rather than evolving. The one advantage to
the examiner is that the emotional theme is usually obvious.
Boundaries between levels of consciousness are damaged in psychotic and
near psychotic patients, allowing contents, affects, qualities of experience,
and organizations of lower levels to flood conscious levels of secondary
process experience. The extent to which this occurs varies but that it occurs
to some extent is universal. Sometimes it is only the quality of lower-level
experience that intrudes into the logic of the higher level, as when a thing
presentation quality is conscious.
When this boundary rupture is subtle, it is confined to the preconscious
or is very limited in extent in the conscious. It is often missed by the
examiner until the problem enters the transference. This can be a shock to
the examiner unprepared for incorporation into a delusion or near delusion.
Mental status clues to this boundary problem are intense affect,
alterations in the quality of the experience of reality, primary process
mechanisms in conscious and manifest patient reports, behavior
inappropriate to the social reality of the doctor-patient relationship, or
perplexity in the patient's observing ego.
Questions must be quick when these episodes are observed, and the
questions must be designed to help the patient elaborate at precisely these
points. Usually this leads to additional, clarifying material.
126 Psychosis and Near Psychosis

Crucial to the examination of different layers is knowing when to use

direct questions, when to use open-ended inquiries and when to remain
silent. Associational material is interrupted and/or derailed by closed-ended
questions. However, an important associational strand may not begin unless
a pointed question is asked, especially if that associational trend is
dissociated and does not spontaneously enter the interview.

Primary Process Thinking

A related boundary is between logical, secondary process thinking and

emotional, primary process thinking. Primary process thinking is more
characteristic of the preconscious than of the conscious, and totally
characteristic of the unconscious. More important than the level of
consciousness at which the processes take place is the ability of the
conscious mind to distinguish and utilize the difference between secondary
process and primary process thinking. Very ill patients have an inability to
distinguish and to differentially use emotional and logical thinking processes.
This can usually be observed in what should be the logical stream of the
patient's historical report. When observed, active questioning about illogical
areas will reveal the underlying primary process condensations. The
examiner's focus on these areas should also encourage unstructured free
exploration. This will enable the examiner to gather logical information and
emotional information, both conscious and preconscious, and to compare
them. It is helpful if the examiner refuses to come to closure without
thorough exploration with the patient. Interpretive descriptions are usually
necessary at various blocked points, but these should be descriptions of
process and not conclusions.
The primary process-secondary process boundary is listed separately from
the conscious-preconscious boundary because the two boundaries are not
congruent. Furthermore, although the primary-secondary process boundary
is always damaged in severe illness, there can be ruptures across the barrier
without loss of the ability to tell the logical from the emotional. Conscious,
primary process fantasy is not an illness state and is common in artistic
states, upon wakening from a dream, or during a daydream. Examiners use
not only their secondary process but also their own conscious capacity for
primary process fantasy to follow the two patient tracks, one logical and one
emotional, and to make hypotheses about their relationship.

Affect-Percept and Concept-Percept

Intense, emotionally charged percepts that are used to confirm and validate
concepts require exploration through active listening and inquiry. Usually
4. Mental Status Examination 127

listening alone will give the examiner some knowledge about whether the
patient can consciously distinguish stimuli in reality from mental percept,
affect, and concept. If not, active inquiry must occur at a tactful point in the
interview. This usually occurs concurrent with the examination of reality
testing.

Affect-Affect

Another important boundary that is sometimes lacking or damaged in very

ill patients is the boundary between affect experiences. Instead of modulated
integration between love and hate, there is either (1) a wide separation or
(2) a mixture without one affecting the other. Another way the affect-affect
boundary may be lost is in (3) affect condensations that demonstrate a
specific primary process relationship between the two.
An example of the first type of boundary loss is a patient with two
intimate relationships with persons of the opposite sex, one an idealized and
loved person and the other a devalued person. An example of the second
type is a certain type of violent physical attack where rage and sexual arousal
are both conscious but do not dilute each other. An example of the third
type is not an angry sexual attack but the perversion form of rape in which
sexual arousal is only possible during a brutal domination scene where sex
is condensed with a specific type of aggression.
Careful observation of the history, questioning of the phenomena, and
active eliciting of the underlying fantasies is necessary to diagnose an
affect-affect boundary defect's particular category and manifestation.
There are two other common manifestations of an affect-affect boundary
loss. One occurs when an affect of a particular type regularly replaces
another affect or all other affects. Some common replacements are the
experience of rage instead of sadness, rage instead of fear, anxiety instead of
sadness, sexual arousal instead of fear, and longing instead of rage. If one of
the emotions is repressed, that is a relatively healthy phenomenon. If the
two are conscious and either dissociated or mixed, that is a relatively sick
phenomenon. In addition, in psychosis and near psychosis, dissociative
elements may be rigid, delusional, displaced to detail, primary processed, and
have thing presentation perceptual qualities.
It is very important to know about the stability of affect boundaries before
engaging in the intense affect experience of psychotherapy.

Realily Testing

Reality testing is one of the most crucial ego functions to examine, because
disturbances in this area define the difference between psychotic, near
128 Psychosis and Near Psychosis

psychotic, and neurotic. It may be the sole criterion if one considers

condensations between reality and fantasy as secondary to the loss of reality
testing. I do not consider this to be the case, because some patients make
such condensations while preserving reality testing. Although this is rare, it
shows that there are two separate boundary disturbances in severe illness.
Even with this view, however, reality testing is one of the most crucial ego
functions in very ill patients.
Performing an adequate mental status examination in this area requires
an understanding of the concepts involved in the various categories of loss
of reality testing, and a knowledge of the actual technique of the
examination. The teChnique involves helping the patient to examine reality
by asking non psychotic aspects of the patient's ego function to engage
psychotic or near psychotic areas of ego function. The examiner does this by
asking the patient questions about reality experience in ways that engage the
patient's capaCity to consider. Nonpsychotic areas of ego functioning may
first be observed in memory. They may also be observed in secondary
process logic in certain aspects of mental content, especially in nonpsychotic
content that contains the same or related affect content as the psychotic or
near psychotic areas. Sometimes it is a non psychotic continuation of the
same plot line. The active questioning then consists of pointing out that the
patient has these paradoxical incongruities. The examination of reality
testing proceeds to see if the patient is able to have an engaged and
considered discussion with himself or herself from the point of view of the
two sides of his or her experience. This tests the capacity to fully engage the
totality of the experience and consider it from the point of view of the
experience of reality as opposed to the experience of the psychotic or near
psychotic condensation.
It is important to realize that one is not testing the validity of the
patient's conclusions about reality, for two reasons. One is that the test is
of the patient's reality testing and not of the content of the reality
experience or of reality itself. These are separate areas. It is possible for only
reality testing to be altered, and it is only reality testing that provides the
definition of illness. The second reason is the practical one that it is usually
impossible to confirm reality, and some people have access to rather strange
and difficult-to-validate aspects of reality.
In any case, the content in reality is irrelevant to the faculty of reality
testing. Someone can reach a conclusion about reality that is merely wrong.
Conversely, someone may be delusional and correct. Reality testing is only
the ability of the mind to compare its conclusions about its experience of
reality with its experience of its perception, and with its experience of
fantasy. Further, it is the ability to change conclusions about reality based
on new information arrived at logically. Reality testing, therefore, should be
a dynamic and active process in areas about which the patient is intensely
concerned. In psychotic patients there is no active reality testing process
going on. There may be an evolution of a delusional system, for instance, but
4. Mental Status Examination 129

there is no corresponding evolution of the process of reality testing. In this

case, reality experience is only used for evidence to build the delusion.
I now turn to the categories of losses of reality testing. Reality testing can
be measured along a gradient. The most severe is a loss of reality testing
that is firm and fixed and without awareness that it is gone. The next most
serious is the loss of reality testing that is firm and fixed with awareness that
it is gone. The next is a suspension of reality testing, without losing the
capacity, but without awareness of the suspension of reality testing. The first
is psychosis. The third is near psychosis. The second most authors categorize
as psychotic. I do not. It is a question of definition.
Reality testing can be lost either globally or focally. It is very rare to have
a global loss of reality testing. Even the most psychotic patient usually has
some areas of response that demonstrate a reality testing ability. More
common is a focal loss. The loss can be in an area of ideas or in an area of
sensation; it may, instead, be in an area of affect or a domain of experience.
If reality testing is lost in the area of ideas, the psychotic phenomenon is
called a delusion. A delusion is an idea about which reality testing is lost.
Rarely, the patient can be aware that this is the case. The near psychotic
phenomenon I call a pseudo-delusion. This is an ideational area where reality
testing seems to be lost, but during the psychiatric interview it can be
demonstrated that reality testing has merely been suspended. An overvalued
ideal is a favorite topic that is full of psychological meaning but that does
not condense with reality experience and for which reality testing is never
even suspended. There is an equivalent hierarchy in the area of perception.
A perceptual event about which reality testing is lost is called a
hallucination. A hallucination has two aspects: the loss of reality testing, and
the perceived mental event itself and its quality. Patients have the experience
of a perceptual event occurring in a hallucination. They can describe the
sensory qualities, whether auditory or visual. If it is a voice, they will be able
to tell you whether it is high or low, male or female, threatening, neutral, or
friendly. Hallucinated patients will be able to tell you about these qualities
of the experience because they are actually experiencing these mental events.
If they have not volunteered the information, they will be able to respond
upon questioning. Near psychotic patients have not had such a conscious
mental event. They talk as if they have, but on close questioning they are
unable to describe the sensory qualities of the pseudo-hallucinatory
experience. That reassures both the examiner and the patient that although
a strong emotional experience has occurred, a hallucinated perception
process is not occurring. A true hallucination that the patient knows is a
hallucination but about which reality testing is not lost may be called
hallucinosis. The usual example is a toxic state in which the patient, usually
due to some externally administered substance, experiences a hallucination,
almost always visual, and realizes that it is a hallucination. An illusion is
merely a misperceived reality stimulus. Reality testing is neither lost nor
130 Psychosis and Near Psychosis

Table 4.1 Alterations of reality experience

Area of sensation

Hallucination
- External stimulus event negative
- Internal sensory event positive
- Reality testing negative
- Emotional experience condensed with and consciously expressed in
perceptual experience

Hallucinosis
- External stimulus event negative
- Internal sensory event positive
- Reality testing positive
- Emotional experience condensed with and consciously expressed in
perceptual experience

Pseudo-hall ucina tion

- External stimulus event negative
- Internal sensory event negative
- Reality testing positive upon confrontation
- Emotional experience condensed with and preconsciously
expressed in reality experience (but not in percept)

Illusion
- External stimulus event positive but misperceived
- Internal sensory event positive
- Reality testing positive
- No condensation in reality experience, consciousness or
preconsciousness

Area of ideas

Delusion
- Idea experienced consciously as real with thing presentation form
and thing presentation quality
- Reality testing negative
- Fantasy condensed with reality experience consciously

Pseudo-del usion
- Idea experienced preconsciously as real with thing presentation
form and thing presentation quality
- Reality testing suspended
4. Mental Status Examination 131

- Fantasy condensed with reality experience preconsciously

Overvalued idea
- Idea is abstract and emotional and not condensed with reality
experience, conscious or preconscious
- Reality testing never suspended
- Fantasy condensations unconscious

suspended (cf. Jaspers, 1923, 1963; Spitzer and Williams, 1987; Sims, 1988;
Skodol, 1989; Asaad, 1990).
Psychotic phenomena are almost always concentrated in an area of idea
or an area of perception. The severity will categorize diagnostically the level
of illness and reveal whether it is psychotic or near psychotic. This can
almost always be done in the first mental status examination.
These are the psychotic and near psychotic phenomena. Without a facility
to engage these phenomena, the therapist is left with poor diagnostic and
dangerous psychotherapeutic abilities.
The examination of reality testing must be active, consistent, and
methodical if these crucial issues are to be clarified. Observation alone can
often be enough. The report of a hallucination with real sensorial qualities
and absent reality testing needs no further elaboration to make the
diagnosis. If aspects of these criteria are absent in the patient's initial report,
they can be inquired about directly. If the entire occurrence is absent in the
report but seems obvious because of shifts in the patient's attention, and
inquiry brings either fearful avoidance or bland denial, a descriptive
interpretation of the response can be made with a question as to the
underlying motivation of the covering response. This will often help the
patient discuss more directly his or her conscious, but either avoided or
dissociated, psychotic experience. The observation of delusional content can
be more difficult, especially if the delusional idea retains secondary process
logic. The rigidity of the idea, the concrete reification in the explication of
the idea, and the affective intensity, often as a penumbra around the idea
which charges the transference, are all clues to the psychotic condensation
that is occurring in reality experience and that is taking thing presentation
form and quality. Upon observing and empathetically experiencing this
phenomenon, the examiner can make focused inquiry so that a more
complete explication of the phenomenon is forthcoming. Should this not be
the case, a descriptive interpretation is often helpful, especially of the affect
that has charged the transference and that guardS and expresses the
delusional idea.
For near psychotic phenomena, pseudO-hallucinations, and pseudo-
delusions, careful inquiries will quickly liberate the manifest content, the
upper layers of latent content, and a return of more secondary process,
integrated, dispassionate reality testing.
132 Psychosis and Near Psychosis

The more experience the examiner has with psychotic and near psychotic
patients, the more quickly will the hints of their characteristic psychotic
condensations be recognized. The benefit of experience enables recognition
of the linguistic propensities for expressing, even indirectly, thing
presentation experiences and qualities. Experience also helps recognize and
clear the countertransference avoidances that deflect the examiner from
clues in the patient's verbal production. There are also clues in the
countertransference experience of the examiner..
I will now give two examples of psychotic and near psychotic spectrum
phenomena.
A common defense in the very ill patient is a compulsion. A compulsion
is a behavioral action that must be carried out. It is usually a required action
in reality experience. Because reality experience is involved, these patients
are usually sicker than neurotic patients. A compulsion, therefore, usually
occurs in the psychotic or near psychotic patient. In psychotic patients, the
action has to be taken to prevent a fear that may be conscious; the patient
believes that the action will forestall the feared dire event. The near
psychotic patient knows that the action is based on magical thinking and is
only magically related to what he or she is afraid of, but must do it anyway.
The few neurotic patients with compulsive-like behavior carry out the
behavior only to ward off anxiety. The content of the fear of failing to do the
action is not conscious. If it is conscious, they do not consciously believe
that the behavior will forestall the fear and know that it is a psychological
mechanism that temporarily relieves anxiety. Such neurotic patients can, if

Table 4.2 Hierarchy of compulsive phenomena

1. Psychotic compulsion: Fear is usually conscious, reality testing always

negative, action is required

2. Near psychotic compulsion: Fear is often conscious, reality testing is

positive but may be suspended, action is required

3. Severe neurotic compulsion: Fear is conscious, preconscious, or

unconscious, but reality testing is always positive; action is required only
for emotional comfort

4. Neurotic compulsion: Fear is unconscious, reality testing is always

positive, and the action is not required for anxiety control but merely
preferred for anxiety control; this phenomenon is higher-level neurotic
and the name changes to a neurotic ritual
4. Mental Status Examination 133

they wish, avoid doing the compulsive behavior, but they experience an
increase in anxiety. Careful questioning and listening are required to clarify
the relationship of the behavior to the necessity for action and to absent or
suspended reality testing.
It may be helpful to think of a compulsion as a stereotyped, repetitive
behavioral delusion or near delusion. The condensation of reality and fantasy
experience is the same as in a delusional or near delusional idea.
Also common in sicker patients are obsessions. An obsession is a
recurrent, stereotyped, repetitive, intrusive thought. The phenomenon varies
from psychotic to neurotic, depending on whether the patient has reality
testing, whether the patient experiences the thought as his or her own,
whether the patient can control the occurrence of the thought, and
whether there is a condensation of fantasy with reality intruding on
conscious or preconscious reality experience.
Obsessions, like compulsions and all other mental phenomena, are on a
continuum of severity from neurotic to psychotic. Careful questioning in the
mental status examination can clarify where on the ego continuum a mental
phenomenon is placed.

Table 4.3 Hierarchy of obsessive phenomena

1. Psychotic: Thought is experienced as ego dystonic, occurrence is not

under conscious control, reality resting is negative, form is rigid with thing
presentation quality, condensation of reality and fantasy occurs in the
patient's conscious reality experience

2. Near psychotic: Thought is experienced as ego dystonic, not under

occurrence control, reality testing is present but suspended, condensation
of reality and fantasy occurs in preconscious reality experience

3. Very ill neurotic: Thought is experienced as ego dystonic, some

occurrence control is possible, reality testing is always positive,
condensation of reality and fantasy is in deeper layers of the preconscious,
and while pressing into reality experience it does not actually invade it

4. Higher-level neurotic: Thought is experienced as painful but is

controllable as to occurrence, reality testing is always positive,
condensations are experienced in the realm of emotional experience

5. Highest-level neurotic: A repetitive thought that is ego syntoniC and

voluntary, although painful, is called a neurotic rumination
134 Psychosis and Near Psychosis

Observing Ego
Observing ego is the capacity to consciously and dispassionately experience
mental functioning. The observing experience should be separate from both
emotional experience and reality experience. Observing ego should be more
allied, however, to secondary process and reality experience. In addition,
some of the sentient experience of the patient should be located in observing
ego experience. For many patients this is not true. Their sentient experience
of themselves is in their behavior or is primarily in their emotional
experience.
The observing ego experience is so important to treatment because the
treatment alliance is best anchored through this mental faculty in the very
ill patient. Reality testing may be absent and self-experience may be
psychotic, so these two potential anchors are not available. Like the other
mental functions, observing ego is examined in three ways.
First, patients with observing ego will often give evidence in their verbal
production by describing an experience of standing back from the reported
phenomenon. Such patients can engage in an impartial discussion with the
examiner.
Second, the examiner can ask directly for a discussion of this nature.
Some patients will then be able to do so. Some patients will not be able to
do so and will respond to the question in their characteristic way.
This brings us to the third method of examination. The characteristic
response to active questioning can then be described back to the patient as
to content and process. Such a description is called a beginning
interpretation or descriptive interpretation and is based on the hypothesis
that the response given is the dynamic resistance to the asked-for function.
The dynamics of these resistances to observing ego often involve the most
basic character defenses of the patient. It may be that only the most basic
and resistant of character defenses could be used to block such an adaptive
mental function as observing ego. Basic character defenses will organize the
sickest of the illness pathology and the worst of the resistances to treatment.
They form a crucial marker in a prognostic evaluation.
In very ill patients, however, observing ego may be blocked not only
because of dynamic characterological defenses but also because of
autonomous inabilities of ego functioning important for this area. Observing
ego involves the ability to dispassionately step back and articulate oneself.
There are many subsidiary ego functions involved. One must have enough
impulse control, affect modulation, anxiety tolerance, and verbalizing ability
to step back from the emotionality of an issue and conceptualize and
articulate in words. Ability to articulate oneself in words is both an inborn
capacity and a trained skill that many patients lack. In addition, it is helpful
if the patient's ego has a generalizing ability and an abstracting ability. This
4. Mental Status Examination 135

will help the patient organize a number of like experiences and discuss the
general principles underlying them. It will help the observing ego understand
thematic relationships between emotion and reality day residue experience,
and this ability can be applied to symptoms. This will help therapist and
patient decipher and untangle condensations of reality experience and
emotional experience that form the core of psychotic and near psychotic
phenomena.
It is also helpful to observing ego function to have boundary functions
intact, such as the ability to separate: one's own emotions, one's experience
of one's own bodily functioning, one's own experience of other peoples'
emotions, and the reality qualities of the inanimate world. Illnesses that
affect ego functions, therefore, put the observing ego under strain. However,
observing ego is not usually attacked directly by psychotic condensation.
Many delusional or hallucinated patients, while lacking reality testing,
maintain the capacity for observing ego. "I know my voices are part of my
illness, but I believe what they say anyway."

Junction Point

Damage to these autonomous ego functions allows feelings to alter reality

experience. Eruptions are therefore one junction between psychopathology
and psychodynamics. This junction point in ego function reveals the
relationship between reality experience and fantasy. It is characteristic of the
illness.
The relationship of reality experience to emotional experience appears in
the condensation, and most clearly at these junction points. Freud used the
term nodal point. 2 He meant the point in psychodynamics (unconscious
emotional experience) where several strands of association seemed to meet
in a single symbol or a part thereof. These nodal points repeat themselves
in various contexts.
By junction point, I mean a nodal point where a symbol joins psychological
themes but at the clearest point of ego dysfunction. Junction points are the
clearest points of disruptive emotional impact on autonomous reality ego
caused by psychotic or near psychotic illness. A junction point is where
illness, autonomous ego disruption, and psychodynamics clearly meet. One
point, in psychosis and near psychosis, is usually at the symbolic alteration
of the day residue.

Day Residues

The first way to examine this function is to listen and observe. Does the
patient describe what happened to him or her, and when it happened, in
136 Psychosis and Near Psychosis

sequence? Note with the patient any absence of a spontaneous or sequential

day residue reality report. When questioned, some patients will then be able
to give some response from their area of reality experience. A second
approach when this fails is to note the emotional response given instead and
to conceptualize the significance of the content, process, and motivation of
that emotional response. This can then be phrased as a tentative descriptive
interpretation for the patient.
One of the most dramatic examples of this is the angry attack upon the
examiner when a question about the missing day residue is asked of many
borderline patients. Pointing out the attack and its relationship to the
question and inquiring about the significance of such a phenomenon is an
example of the analytic examination of defenses against day residue
experience.
The day residues are crucial because they are contact points (nodal points,
switch pOints, or junction points) between reality and fantasy that can help
decipher the emotional and reality logic of symptoms. Often these day
residues form an evolving reality story that the patient's family knows and
can report, if asked. They may even be aware of the emotional significance
these events have for the patient. It is then much easier to understand the
symbolic alterations of psychotic condensations. Normal development in the
mental life cycle also provides clues about which reality events may be day
residues. Some patients know the day residue precipitating events but cannot
relate them to their symptoms. In this case, a parallel history is taken of
each track, one for the day residue precipitating event story and the other
for the story of the evolving symptoms. This is the characteristic history
needed for neurotic psychosomatic patients.
Without the day residue as a guide, symptom occurrence, subtle layers of
emotional experience, sequencing of emotional layers, and dominance of one
side of the conflict theme are all in doubt, ambiguous in direction, or prone
to infinite regression.
Careful questioning about the capacity for conscious observed day residue
experience is a key to deciphering the symbolic alteration of the reality.
Knowing what aspects of reality were changed will give you a better chance
to figure out the emotional reasons the change expresses.

Modulating Capacity

The ability of the ego to modulate its emotional responses (see Krystal,
1975) can be easily observed during the verbal stream of the patient's report.
There are patients who cannot contain the strength of the emotion evoked
by their own telling of their story. These patients become extremely agitated
as they speak. Patients at the other extreme of the spectrum cannot express
emotion, despite the most emotionally evocative stories. This can likewise
be observed by the examiner. Being able to appropriately express yet contain
4. Mental Status Examination 137

emotion as one moves from content area to content area and from reality
experience to emotional experience is a hallmark of a healthy ego.
Although observation is the most important examining instrument for this
faculty, inquiry about what must be painful content areas may be necessary
for a judgment to be made about this capacity.
When observation and inquiry demonstrate some problem in the
modulating capacity, this fact can be told to the patient as a descriptive
interpretation. A discussion will either ensue or not. If it does not, the
response given in place of a dispassionate discussion can sometimes be
described, the motivation postulated, and the effect of this description then
observed. This descriptive interpretation may help an observing ego presence
appear for dispassionate discussion of the lack of modulating capaCity and
may liberate affect that has been isolated or help the ego contain affect that
has erupted.
When this capacity is greatly dysfunctional in the direction of
disinhibition, active and frequent comment may be necessary in order to get
the full details of the story, to help make the patient aware of his or her
deficit in this capacity and therefore to partly control the dysfunction.
Otherwise, uncontained affect explodes the interview and the treatment.
One can observe an affect appear as a patient talks, for instance, as
sadness escalating to tears, then to uncontrollable sobbing. The content of
ideas gets more and more despairing and associated sad ideas and memories
are recruited and reexperienced and the sobbing gets worse. This experience
can last beyond the interview. "Now you've spoiled my whole day!" the
patient may say, and this may be an accurate description of his or her
inability to control the duration as well as the intensity and spread of the
affect.

Integrating Capacity

Integrating capacity of the ego is, along with reality testing, a crucial aspect
of the ego to examine in the very ill patient. Very ill patients do not
integrate one aspect of their mental experience with another. All the
contents of a particular conscious mental experience-ideas, affects,
experience of self, experience of others, and experience of reality-are
separated from other areas of conscious mental experience. It is the sharp
demarcation in conscious experience (or preconscious experience) that is
characteristic of sicker states.
The hallmark in the mental status examination is to elicit two areas of
conscious mental functioning that are paradoxically opposed in content but
maintained without realization, logical or emotional, that the two states are
mutually incompatible. If there is realization of incompatibility, the
realization does not result in an intellectual or emotional integrative
resolution. These paradoxical areas, when they are observed, can be pointed
138 Psychosis and Near Psychosis

out to the patient. The patient is either able or unable to see that they are
paradoxical. The patient responds either with distress or with a mental
mechanism that mediates and protects him from that distress. 3 Thus the
mental status procedures of observation, active inquiry, and beginning
descriptive interpretation hold for lack of integrations just as they hold for
other mental phenomena that emerge.
Vertical dissociations are maintained by autonomous integrative deficits
of ego functions, ego defense mechanisms, or both. Ego deficits are often
revealed by perplexity and failure to understand a confrontation by the
examiner. Defensive structures that maintain vertical dissociations may be
revealed by intense affective responses to the examiner's confrontation or by
primary process responses. Thus, each of the major contributors to lack of
integration may be recognized in the mental status examination.
It is crucial to examine the ego's secondary process, integration-building
conceptualization capacity and the abilities to abstract, generalize and apply
concepts. These capacities are listened for and observed in the spontaneous
flow of the patient's story. These capacities are challenged when the
interviewer asks a question about the story that requires a conceptual
response.

Defenses

Defenses are mental mechanisms that change emotional experience so that

painful affect is hidden from the patient's self-experience and altered. In
sicker patients, the experience of reality is also altered to do this. A
defensive maneuver is observed when the examiner, in following the logical
and affective line of the story, notes an affect absence or alteration that is
not in keeping with the evolving inner logic of the narrative. Alterations are
especially obvious when the patient uses these defenses in their reality
experience of the interview with the analyst. Very ill patients commonly do
this.
Because defenses have stability over time, these defenses are repetitive.
They are also limited in number. Actually, the hallmark of a very ill patient
is to have a limited number of rigid defenses. 4 These defensive maneuvers
can then be observed, inquired about, and descriptively interpreted. With
successful intervention, the patient will be able to observe, understand, and
use autonomous ego capacities rather than defensive ego to contain the
affect. These therapeutic interventions thus liberate more appropriate affect
and deeper layers of story which have been repressed or dissociated because
of their affect. In very ill patients, these maneuvers will often liberate
relevant day residue memories. The story then begins to make more
emotional sense to the patient and more reality/logical sense to the
examiner.
4. Mental Status Examination 139

The examination of the defenses is undertaken not just to understand the

type, organization, and level of consciousness at which they operate. It is
also done to understand the rigidity with which they are maintained. Very
early in the physician's relationship with the patient, this crucial parameter
can be observed if the mental status examination is active and interpretive
from the beginning. Usually within the first interview, almost always by the
second interview, and certainly by the third, an accurate estimateofrigidity
can be made. Especially crucial to this examination with very ill patients can
be the second interview when one inquires about the effect on the patient
of the first interview. 5 One hopes for some effect, because it demonstrates
flexibility of defenses as well as the capacity to observe, integrate, and
change (see also Shapiro, 1981).
Rigidity crucially determines the prognosis, because this characteristic will
contribute to the ability to change and the rate of change. Rigid defensive
structures block observing ego, maintain vertical dissociations, and rigidly
maintain repressions. Therefore, progress toward a more integrated state is
blocked. Rigidity of defense therefore is a most serious prognostic sign.
Rigid defenses occur more frequently in certain illnesses than in others and
in certain phases of certain illnesses (see chapter 5).
Rigidity of defense, more than any other ego problem, determines the
prognosis. There are some psychotic and near psychotic patients who are
quite plastic and adaptive to treatment. There are some rigid neurotic
patients who are so rigid that treatment is long, frustrating, and perhaps
futile.
Two common defensive structures in the very ill patient are projective
identification and denial of fact.
Projective identification is that form of projection in which the real Object
experience or real self-experience is captured (see chapter 3). It can quickly
make its appearance in the mental status examination interview when the
patient experiences as real a fantasy he or she has about the physician. This
can be observed when a patient makes a statement to the examiner about
the examiner's conscious behavior or emotion that is totally out of keeping
in content or degree with the conscious experience the examiner has of
himself. The process of the projection, the content of the projection, and the
precipitating event for the projection in the examiner's unconscious
behavior, in the trigger point of the patient's narrative, or both, must all be
carefully explored and described with the patient. The hypothesis that this
projection occurs in all Object relations that touch upon the trigger point
which has been elicited in the mental status interview is usually confirmed.
Many examiners try to avoid these projections in psychotic and near
psychotic patients because of their own fear. They fear the patient may act
on the basis of the projections. It is important to realize that avoiding these
projections can only be done with sophistication. Since the exact conscious
content of the trigger may not be known, and the exact latent content of the
projection cannot be known early on, avoiding is difficult to do and requires
140 Psychosis and Near Psychosis

experience and intuition. In any case, avoiding does not mean that the
doctor should avoid recognizing the projection process. Avoiding means
avoiding being a target. It is important that the physician realize that a
projection process is going on in order to decide whether to try to avoid or
to engage and confront the projection. The danger of avoiding is that the
patient may be proceeding silently in his or her mental experience along the
projective line. Not talking about the projection may not change this. It may
merely allow it to continue and to build in intensity, out of control of the
therapist. Therefore, if one chooses to avoid the projection one must be
certain that one is actually avoiding it. A clear statement of how the
examiner experiences the reality may be necessary.
The next characteristic defense, almost definitional for very ill states, is
the denial of factual reality (see Freud, 1925). It is crucially important to
remember that this is the denial of the patient's own experience of factual
reality. The most dramatic and obvious examples of this occur in very ill
medical patients whose mental functioning does not allow them to process
the terror involved in their physical illness experience. This is commonly
seen in such physically ill patients as a person with a sudden heart attack
admitted to an intensive care unit. Such patients may blandly say that there
is nothing wrong with them in spite of the obvious evidence available to
them from their observation of their body, their physical experience of their
body, or their observations of the reaction of the medical personnel around
them. Mentally ill patients may also deny their own mental illness. The
physician may best observe this phenomenon when the patient reports an
event in which the interviewer was a participant. Observation, active inquiry,
and interpretive description can all be used at this point.
Because such denial involves the experience of a reality fact, much as very
young children at times do, it is called primitive denial. Primitive in this case
usually means developmentally early and usually means maladaptive. I feel
it is primitive because reality experience is affected. Sometimes it is called
simple denial because the manifest content involves only denial without
symbolic alteration.
Simple denial of fact mayor may not be psychotic. It depends on whether
reality testing is intact or merely suspended. This requires examination by
active questioning on the part of the therapist to see if the patient can
question the denial. Usually such denial is not psychotic. The function of
denial is to try to rid the mind of a reality day residue experience because
the day residue triggers catastrophe affect and fantasy.

Thing Presentation

Because thing presentation experience dominates the very ill patient's mental
life, observation and inquiry about this are important in the mental status
examination. Thing presentation experience focuses on the detail of concrete
4. Mental Status Examination 141

things rather than feelings. Emotional causality is experienced as a property

of the reality of details of things rather than of events and feelings. Thing
presentation takes the form of perceived reality rather than of abstract
thoughts. Thing presentation form has its own rigidities, as do reality
attributes of physical Objects.
This is easy to observe in the mental status examination by the attention,
concentration, and obvious emotional involvement in concrete details that
the patient reports. It is as if the interview gets stuck at those points. One
can inquire directly about them when they do occur. A psychotic patient, in
describing women who he believes are in love with him, refers to their "clear
cloth coats." This phrase is repeated over and over with an intensity that
indicates it is crucial.
The most common normal example from everyday life is the sometimes
thing presentation content of sexual arousal. In this phenomenon, details of
the sexual partner's physiognomy are arousal levers. In the description of the
partner, the person will give emphasis to that detail. Depending on the
intensity of the experience, the person will ascribe a greater or lesser
crucial ness to this detail. When asked why that detail is so crucial the person
will respond that it turns him or her on. When the reasons for that are
inquired about, the person usually does not know. This is because the
reasons are unconscious and condensed in the detail.
Thing presentation quality is an experience of perceptual reality quality.
It is at the same time the experience of various affect qualities. The quality
is inherent in the intensity and attitude of the patient. Sometimes an
attempt, usually vague or overelaborated, is made to describe it directly. The
best description is in Freud's Case of Elizabeth von R (1893-95). The
particular condensation of perceptual and affect qualities is hard to describe
in words. A picture does this automatically by encoding the experience in
concrete detail, which then evokes the quality. The analyst, therefore, would
do well to gather the details, try to experience the thing, and then describe
back to the patient the evoked affect quality. Many times, although a patient
cannot translate to word presentations, he or she can recognize the proper
word presentations. This is especially true of near psychosis.
Sometimes, however, the quality is conscious but not the thing
presentation content. If free-floating (unconnected to conscious, logical
content), the quality may be possible to name and then the patient
recognizes this if the analyst is correct. But sometimes the primary process
thing presentation appears in consciousness linked to some inSignificant
logical content. The analyst can then point out the incongruent intensity
factor and begin, in associations, to tease out the condensed thing
presentation quality.
Rarely, the thing presentation quality is attached to significant logical
conscious content, as in certain paranoid patients. The content and the
quality reinforce and validate each other. It is still helpful to try to name the
142 Psychosis and Near Psychosis

affect(s) and then to listen for subtle primary process or dissociations where
one could, with available observing ego, gain entry.

Notes

1. Spitzer and Williams (1987, DSM-III-R p. 402) discuss overvalued idea.

The definition there is more like my definition of pseudo-delusion. The
problems with their definition are:

A. If the DSM-III-R is accepted, then there is no category for a favorite

topic of intense emotional meaning and spreading through personality and
agency function, but with fully maintained reality testing. This is my
definition of an overvalued idea. To merge pseudo-delusion and
overvalued idea as DSM-III-R seems to do blurs the distinction
diagnostically and therapeutically. One is near psychotic and the other is
not. The treatment of the two is quite different.

B. DSM-III-R's overvalued idea (my pseudo-delusion) is not well defined.

DSM-III-R uses content criteria (see chapter 4 for the problem with
content criteria as a definition of delusion and pseudo-delusion) and also
does not accurately describe the reality testing function alteration (see
chapter 3 for a description of the reality testing alterations in pseudo-
delusions).

2. Freud (1900): "Words, since they are the nodal points of numerous ideas,
may be regarded as predestined to ambiguity." Hans Sachs, quoted by
Freud: "The dream work may exploit ... (ambiguity) ... by using the
ambiguity as a switch-point: where one of the meanings of the word is
present in the dream thoughts, the other one can be introduced into the
manifest dream.

3. This aspect of the mental status examination is most clearly described by

Kernberg (1977) but is also inherently present in Freud's [1940 (1938)]
discussion on splitting of the ego and in Reich (1945).

4. This characteristic of very ill patients was first pointed out to me by Dr.
Kernberg.

5. This too, was first pointed out and demonstrated to me by Dr. Kernberg.
5
Psychiatric Illnesses and
Mental Structure

Introduction
This chapter describes the specific effects of certain psychiatric illnesses on
ego function, and on psychotic or near psychotic ego structure. Weinshel
(1990) calls for a more solid structural model of severe mental illness to
support the widening scope of analytic treatment. Jacobson (1967, 1971) and
Kernberg (1975) did so with object relations theory, as did Fairbairn (1952)
and others. Glover (1958), Arlow and Brenner (1964), and Beres (1971)
began this for ego psychology.
Psychiatric illnesses have characteristic effects on the ego. Delusions or
hallucinations vary in organization, content of day residues, symbol
organization, intensity of affect, and relationship to nonpsychotic ego areas.
Different psychiatric illnesses have different Object relations expressed in
their symbolic alterations. Likewise, identification processes vary because the
illnesses alter the ego's reception of the Object in reality into the real Object
experience, the object representation, and the self-representation. In
addition, there are illness-characteristic contents, qualities, and organizations
to self-representation.
The illnesses I will discuss are schizophrenia, which fragments ego
function; manic-depressive illness, which disorganizes ego function; organic
brain syndromes, which destroy some ego functions and disorganize
relationships between others; adult attention deficit disorder, in which
certain aspects of ego function never develop completely; and severe
personality disorders, whose conflict themes condense in psychotic and near
psychotic ego phenomena.

143
144 Psychosis and Near Psychosis

Schizophrenia
Introduction

There is no blood test for schizophrenia, and because the disease processes
are complex and vary in extent, the pathognomonic features are debated
within psychiatry. This makes a psychoanalytic description of such states
more difficult. The most striking aspect of those illnesses that tend to be
labeled schizophrenia is fragmentation of mental function. Various aspects
of this phenomenon have been noted since Bleuler (1950). But questions
have arisen as to whether fragmentation is pathognomonic, where the
fragmentation must occur within mental structure to be pathognomonic, and
therefore what the definition of fragmentation is. Can one reliably identify
and separate a fragmented group of ego function illnesses from the broader
group of disorganized ego functions characteristic of all severe mental
illness? (See Freeman, 1969.)
In my opinion, the observation of the fragmentation of the function of
idea formation, and therefore of objects, agencies, affects, symbols, processes,
and condensations, is the pathognomonic feature of a schizophrenic thinking
disorder (see Bleuler, 1950). The idea fragments along fault lines that do not
obey categories of secondary process, object relations, or affect and their
content condensations. The fragmenting fault line crosses all these
boundaries and therefore fragments primary process. The illness may be mild
or severe, referring to the extent of mental functioning that is disrupted by
these fragments. The other potentially psychotic illnesses affect thinking and
the organization of ideas. But they do so by different mechanisms, so the
manifest psychopathological features of their thinking are different (cf.
Freeman et aI., 1958; Vetter, 1968; Arieti, 1974; Hurt et aI., 1983).
This fragmentation manifests itself in the mental functioning of the
schizophrenic in certain ways. A crucial feature is that affect contents are
disintegrated. Disintegration is different from the dissociation of thinking
from feeling in which intact feeling states and their contents are kept
separate either from each other or from different intact affect content areas.
In schizophrenic disintegration, affect contents are fragmented and the
fragments are separated. The separation therefore doesn't follow any known
mental category. No coherent affective state can be experienced because no
integrated affective state is achieved. There is no intensity with associated
content that can be experienced. As a result, blandness and apathy occur.
The schizophrenic disintegration phenomenon, the characteristic way in
which schizophrenic thinking is disorganized, has its impact on psychotic
signs. The characteristics of schizophrenic delusions are (1) integration is
5. Psychiatric Illnesses and Mental Structure 145

fragmented, causing symbol elements to be "autistic" and "bizarre"; (2) affect

is missing, apathetic, or noncongruent; (3) cognitive dissonance of opposites
is tolerated without anxiety, without recognition, and without explanation if
pointed out. This disintegration phenomenon has the same effect on
hallucinatory experiences, which in schizophrenia are fragmented and
therefore autistically bizarre. They are bizarre because of irregular
fragmentation and also because any meaning and validity adhere only to
fragments. Pieces of all three mental agencies may appear in one mental
experience and one production, within one voice or one piece of the
delusional system. These structural aspects of delusions and hallucinations
are often helpful in diagnosis.
Although it is said in general psychiatry that organic hallucinations are
visual or somatic and schizophrenic hallucinations are auditory, in fact,
schizophrenic hallucinations can be somatic and depressive hallucinations
are usually auditory. Manic hallucinations can be auditory, and although it
is said that they can be visual, the usual visual phenomena in mania are
visual illusions and pseudO-hallucinations. It is therefore the organization of
hallucinations and delusions that is most helpful in diagnosis.

Boundaries

The major pathognomonic boundary problem in schizophrenia is a result of

a fragmentation fault line crossing all other internal boundaries. Multiple
fragmentations are created, each with an unpredictable boundary, domain,
and location. In the acute phase, the fragmentation boundary is not only
unpredictable in shape and bizarre in the territory it traverses and
dissociates, but also rapidly changing, thus adding to the bizarre experience.

In-Out Boundary
The loss of the in-out boundary is often used by psychoanalysts to define
schizophrenia. A fusion between inside and outside is said to be
pathognomonic. Regression to a symbiotic or autistic phase of infant
development is postulated. However, I have observed this boundary to be
sometimes damaged in acute mania and also in organic brain syndromes. I
have also seen many schizophrenics where this boundary is not severely
damaged. And no one has demonstrated this in normal infants: quite the
con trary (Stern, 1985).
Can one say anything about the in-out boundary in schizophrenia? I
think we can. There is merger of fragments in schizophrenia. Because some
of those fragment mergers involve self-representation, Object representation,
and real object and real self-experiences, it seems as though mergers of these
involve loss of the in-out boundary. Actually these are all internal
experiences, albeit about the outside world.
146 Psychosis and Near Psychosis

Sometimes in schizophrenia, however, the in-out boundary is damaged.!

The object in reality is fragmented, merged, and dominant. Stimuli from
reality fuse with mental life. This fusion tends to be restricted to acute,
unmedicated patients or some very deteriorated, chronic cases (d. Searles,
1964).
But the merger of fragments that does routinely occur is pathognomonic
in schizophrenia. The mergers add to the bizarre shape and quality of the
schizophrenic experience. The mechanism of merger is mixed: sometimes
fusions, sometimes condensations, usually both. This mixed mechanism also
distinguishes schizophrenic illnesses.

Conscious-Preconscious-Unconscious Boundaries
The boundaries between the unconscious, preconscious, and conscious are
crossed by the schizophrenic fault line, resulting in fragments with elements
of all three. Fragments involve both contents and processes characteristic of
the three levels. The psychological content revealed by the schizophrenic
fragmentation process is difficult for either therapist or patient to use,
because even the primary process is fragmented. The fragments may have
layered, partial affect conflict experiences within them, but they are difficult
to assemble. Furthermore, the apathetic affect milieu together with the
cognitive disruption of the patient may not permit elaborated or useable
experience.

Primary Process-Secondary Process-Tertiary Process Boundaries

Secondary process is severely attacked by schizophrenic fragmentation.
Logical capacities in conscious, cognitive functions are severely impaired.
Secondary process becomes infiltrated with fragmented primary process. It
may be as easy to observe a piece of rigid, frozen, hypersecondary process
logic in the SChizophrenic patient as it is to observe a disrupted, affectless
piece of primary process. The boundary between processes is unpredictable
because the illness follows no stable boundary line in its disintegrative
process.
Tertiary processes, integrative mixtures of primary and secondary process,
(Arieti, 1976) paradoxically may seem more intact than either the primary
or secondary process, and many schizophrenic patients may seem "creative."
But these seemingly tertiary constructs are the result of fragmented primary
and secondary process mergers rather than of imaginative integration. They
are, hence, irregular, nonrepetitive, unelaborated, and sparse in derivatives.
They are reified and concrete. The observer may admire them but the
schizophrenic patient usually cannot use them and their own experience of
them may be bizarre, real, and frightening. Nonetheless, artistic
schizophrenics may experience an esthetic from their creative productions
even if that esthetic experience is bizarre and frightening.
5. Psychiatric Illnesses and Mental Structure 147

Affect Boundaries
Because affect is also fragmented, the fusions of affect that occur in
schizophrenia may not summate to the intensities seen in manic patients or
organic brain syndrome patients. Although sometimes a schizophrenic
patient can erupt with enormous force ("catatonic excitement," "paranoid
schizophrenic rage"), the usual, rare schizophrenic eruption is not coherent
unless transiently directed against a tormentor in reality or against a
delusionally perceived external tormentor, as in chronic paranoid
schizophrenia.

Reality Testing

Reality testing in schizophrenia is severely impaired. If patients are

psychotic, reality testing contents and processes are part of psychotic
condensations. Because in schizophrenia the psychotic condensations are
fragmented, there can be little secondary revision or rational organization
of them. In addition, nonpsychotic ego areas may also be fragmented, so that
little secondary accessory ego function may exist to help the patient with
reality testing. Fragments that have fixed, delusional loss of reality testing
exist alongside of nondelusional fragments. The pattern is changing in acute
illness and rigidly fIXed in the chronic form of the illness, but in both cases
the resultant pattern makes neither primary, secondary, nor tertiary process
sense. Therefore, cognition makes no sense to any intact reality testing
processes.

Observing Ego
Because most accessory ego functions may be badly damaged in
schizophrenia, observing ego tends to be limited at best. Nonetheless, there
may be observing ego of at least some aspects of routine social interaction.
Because this may include the doctor-patient relationship, the little
observing ego there is may be crucial. The despair of some schizophrenic
patients may come from their partially intact observing ego which
experiences the horror of their illness.

Integrating Capacity
Schizophrenic integration is described in the introductory section on
fragmentation (p. 144), the section on primary-secondary process boundary
148 Psychosis and Near Psychosis

disruption (p. 146), and the section on conscious-unconscious boundary

problems (p.146). Emotional experience and reality experience are
condensed, fused, and fragmented. Individual fragments may be further fused
together, condensed or dissociated. There is no predictable integration
pattern except the fragmentation. Normal primary process, secondary
process, and tertiary process integration patterns shift to schizophrenic
fragmentation and fusion. This is the schizophrenic integration pattern.

Relationship of Reality Experience to Emotional Experience

Schizophrenia has profound effects on the relationship of emotional

experience to reality experience. Because the relationship is characterized by
fragments and fusions, because the fragmentation-fusion line crosses reality
experience-emotional experience boundaries, because primary process
emotional experience itself is fragmented, and because secondary process
reality experience is severely affected, the relationship between reality
experience and emotional experience areas is chaotic. This is especially so
in acute schizophrenic illnesses because of the rapid changes in
fragmentation patterns. Zones are thrown into chaotic disruption, including
the transitional zone, so there is usually little or no intermediate creative
play area left, although some patients can maintain a sense of humor even
if bizarre and concretely experienced.

Day Residue

Because secondary process and reality experience are fragmented, the day
residue is also. This distinguishes schizophrenia from other psychotic and
near psychotic illnesses. Even a simple life history may only be obtained by
talking to relatives. Some acute schizophrenic patients can at least recognize
their integrative life experience if told to them. The lack of intact day
residue makes psychoanalysis of symbols even more difficult. Observation of
here and now day residue events can be helpful. A characteristic and classic
day residue event which may precipitate an acute episode occurs when an
Object in reality who is an ego integrator and support for the patient leaves
for vacation.

Thing Presentations and Qualities

Of course thing presentations arc also fragmented. Even somatosensory

processing has little coherence and may lack reality qualities. No coherent
validity can be achieved even in this realm. It is no wonder that patients
5. Psychiatric Illnesses and Mental Structure 149

appear perplexed. In chronic forms, stable thing presentations can be

achieved but they are conglomerates of fragments and fusions and so lack
effective somatosensory understanding. Because they are not solidly in any
mode or zone and have no coherent syntax, new or accessory information
cannot be productively sought by the patient. The most coherent aspect
achieved tends to be only analog intensities such as "electricity" or "space
rays."
Thing presentation quality, because it is analog intensity, can be
experienced, although not coherently and consistently. But along this mode,
certain presentient self qualities may be experienced by the patient and
related to by the therapist. This is important in working with such patients
(Pao, 1979). Some therapists are intuitively gifted and well experienced in
understanding this mode and in making a kind of elemental but important
contact with patients via this channel. They can do so either verbally through
recognition/description or through constancy of empathic and physical
presence.

Symbols

One can now descriptively understand the severe disruption schizophrenia

causes in symbolizing function, in symbols, and in symbolic alterations.
Symbolic elements as well as symbol construction are severely damaged. The
day residue, primary process, and secondary revision and elaboration are
fragmented; some fragments are fused, others dissociated, still others are
lost. Some large pieces are reified and concrete, while others are totally
disorganized. Hence, symbol experience for the patient and doctor is
perplexing. Symbol use is paralyzed (usually) or abrupt and impulsive
(rarely).

Object Relations

Fragmentation and fusion affects object relations, of course. Because the

fusion aspect may affect the relationship of real object to real self,
psychoanalysts have wondered if conflicts over dependency (need fear
dilemma) or over aggression (Pao, 1979) were etiologic. I feel that because
conscious cognitive functioning is so disordered, because no normal
developmental state is so fragmented, and because there are similarities to
organic brain deterioration (boundary disruption, fusion of affect, stimulus
order confusion), the unknown biological component is paramount, probably
on a neurochemical or microcellular level.
Basic to the schizophrenic object relation is not only condensation but
fragmentation and the lack of boundary between inside and outside. There
150 Psychosis and Near Psychosis

are fusions and then fragmentations of real object, real self, object
representation and self-representation. The mechanisms may involve
condensations, fusions, and then introjection and projection. The intensity
of the real object may result in a fusion with the real self as easily as an
intense affect state in the self-representation can fuse with the real object in
a projection. All object relations contents are usually from all developmental
levels, chaotic and fragmented. Several levels may appear in one
fragmentation (cf. Searles, 1964).

Defenses
Personality defenses are quite disorganized in schizophrenia. Their stability,
consistency, functions, and contents are usually so impaired that no coherent
personality diagnosiS is possible in the middle to advanced stage of
SChizophrenic illness. In milder forms of schizophrenia, or when it is possible
to stabilize the chronic form in an early phase, there may be significant
intact personality defenses with some cohesion. But because of the
schizophrenic fragmentation line, such patients are very vulnerable and need
an integrating, supportive treatment in which varying degrees of uncovering
occur.
Again, the issue of fragmentation as defense is a main psychoanalytic
postulate. Some say it is defense against merger (Kernberg, 1986), some say
against aggreSSion (Arlow and Brenner, 1964; Klein, 1975; Pao, 1979; Bion,
1984), and some say it is oedipal (Brenner, 1976). Although it may seem to
be used sometimes secondarily for defense, I do not believe fragmentation
is caused by psychic conflict or is a phenomenon of defense. Such theorizing
does violence to realities of mind-brain interactions and also to
psychoanalytic ideas and observations of normal development and function.
There is no such normal developmental state for regression (Stern, 1985).
Interpretation of dependency and aggressive conflicts may be helpful, but
postulating etiology from therapeutics is always an illogical and hazardous
proposition. The dynamics could be the result as well as the cause of any
given illness, and we know that accessory ego function can be mobilized by
interpretations to help damaged ego functions even when the illness is
known to be organically based, as in strokes. On special techniques of
psychotherapy and psychoanalysis with schizophrenics see Fromm-Reichman
(1948, 1950, 1959), Redlich (1952), Sullivan (1953), Boyer (1961), Searles
(1964), Arieti (1974), Boyer and Giovacchini (1980), and Stone et al. (1983).
For a review of modern neurobiology as it relates to schizophrenia see
Willick (1991b).
5. Psychiatric Illnesses and Mental Structure 151

Manic-Depressive Illness
Introduction

Manic-depressive illness comes in all combinations and degrees of severities

in the different forms of depressions, manias, or both, and either chronic,
cyclical, or mixed (see Goodwin and Jamison, 1990). The structural effect is
due to the intensification of affect and the resultant ego changes in processes
dealing with affect containment. All ego processes are affected that are
affect-derivative organizations. Psychic boundaries are put under strain,
cognitive processing shifts, defensive organization rigidifies and shifts, and
object relations change in quality and content.
It is important to realize, however, that variation of severity between
individuals and over time in one individual is characteristic of these illnesses.
This makes it difficult to describe the structures, because the spectrum of
intensity and hence the severity of structural changes is analog, i.e., infinitely
varies. Any description of a point on that spectrum is therefore meant as a
helpful guide and not as a necessity for the illness, for any given case or
time. On the psychodynamics and special treatment considerations see
Abraham (1911), Lewin (1951), Greenacre (1953), Jacobson (1971), Klein
(1975), Scott (1963), Gabbard (1990), and Frosch (1990).

Boundaries

In-Out Boundary: Introduction

Increased affect intensity spreading into mood, whether in mania or
depression or both, puts boundaries under strain. The boundaries do not
seem to be attacked directly, since they return to their usual functioning as
the intensity of the episode subsides. But this fact does not rule out a direct
but reversible attack.

In-Out Boundary: Mania

The in-out boundary is obviously and severely affected by extreme mania,
so-called stage four mania. External stimuli will flood mental functioning
when the stimulus screening and modulating barrier is lost. On a hospital
unit, nurses' conversations or even hallway noise will intrude on a patient's
verbal stream and be repeated by the patient (echolalia). Affect from other
people will easily evoke patient affect. Affect in the patient will seem to the
patient to be in others as well. The patient will behaviorally respond as if
this were true. These fusion experiences may take hallucinatory thing
presentation form. There may be loss of reality testing. The more thing
152 Psychosis and Near Psychosis

presentations are based on fusions, the more fleeting will their content be.
But there are extreme manic patients who can stabilize a condensation of
primary process, emotional experience content with inner reality experience,
as a hallucination that is not only quite stable for an episode but may be
repetitive with each episode. These condensations are true hallucinations of
psychotic condensations rather than fusions across the in-out boundary. For
example, an episodically manic woman hallucinated a cross in the sky with
each episode and delusionally believed it proved she was engaged to be
married to Jesus. She dressed for her wedding and in some episodes tried to
jump off a bridge to get to the combined baptism/marriage.
Lesser degrees of mania and hypomania put the in-out boundary under
strain without actually breaking it. With stimulus screening and stimulus
modulation/attenuation inadequate to inner intensity, stimulus augmentation
occurs. This is because of failure to screen externally intense stimuli, but
also because of affect augmentation, transmodal affect condensation or
fusion of affect with these external stimuli. This increases the perceived
intensity of the external stimulus.
Central to the description of each manic state is the degree to which the
in-out boundary is strained. To what extent are fusions occurring as
opposed to condensations? To what extent are inner condensations then
fusing with external stimuli? The intensity of manic hallucinations and
delusions is increased when a psychotic condensation fuses with a reality
stimulus. This greatly increases validity and veracity, adding to conviction
and therefore making behavioral enactment irresistible. Hence, manic
patients may be dangerous to themselves and others.
In summary, manic hallucinations, when they occur, often involve the
in-out boundary. They are composed, in large part, of external stimuli
fusing with internal affect. Stimulus augmentation, stimulus overinclusion,
origin confusions, and transmodal processing are all aspects of these
internal-external fusions.

In-Out Boundary: Depression

In severe depression, this boundary is much more solid than in mania.
Usually, only affect as an external stimulus enters the self experience and
ego organization. For example, a depressed woman refused to go to sad
movies because when a character cried on the screen, she cried herself. Even
then, the separation of external stimulus and internal evoked response is
usually maintained, even in psychotic forms of depression. The apparent
in-out boundary problem is, therefore, really a form of affect coincidence
and evocation with poor modulation. The difference can be seen in the
condensation of content mechanism rather than fusion.The maintenance of
the in-out boundary in the presence of psychosis is a strong indication of
depression, although not pathognomonic.
In near psychotic depressions, the "affect leak" across boundaries may be
5. Psychiatric Illnesses and Mental Structure 153

despair, degradation, or anger in addition to or instead of sadness. The

predominant affect depends, in part, on the developmental level achieved in
ego integration and defensive structures, hence on the characteristic dynamic
conflicts before the onset of the depression.
Some alterations of perception that may occur in depressive hallucinations
(auditory, somatic) are condensations, originating in affect states and not in
reality stimuli (although the day residue of a somatic hallucination may be
an altered physical state). But these occur in reality experience inside an
intact in-out boundary. Hence they are depressive projections rather than
fusions and evocations by reality stimuli. When hallucinations or delusions
involve the real object, the content is usually about the inner state of the
Object, which is imperceivable. The meaning of reality stimulus qualities of
the object is contaminated by projection mechanisms, but usually not the
stimulus itself.
Depressive hallucinations and delusions do not, as a rule, involve fusions.
If they do, and if the external stimulus barrier is damaged, suspect a physical
brain problem in addition (see section on organic mental syndromes, p. 165).
Depressive psychotic phenomena usually involve only condensations across
the internal emotional experience-reality experience boundary organized in
intense thing presentation experiences, projected to the reality experience
with the preserved ability to experience a separate actual reality. Only affect
may leak into the self-representation from the object in reality, and then its
effect is evocative of the patient's affect rather than becoming the patient's
affect.
In those rare cases where percept is altered (it is usually one's self-
experience as in somatic delusions or hallucinations), the perceptual
alteration is a transmodal processing of the patient's mood and not a fusion
experience from stimuli in reality, except when there is physical illness.
Conscious-Preconscious-U nconscious Boundaries
In mania, intense affect seems to erupt from unconscious pools and primary
process encoding systems. Affect and primary process push into preconscious
and conscious secondary and tertiary process functions. There are the most
striking shifts to primary process formation in what should be conscious
secondary processes. Loose affect associations, puns, condensation of
concepts and affect contents, and intense surreal symbolizations are all
readily apparent. The boundary between unconscious and
preconscious-conscious should normally function as an internal affect
stimulus intensity barrier similar to the in-out barrier for external
perceptual stimuli. In mania, this repression barrier is severely overwhelmed.
The flood of intense affect brings with it primary processes that dominate
preconscious and conscious functioning, sometimes obliterating the higher
levels altogether. The affect eruption is usually along a broad front, affecting
most areas of mental content and distorting or eliminating many ego
functions.
154 Psychosis and Near Psychosis

In depression, the affect is better contained in conscious and preconscious

symbolic structures, particularly in those patients who had reached neurotic
levels of organization. Primary process usually does not infiltrate broadly. It
is confined to a single content theme. Affect is usually also free-floating and
may contaminate the quality of all content areas with depressive mood but
does not result in massive primary processing, unlike in mania. A
psychotically depressed patient may have quite rational secondary process
organization outside the delusional system, while being quite sad.
Borderline patients who become severely depressed may show broad shifts
to primary process functioning together with other evidence of poorly
contained mood eruption such as irritability, impulsive behavior, stimulus
augmentation, and intense projections. Introjection, augmentation, and
projection are particularly intense in response to external criticism or anger.

Primary-Secondary-Tertiary Process Boundaries

Mania causes the most intense and widespread shift from secondary to
primary process. With increasing mood disorders, one can see the
progressive increased capture of cognition by primary process.
Tertiary process is usually also disrupted, but in creative patients with
extensive craft training, tertiary processes may hold together in the
hypomanic phase, resulting in a creative burst of great productivity.
Depression with its less severe primary process capture of cognition, may
preserve secondary and tertiary processes until the depression is so severe
it approaches stupor. Depression in trained artists may charge tertiary
processes with intense affect and thing presentation qualities, resulting in a
most productive creative phase. Esthetic appreciation can increase in
depression because thing presentation qualities are more intense and
transmodal processes are more available.
Although shifts to primary process occur in organic brain syndromes, in
manic-depressive illness the mood-congruent content, the concomitant free-
floating affect, the intensity of symbolism, and the neurovegetative
symptoms, are all clues, as is the course of illness, which begins with
affective symptoms.
Loosening of associations, i.e., jumping from one logical topic to another,
in manic-depressive illness is organized by affect. The loose associations are
affect-congruent associations, unlike organically loose associations. In
manic-depressive illness, affect intensities are no longer boundaried by
ideational content, because the affect is spread past such boundaries into
mood.
Remember that affective illness causes an increased shift to primary
process, because primary process is an affect-processing system linking ideas
in an analog organization by intensity, as well as themes. For this reason,
affect-associated contents are incorporated into mood regardless of category
5. Psychiatric Illnesses and Mental Structure 155

or boundary. The boundary crossings to achieve recruitment depend only on

intensity once the primary process system is activated in consciousness.

Affect Boundaries and Modulation Function

Affect boundaries separate different affects and also separate affect and
mood (affect in all mental areas). (See Jacobson, 1971.)
In mania there are fusions between affects and transmodal transfers of
affect. The normal layering complexity, conscious to preconscious to
unconscious, becomes a homogeneous conscious mass. Laughter and tears
may occur together with rage. A verbal confrontation may produce an
erection, a sexy picture may evoke anger. The lability and intensity may
occur also in organic brain syndrome or in acute-onset schizophrenia, but
the affect fusions and transfers are particularly characteristic of affective
illness, manic phase.
These changes may be seen in borderline patients with depression or in
mixed affect states. In more integrated patients with depression, depressive
affect may color or obliterate other affects but does not fuse with them. The
exception is lustful affect in certain patients who sexualize their depressive
affect.
More striking, of course, in all kinds of manic-depressive illness is the
pathognomonic spread of affect across all mental areas into moods until no
content area is left untouched. All ideas are colored by the same affect. The
ability to prevent transient, situation-specific affect from spreading into an
intensifying mood is lost. Likewise, the ability of the ego to modulate the
intensity of the evoked affect or of the received affect is severely damaged,
so that patients may be exquisitely vulnerable to and hence avoidant of their
affective social attachments. This modulation failure of intensity, duration,
and spread is the hallmark of a mood disorder. The modulation capacity is
the pathognomonic ego function damage that causes the psychopathological
pathognomonic features.
Mood selects, recruits, reinforces, and reintegrates many content areas and
Object relations. Because mood adds tone and quality to content and Object
relations, mood affects judgment and choice. Mood changes the intensity and
hence the relative value of elements. Intensity is part of what judgment and
choice use for decision. For example, a hypomanic man sees a pretty woman
and says "I'm in love" and means it! If he is more intensely manic, he will
think she also is in love with him. He may leave a wife of 20 years for this
instant romance, even if it is unconfirmed by the target.
The relationship of content to mood is bidirectional, with content both
causing and resulting from mood to differing degrees in different patients.
The same is true of the day residue. If one observes evolving, intensifying
depressive episodes, one can see the recruitment of content and of day
residues as the mood spreads and intensifies.
Likewise, mood changes in content make psychoanalysis difficult and are
156 Psychosis and Near Psychosis

one reason for Freud's "stickiness of the libido" idea. The id does give
intensity and force, but it is the ego that controls, regulates, modulates, and
releases-Freud's "taming of the instincts." For example: (1) "Just thinking
about it makes me uncomfortable" (i.e., content evokes affect overload). (2)
In the hypomanic, overstimulation, i.e., intense external stimuli, causes lack
of affect control, so turn down loud music and don't argue.

Reality Testing
Reality testing in affective illness is on a continuum from unimpaired to
severely impaired (Jacobson, 1971). It may alter dramatically during the
course of an illness or may be quite stable. When it varies, it usually seems
to do so according to variations in mood intensity. However, there are some
cases where the loss of reality testing and the delusional content are the
most prominent features of the mood disorder.
Because of the potential for shifts along the severity spectrum,
psychotherapeutic, milieu, and behavioral interventions are often tried and
often are successful in moving reality testing back toward health.
Antipsychotic medication will move psychotic reality testing across the near
psychotic border but no further in both depression and mania.
Antidepressant medication added to neuroleptics will dramatically shift
reality testing for the better in depression, but antidepressants alone in
psychotic depression either do not work well or take too long to work.
Reality testing is the most fluid in mania, with continuous shifts as affect
intensity shifts from moment to moment, unless the patient is in a severe
mania with a fIxed delusional/hallucinatory system. Depression tends to
cluster around a fIxed area of content and to have only diurnal variation in
intensity, and so reality testing is more stably placed along the continuum.
Shifts also can be seen reflecting emotional evocation by external events and
objects that actualize, or are experienced as actualizing, inner depressive
content.

Observing Ego
Observing ego is most likely to be potentially preserved in the mood
disorders, especially in depression. It is one of the helpful signs of a
depressive psychosis that although reality testing is gone, observing ego is
present, spontaneously or with confrontation. This also accounts for some
of the suffering and horror of this illness. The process of self-perusal, the
maintenance of dispassionate observing ego content, and the ability to use
secondary process for weighing of evidence and reaching conclusions about
reality, can all be a remarkably intact, albeit dissociated, area of complex ego
5. Psychiatric Illnesses and Mental Structure 157

function in depression. When observing ego processes are intact but

depressive content has infiltrated, this is an ominous sign and requires quick
and effective intervention. The next step is capture of observing ego
processes and serious suicide risk, because all sentient experience is now
captured by depression and validated even by the observing ego.
In mania, observing ego is most likely to be suspended or captured,
depending on the severity of the mania. This makes mania more dangerous,
as a rule, than depression.

Integrative Capacity

The mood disorders are marked by primary process integrations and

dissociative failures of secondary process integration. There is a failure to
integrate processing of mood with secondary process. At times, in the
creatively talented and trained, tertiary process provides an intact integration
pathway.
Depression preserves the integrity and authenticity of primary process
integration. Mania may give the primary process a fleeting, superficial, and
even disjointed form, especially if the mania is severe.
In both mania and depression, the integration task involves intense, deep,
and widespread affect intensities. Moderate mood disorders, especially in the
developmentally disadvantaged, make intense ambivalence hard to integrate.
In children this is normal. For example: Three-year-old, denied a candy: "I
don't love you anymore!" Three-and-a-half-year-old, same situation: "Daddy,
even when you're angry at me, you still love me; that's silly!" Four-year-old,
same situation: "Daddy, even when I'm angry at you, I still love you!"
The inability to integrate oppositely valenced affect states is particularly
pronounced in mania or in mixed states of simultaneous mania and
depression. Patient example: "If all these feelings are mood-related, then I
don't know who I am!" But of course, if the mood explanation is denied,
then the patient complains of being different from moment to moment, or
from phase to phase.
Splitting of affect is the adult, pathological form of intense infantile
emotional storms or temper tantrums, hence its connection with mood
instability in the adult. In some severely impaired, personality-disordered
adults, splitting can emerge as a defense in conditions of frustration
(infantile) or narcissistic confrontation (narcissistic character disorders).

Relation of Reality Experience to Emotional Experience

Because of the affect intensity and because of the primary processing

predominance with dissociations and captures of the link between
158 Psychosis and Near Psychosis

affect/mood and validity, especially in sentient experience, reality experience

is greatly influenced by emotional experience in manic-depressive illness.
Affect leaks and attachments infiltrate reality experience with emotional
experience meaning. Reality experience may be captured to a greater or
lesser extent. The interplay of these relationships along a spectrum of
intensity accounts for the features of this aspect of the illness. The
relationship is one of primary process and dissociation, but this does not do
justice to the compelling intensity of the resultant condensations, especially
when they reach a certain point of intensity and condense in reality-
experienced thing presentations.

Example:
A manic-depressive, bipolar, 45-year-old man was usually chronically
depressed. He was happy with his wife and three children. He found his wife
supportive, calm, and effective. She shouldered many of the burdens of house
and children, leaving him free to pursue his career. He liked this arrangement.
But when he was manic, he felt she was a boring, unexciting, humdrum slave to
hearth and home with whom he would have nothing of zest or growth. He would
promptly fall in love and have an affair. He would leave his wife and chase after
the other woman, usually an independent career woman who did not want to
settle down. When the episode ended, he would return to his wife, blaming his
loss of interest in the mistress on flaws in her.

This is an example of the capture of reality experience by mood-related

content. It is also an example of the inability to integrate oppositely
valenced object relations contents.

Day Residue

One of the most interesting intersections between reality experience and

emotional experience in the mood disorders is at the day residue.
Manic-depressive illness has a lower stimulus threshold for emotionally
evocative events and also attaches intense affect to reality experience. These
reality experiences become, in turn, even more dramatic evokers and
instigators of affect. The decreased affect-modulating capacity of evoked
affect together with the increased intensity of the evocative stimulus due to
stimulus enhancement of condensed affect is a summating cycle. In addition,
bad things do happen to people, especially to some maniC-depressives who
enact their inner world and thus provoke their outer world to respond.
Sometimes the response is a day residue trigger!
For patients with severe manic-depressive illness with autonomous
cycling, the day residue may be nonexistent or irrelevant. With less
autonomous cycling, the day residue may be significant but not causal,
necessary but not sufficient. With still less autonomous cycling, the day
5. Psychiatric I11nesses and Mental Structure 159

residue may be causal and sufficient as a trigger. Because most

manic-depressives are not at the severest end of the spectrum,
understanding the day residue's power to initiate episodes is helpful for
treatment. The day residue is a day residue because of psychological
meaning. Psychological meaning ties in with defenses and character
structure. If there is a severe character neurosis in addition to the
manic-depressive illness, the neurosis must be treated to defuse the day
residue. A day residue has its power not only because of what really
happened, but also because of the significance it has. Because the day
residue may be quite specific as an initiator, the clearest link can be seen
between psychology and biology where psychology is a trigger for the
biology. Nowhere, therefore, is the necessity for a psychological treatment
as part of the treatment plan more clearly demonstrated in psychotic and
near psychotic illness. The integration between mind and brain and between
psychotherapy and pharmacotherapy is thus demonstrated. One person's
trigger (loss of relationship) is not the same as another's (loss of job). The
reasons for this difference have to do with the different psychological
meanings of reality events for different people. In manic-depressive illness,
the meaning is seen in affect and self-significance condensed with the reality
evoker event. Intermediate layers linking affect to event, deeper layers of
psychogenetics, the full elaborated meaning, need to be explored in an
analytic psychotherapy. This, together with medication, can make recovery
from an episode more rapid, may result in lower doses of necessary
medication, and can probably even serve to prevent episodes. There is no
research yet to prove this, but it is my strong clinical impression and I
believe it will be documented. In any case, even for relief of the acute
episode, if the day residue continues in reality as an irritant stress, half of
depressed patients will not respond to medication (Sarwer-Foner, 1991).

Example:
A 38-year-old woman in a stormy love relationship experiences the abrupt
termination of the relationship when her boyfriend leaves for another woman.
The woman is tearful and sad, and 24 hours later plunges into a suicidal
depression. Consciously she feels that the relationship, although troubled, was her
last chance for marriage. She also feels that being in a committed relationship
proves that she is not bad, envious, domineering, controlling, and man-hating like
her mother, who had divorced her father when she was young. She is not aware
of exactly why a relationship with a difficult and unreliable man was seen by her
as a test of her own worth. She had two previous, less severe depressions also
when a relationship broke up. Her first depression was as a child after her father
left.

In affective illness, the day residue tends to be an integrated, whole object

or self-experience or event. It is relatively undisplaced even in manifest
content from childhood events and deeper Object meanings. Further aspects
of this day residue phenomenon will be discussed in following sections on
160 Psychosis and Near Psychosis

object relations (p. 162) and on symbolic alterations of reality (p. 161). In
any case, although the undisplaced concordance with childhood events is
fairly direct, the emotional significance, reverberations in the self-esteem
system, reluctance to move past some traumas, intensity of the repetition
compulsion, and subtleties of dynamic layers, are all unknown to the patient.
The significance of the day residue and even its occurrence are often
defended against, often with basic character defenses or with simple denial.
The denial is often quite rigid. The defense occurs because the patient fears
that full, conscious recognition will make the mood worse or trigger a severe
episode because a loop will be closed. Conscious recognition will unite
dissociated affect with reality event, proving the patient's worst fears and
making the mood even worse and the day residue even more evocative.
Avoidance of this downward spiral is a life-and-death matter for some
patients and accounts for the rigidity of their defenses against the day
residue and sometimes their avoidance of social situations that may provide
dayresidue triggers. Intensive analytical psychotherapy or psychoanalysis plus
medication can disassemble the triggers without risking a serious mood
episode.

Thing Presentations and Qualities

Thing presentations and their qualities are most intense in affective illness.
This is a hallmark of mood disorders. Symbolic processes are intensely
charged with affect and rich in transmodal processing. Percepts are charged
with affect; affect and percept qualities are condensed. As intensity of mood
increases, thing presentation quality increases. Symbol details become rich
with affect and their perceptual details become rich in perceptual overtones
and intensity, as affect becomes transmodally processed into perceptual
details and self-experience.

Example:
A 30-year-old woman is in a severe retarded depression. She sits in the
hospital examining room mute, motionless, her head on her knees and her hands
hanging down at her sides. Her face is in a grimace.
Therapist: "You look as if you are experiencing something terribly
unpleasant."
Patient: "Shit! I'm covered with shit! Phew! It smells horrible!"

The reality-experienced transmodal perceptual quality of thing

presentations may spread to all areas contaminated by the severe mood.
Thing presentation quality heavily skews judgment and certainty because of
reality-experienced thing presentation veracity and validity.
As intensity of affect-percept transmodal processing increases, the rigidity
of the structure increases in an attempt to provide a perceptual thing
5. Psychiatric Illnesses and Mental Structure 161

presentation containment barrier to the spread of affect. This causes a rigid,

unchanging, unyielding symbol, unavailable to word presentations and to
generalization of concept. Either might spread the affect beyond the
boundaries of the thing presentation. Often, however, even the rigid thing
presentation cannot contain the affect. The increasing intensity of the affect
then "drips over" the symbol experience into free-floating affect of the same
valence, tone, and quality as in the symbol. The failure to bind affect, even
in the primary process and even in perceptual thing presentation experience,
leaves the ego at the mercy of the mood flooding. This is experienced as
traumatic, and indeed, there is a strong resemblance to traumatic states and
to traumatic symbolic processes. Like traumatic neuroses, therefore, manifest
content in manic-depressive illness must be attended to because of
the manifest affect charge and resulting thing presentation qualities,
validities, and veracities. The affect intensity causes condensing of latent
content into manifest content. This is another reason for attending to the
top layers of manifest content where the leading edge of this condensation
is. One symptom of subtle affective illness is tightly condensed, rigid,
manifest content material, highly charged with affect.
In manic-depressive illness, even memory may be highly charged with
affect that does not fade and hence may exert a continuous traumatic effect
on later ego organizations, experiences, and developmental phases. This is
similar to the memory of highly traumatic episodes. Manic-depressive
dreams may show the same characteristics for the same reasons. Imagination
in the manic-depressive may also be so charged with validity and veracity
thing presentation affect that in memory, the fantasy seems real.
The rigid thing presentations acting as perceptual containment barriers to
affect flooding resist translation along word presentation channels because
generalization of concept may cause further spread of mood and hence
further disruption of secondary process ego functions. "Talking about it only
makes it worse!" Preliminary treatment must be done with medication
containment barriers, with reinforcement of secondary processes and word
presentation pathways and also with defenses. Then with interpretive
decondensing, each layer is less intense and more containable than the
summation of the thing presentation. The patient gradually reintegrates
along secondary process lines of conceptualization, generalization, and
application.

Example of intense affect charging memory, causing a kind of eidetic memory:

"My impressions of people are seared into my memory and they become a
part of my life. It makes me feel they mean more to me than I do to them. I
remember the color of dresses I admired in grade school!"
162 Psychosis and Near Psychosis

Symbols
Manic-depressive symbols show two related characteristic features: the
intensity of affect and the dramatic alteration of reality. Because affect
evokes, organizes, and leaks intra- and intersymbolically, all areas of symbol
formation become colored as mood spreads. Reality experience is always
affected from mild condensations of meaning to actual perceptual changes.
Whether the symbol experience is in word presentations or thing
presentations, conscious or preconscious, reality experience, emotional
experience, or third space experience, affect intensity is the hallmark. All
aspects of symbol structure are intense: affect, perceptual qualities, detail,
content, plot, day residue, and primary processing.
The intensity and easy, fluid capture of reality experience results in
symbolic alterations of reality with dramatic content and rich perceptual
detail. The exceptions are severe, disorganized manic states or moribund
depressive states with monotonal qualities and poverty of content.
Because of the affect intensity, because primary process increases, and
because the ego is not fragmented, intense symbolic alterations of reality
usually involve whole, intense Object relations in the manic-depressive
illnesses. The contents and plots are so compelling that one can lose sight
of their symbolic purposes, structures, and uses.

Object Relations
The Object relations of this spectrum of illnesses are described in pioneering
psychoanalytic works on mania by Lewin (1951), and on depression by
Jacobson (1971). Earlier pioneering work on the Object relations of
depression was done by Rado (1928), Klein (1975) and Freud himself (1917).
For more recent statements abut depression see Stone (1986), Milrod
(1988), and Brenner (1991). All of these focus mostly on psychodynamics of
agency conflict and the content of object relations; Freud, Rado, and
Jacobson also describe their ego structure.
I have only minor disagreements with and additions to their work on
depressions. My emphasis is on (1) structure, not content, (2) content as
broader and more inclusive (spectrum phenomena: formes frustes), and (3)
Object relations as the effect, not the cause or not the only cause, of ego
disruptions.
My differences about structure have to do with the ego, of course. The
most characteristic are the changes in self-representation. In depression,
debased, criticized, failed self-representations emerge in preconscious and
conscious mental life, gradually capturing the real self-experience. This is the
defining structural feature of depressive object relations. The captures of
reality testing and even observing ego are progressive changes as the illness
gets worse.
5. Psychiatric Illnesses and Mental Structure 163

The merger that occurs is a condensation, not a fusion, and it is the major
and most common boundary crossing. When merger of self and object is
mentioned in the psychoanalytic literature, usually self refers to the entire
ego experience of self; object usually refers to a superego interject. Actually,
self-representation and object representation do not fuse or even condense.
There may be similar affect but usually not. When object experience is
contaminated, it is an object representation-real object merger, or more
commonly, a self representation-real self merger. Next most common are
malevolent representations of objects, especially early superego introjects
that are projected onto Object relations and real objects. The depressive self-
representation may be lying in wait in the unconscious but may not be. It
may be under constant or intermittent attack by a superego Object introject,
may be ground down by a reality Object tormentor, or may be absorbing
intense internal aggression that is not cycling through the superego. The
aggression may be dissociated, as in certain mood-unstable "borderline"
states. What is constant along the severity axis of depression is the
depressive affect of the self-representation. This affect may vary from
depressive despair to depressive rage. Hence, we see there are a variety of
Object relations organizations of depressive affect within the general
structure of merger of depressive self-representations.
The content of object relations varies according to the intensity of the
depression, the level of ego function associated with the present affective
episode, and the level of ego function before the episode. The content can
vary from depressive loss of the positive or negative oedipus, to
separation/punishment fantasies of the preoedipus, to even earlier anaclitic
loss and abandonment. The content may be rage. Depression may cast its
pall over all phases of development.
The ego may be affected in all phases of illness or in some phases more
than others, making the content and plot of Object relations in depressive
illness quite variable.
In addition, there are changes in content and plot, depending on intensity
of illness. One can see manifest content, latent content, dream content, and
the content of deeper unconscious layers shift in plot, structure, and
motivation as affective illness intensifies. How could this be otherwise when
primary processing of affect expresses intensities with changes in symbol
formation, both processes and contents? In addition, the content may
express various dominant affects in depression and not just various
intensities. Anxiety may be the predominant affect, with a particular
depressive quality, or depressive irritability.
There are also contentless depressions, the so-called apathetic or
stuporous depressions. In milder form, they may be called alexthymic
depressions.
We now consider the role of Object relations in the etiology of affective
disorders. The neoclassical psychoanalytic view is that depression has to do
164 Psychosis and Near Psychosis

with oral phase ambivalence. The later neoclassical view is that depression
also has to do with emotionally deprived mothering. Brenner (1976) more
recently has insisted on the oedipal aspects. I do not totally disagree with
any of these etiologic statements, but ascribing etiology to psychopathology
is a dangerous circular argument, as is ascribing etiology from assumptions
based on treatment. The psychopathological data on which such assumptions
are based are not consistent but vary along the spectra of severity, intensity,
and ego maturity. When the superego and ego have malevolent introjects,
depression is a distinct possibility. But it is also true that when one is
depressed, introjects get more malevolent! It is also true that then
malevolent reality day residue objects may be taken in as malevolent
introjects. The oral rage at feeling not taken care of can be a reflection
either of inadequate mothering or of an early childhood depression diathesis
for which no mother is good enough. The interplay of nature and nurture,
of cause and effect, of brain and mind is nowhere more clearly demonstrated
in psychiatry than in affective illness. Each patient presents a different
combination of etiologic factors.
In mania, the ideal self condenses with the self-representation, then real
self with the self in reality, depending on severity. The real object and Object
representation may not be affected, although they are usually influenced.
The grandiosity, therefore, is of a different structural organization than in
narcissism as described by Kernberg (1975). The grandiosity may be with
euphoric or irritable paranoid affect. The latter can be quite dangerous. The
content may be from any phase of development and often involves all
phases. Lewin (1951) stressed the oral phase.
Morality may be severely affected or not much at all, depending on level
of ego maturity and superego development before the episode, if the episode
is intermittent.

Example:
A responsible, middle-aged businessman suffers a manic episode, believes he
can fly, and jumps from his second-story office window, breaking his leg. In the
hospital, on a locked psychiatric unit, he wants discharge because he does not feel
he is psychiatrically ill. When the discharge is refused by the admitting doctor, the
patient requests a phone call to his wife. The patient phone is outside the locked
ward door in the hospital corridor. The doctor wonders with the patient why the
patient would return after the phone call if the patient feels he is not
psychiatrically ill. The patient replies, "But you are the doctor and if you say I
must stay then I must. I will be back to argue with you some more!"

Defenses
The hallmark of manic-depressive defenses is their rigidity. This rigidity has
its distinctive causes and effects.
5. Psychiatric Illnesses and Mental Structure 165

Descriptively, the "cause" of rigid defenses is the attempt to contain

intense affect experience and associated object relations. The attempt is to
control the intensity, the shift to primary processing of that intensity, and
the spread across the range of ego functions and contents to all mental
areas, a process we call mood (see Mahler, 1966; Jacobson, 1971).
The rigid defenses can be of any type or level. They usually include
vertical dissociations, in an attempt to limit spread of affect. Abstracting and
generalizing are impaired by these vertical dissociations. When concept
crosses a vertical dissociation, affect may spread. As intensity increases
during the progressive episode, the vertical defenses may hold, resulting in
an eruption of primary processing in one ego domain or content area only.
An example is a somatic delusion with depressive content in a patient with
an apparently minimal mood disorder.
Patients with labile affect, in hypomanic states or with hysterical
characters and agitated depression (infantile borderline patients) seem to be
chaotic r~ther than rigid. They use affect to defend against affect, and affect
storm as a defense against specific and complex affect. Often overlooked is
the stereotypy of response and the fixed relationship of elements: of affect
type, of day residue event triggering, and of object relations organization. In
these ways, such chaotic states are actually quite rigid.
Although the psychoanalytic literature talks about specific levels of
defense, contents of defense, and psychogenetic origins of defense, in fact all
vary from patient to patient. It is the form the defenses take that is
invariant.
The repression barrier, if it can be considered a primary defense, is both
rigid and porous. Areas of repression are quite rigid and unyielding, other
areas crumble, and intense primary process emerges in a mini-affect storm.
Dissociative defenses try to contain this eruption and exaggerate the
difference between the rigid repressed areas and the erupted, flooded ego
areas.
Affective illness also seems chaotic because as intensity increases there is
a shift to more intense primary process organizations and boundary crossings
of defenses. Defenses are said to be "more primitive" and patients are said
to be " really borderline underneath" or "really psychotic at core." What is
phenomenologically occurring is a shift in defenses with affective episodes:
a shift in content, organization, level of consciousness, location, domain, and
processing. The shift may be temporary. This does not mean this shift is the
"core." It may be and it may not be, depending on the patient. There are as
many neurotics with borderline affective storms against oedipal issues as
there are borderline patients with flimsy neurotic defenses.
166 Psychosis and Near Psychosis

Organic Mental Syndromes

Introduction

So-called organic mental syndromes involve some type of brain damage,

anatomic or physiologic, diffuse or focal. The category is therefore also
called organic brain syndromes. The diagnostic category has been under strain
recently because functional biochemical and brain flow changes are being
documented in affective illness, and I believe they will be found in
schizophrenia. Nonetheless, the category remains.
Traditionally, the organic mental syndrome category was composed of
illnesses causing macrocellular disruptions of brain tissue, such as strokes,
bleeds, tumors, and infections. In modern times physiological disruptions
such as electrolyte imbalance have been included. Lishman (1978) is the
most complete resource. In psychoanalytic psychiatry, see Freeman (1969).
Because these illnesses attack the brain, a concerted effort to find the cause
must be rapidly initiated as soon as the diagnosis is made.
Attention deficit disorders (minimal brain damage, dyslexias, learning
disabilities) are among the most common manifestations of organic mental
syndromes, although they are not usually thought of as belonging to this
category.2 The many names reflect the syndromal manifestations of a group
of phenomena that very in severity and overlap with each other (see Tupper,
1987; Rudel et aI., 1988; and Rothstein, et al. 1988). Some of them represent
diffuse brain problems and some of them represent focal brain problems (see
Galaburda et aI., 1985; also Duane and Gray, 1991). They may dramatically
affect manifestations of other psychiatric illnesses when there is comorbidity
(see Shaywitz and Shaywitz, 1991), and they dramatically affect development
and personality functioning (DenckIa, 1991; Duane, 1991). They are
extremely common illnesses.

Boundaries

These illnesses often involve boundary problems, and hence the frequent
confusion with SChizophrenia. Confusion is especially likely when the
boundary damage involves data categories and integrated secondary process
cognition. But the two illnesses are very different. Schizophrenia is
frequently misdiagnosed when a dyslexic with boundary problems also has
an affective illness and becomes psychotic. This misdiagnosis can also occur
in a non psychotic dyslexic with severe disruption of cognition.

In-Out Boundary
The in-out boundary in organic brain syndromes may be damaged severely
5. Psychiatric Illnesses and Mental Structure 167

or mildly. The usual problem is with the stimulus barrier so that external
stimuli flood.

Example:
A six-year-old severely retarded boy is playing in the playground. He walks
under the slide just as another child, sitting high on the slide, pounds with his
feet. The loud rat-a-tat-tat on the metal slide sends the retarded child underneath
tumbling to the ground, his body shaking in rhythm to the sound. He appears
panicked and confused.

Because the stimulus barrier is impaired, the hospital milieu treatment of

these severe illnesses focuses on decreasing intense, complex, external stimuli
and replacing them with clear, regular, predictable, and simple stimuli
routines.
The in-out boundary problem can also involve transmodal thing
presentation projections. Hallucinosis is the classic example.

Example:
"Doc, I'm getting DTs (delirium tremens; acute alcohol withdrawal
syndrome) again."
"How do you know?"
"I'm seeing bugs crawling on the walls again!"

Example:
57 year-old-man in coronary care unit with myocardial infarction being treated
with intravenous lidocaine medication: "Doc! I'm going crazy!"
"What makes you think so?"
"I'm seeing people coming through the walls!"

In-out boundary problems may also exist to varying degrees in the

dysiexias. Their most common form is the stimulus barrier problem. The
stimulus barrier in the attention deficit disorders has as its hallmark an
uneven distribution and paradoxical density. The unevenness varies from
severe to absent, from case to case or over time. Paradoxical density
describes too much porosity with stimulus flooding and fusion, alternating
with too much density with absent response to external stimuli. This switch
sometimes depends on attention, but the deficient stimulus modulation is
also present as a separate problem.
Stimulus discrimination, stimulus blocking, and stimulus flooding and
fusion may be present alone or in combination. Similarly, category fusion,
origin confusion, and/or causal disruptions may result. In mild cases, the
occurrence, reception, and localization of stimuli will depend on attention
cathexes. Depression will therefore exaggerate this problem. In mild cases
disruption is rare. In moderate cases disruption is not rare but is
compensated by intense overattention or by avoidant reaction formations
168 Psychosis and Near Psychosis

(plunging ahead in behavior). In severe cases there is inability to function

in certain cognitive domains.

Example of stimulus origin confusion in a dyslexic:

A 40-year-old obsessional man with dyslexia and attention deficit disorder
reaches into his pocket just as a clock in the room clicks when the second hand
rounds the twelve mark. The patient perceives his pocket as clicking and fears he
is going crazy.

A paradoxical problem with the dyslexic stimulus barrier is the patchy

increase in density. Stimuli that should cross the in-out barrier do not until
and unless their intensities increase. Sometimes it seems to require
saturation intensity before the threshold is reached. In some cases this is due
to inability to shift attention to the incoming stimulus.

Example:
Mother shouting at a child who, unknown to mother, is dyslexic: "Don't you
hear me unless I shout?"
Child: "Mother, why are you always shouting at me?"

The child feels reprimanded and rebuked, not for what he did, which he
does not understand, but for who he is. Some parents or children come
spontaneously to the strategy of using a variety of input channels because
only some are blocked at anyone time or characteristically. Tapping such a
child lightly on the shoulder may be more effective than yelling. Such
children and parents may come to understand that the dyslexic may need
multiple, varied-angle approaches to problems, to solutions and to learning.
Saturation with varied-angle information may be needed (Samberg, 1986).

Percept-Concept-Affect Boundaries
The boundaries between concept, percept, and affect are damaged in organic
brain syndromes (cf. Deutsch, 1954; also Benton, 1985). The transmodal
processing among these three may be global or focal, intense or apathetic.
As the ability to build abstract concepts fails and becomes more concrete,
as affect controls become disinhibited, as the boundaries between percept
occurrences and organizations blur, there are confusions among these three
areas. Primary process may become the dominant organizing principle, and
conscious thing presentation experiences may emerge. This occurs with
varying affect intensity, which distinguishes it from the maniC-depressive
illnesses.
Fusion of two simultaneous stimuli, fusion of associated concept with
simultaneous stimuli, and blurred perceptual boundaries of stimuli all
predispose to transmodal processing of experienced concept in experienced
percept. When primary process intrudes because of emotional conflict,
anxiety, mania, or depression, the transmodal shift from affect to percept,
bypassing concept, starts its organizing capture of reality experience.
5. Psychiatric Illnesses and Mental Structure 169

The dyslexias have their own characteristics. Their hallmark is patchy,

uneven, and varying severity from domain to domain and from time to time.
Concept is particularly affected. Conceptual blurring occurs with category
fusions, category reversals, category repetitions, and perseverations.
Condensation of concepts may seem to occur and be confused with primary
process, which it resembles, but the specific concept junction points and
secondary process overlaps that are the linkage points are not affect
associations or true condensations of affect-content. The verbal behavior of
such patients may resemble loose associations with topiC derailment and
intrusions (see also Resnick and Rapin, 1991). The perseverations and
repetitions may also distinguish this from primary process. Comorbid
affective illnesses (see Shaywitz and Shaywitz, 1991), which are commonly
seen in a psychiatrist's office, are sometimes difficult to diagnose because
they produce mixed cognitive states by accentuating the dyslexic signs, which
are then mixed in with the affect primary processing.
In comorbidity with psychotic depression, dyslexic patients may be
inappropriately concrete and abstract even outside their delusional systems.
The difficulty is in the differential diagnosis with schizophrenia, where there
is early fragmentation of concept. Attention to details of concept use,
pattern recognition based on experience, and neuropsychological testing all
help in differential diagnosis. Because these are very different ego
organizations with different treatments and prognoses, differential diagnosis
is crucial. The treatment for one will not help the other.

Example:
An educated and intelligent woman sees a young psychoanalytic friend
carrying a volume of Freud's collected works. "What is Freud writing these days?"
she says. What she means is, "What book of Freud's are you reading these days?"

This is an example of three reversals of paired categories: writing instead

of reading, present instead of past, and Freud as subject instead of Freud as
object. The result is a concept reversal. It may also be understood as concept
fusion-Freud writing with Freud being read. The use of present for past
tense may actually be a perseveration from the present-reader concept
carried over into the Freud-past-writer concept. This woman on first hearing
seems to have a schizophrenic thinking disorder but on close inspection does
not.
Reversals, fusions, and primary process intrusions can, if limited in extent,
with perseveration of intact secondary process ego in the highly intelligent,
be very creative capacities and can be developed with diSCipline into great
productivity. The creative capacity occurs because of leaps over categorical
boundaries which provide a spontaneous transcategorical processing system.
This system can be most effective if it can be disciplined, corrected, and
remodeled where necessary by secondary process translation, revision, and
application.
170 Psychosis and Near Psychosis

Affect-concept relationships in dyslexia also may be characteristic.

Because secondary abstraction may lack robustness and facility, affect
experience may be linked instead to either the concrete and specific or the
hyperabstract and the metaphor. The language of psychoanalytic
psychotherapy must be at the level of affect veracity.

Conscious-Preconscious-Unconscious Boundaries
Particularly relevant here is the porous repression barrier. Repression is
severely disinhibited in diffuse degenerative brain diseases of the organic
brain syndrome category.
The dyslexias show a patchy repression barrier with eruptions varying in
domain, intensity, and timing. The lack of coordination with intensity helps
distinguish the dyslexic repression eruptions from those of affective illness.
These patients are sometimes seen as sicker than they are. The primary
process eruptions may cause the interviewer to overlook the solid neurotic
defensive structure of most of the ego.

Primary Process-Secondary Process-Tertiary Process Boundaries

The failures of the repression barrier cause an eruption of primary process.
It is most interesting that primary process is so much better preserved than
secondary process in the organic brain syndromes. This may argue again for
a subcortical processor! Primary process may extensively replace secondary
and tertiary process in severe, diffusely degenerative brain disease. Loosening
of association, unrelated to mood and due to failure of repreSSion, is the
mental status exam feature of these illnesses.
The dyslexias may show a patchy, irregular primary process intrusion
pattern, which if not too frightening, can then be organized by secondary
process and used for tertiary processes. New secondary process sequential
material is difficult to learn, but analog, pattern material is easy. Such
patients are sometimes said to be "intuitive."
The hallmark of diffuse brain disease is the decrease in secondary process
capacities. The defect is measured by IQ decrease and especially by a
decreased ability to understand higher-order abstractions. A decreased ability
to assimilate new information, especially concepts, is characteristic. Patients
become more concrete and less facile with analogy. Social milieu processing,
often very complex, may be severely damaged early on.
Dyslexics show a patchy IQ with great variability in performance. Patients
can have an outstanding verbal IQ and be almost acalculic. The reverse may
be true. Social processing and judgment may be superior or severely
damaged. There may be an aphasia.
Memory defect is the hallmark symptom of all the organic brain
syndromes. Retention, integration, storage, or retrieval, especially of new and
complex secondary process information, is damaged. Memory is severely
affected in bilateral, diffuse cortical disease of the temporal lobes.
5. Psychiatric Illnesses and Mental Structure 171

The same may apply in dyslexia, although not in all cases. Usually
secondary process, linear sequential occurrence memory is affected with
relative preservation of process memory. Example: "I can't remember names
but I never forget a story."
Sometimes recognition memory is better preserved than retrieval memory:
"I know it when I see it." But recognition is tied, in part, to context, and so
a dyslexic might remember a person in the usual context but not in a new
context.

Example:
A dyslexic adult said hello to a fellow in the same business office when they
passed in the hall once or twice a week for a year, but chatted with him at the
office Christmas party for half an hour before realizing who he was.

Because process memory is. better than linear sequential occurrence

memory, data storage and retrieval are by complex pattern recognition rather
than the usual pattern recognition via linear data recognition and recall. But,
again, these analog hologram patterns are characteristic of some higher
learning areas, and hypertrophy of this capacity can be quite adaptive and
result in outstanding achievement.
Memory of names, phrases of speech, or categorical data may be damaged
even though there may be intact concept memory. As a result some dyslexics
seem inarticulate and perseverative. This condition is sometimes mistaken
for low 10.
The patchy memory in area and time makes continuity of experience a
problem. Many such patients try to compensate by living in a timeless
present. This can add to the delay in their personality growth and
development. Some patients even have trouble remembering past affect
states, adding to their exaggerated present moment capacity and their
impulse-ridden judgement.

Affect Boundaries and Mood Boundary

Because of repression eruptions and primary processing, affect boundaries
may be more unstable in all the organic brain syndromes, often including the
dyslexias. There is the affect lability of the frontal lobe syndrome, the
contentless affect eruption in pseudo-bulbar palsy, and the primary process
eruptions of the dyslexic. In addition, affective illnesses-mood disorders-are
probably more frequent. With or without a manic- depressive mood disorder,
affect instability is often seen in organic brain syndromes. Modulation is
affected as well as affect-mood boundaries. Ease of evocation of affect is
also lowered, as is the stimulus threshold in general.
In addition, fusions of affect, such as anger-sexual arousal or
depression-sexual arousal, may be seen. Affect regulation problems
predispose to judgment problems because judgment weighs quantity as an
important factor. Affect-eruptive patients from any cause, therefore, may be
172 Psychosis and Near Psychosis

impulsive because of an ego problem, not a superego problem. They know

it is wrong but can't stop themselves.

Reality Testing
Reality testing varies from severely affected in organic brain syndromes with
psychosis to perfectly intact in the mild dyslexias. The spread of illness and
unknown severity mediators are the covariables.
In the dyslexias, reality experience may be altered because of dyslexic
perceptual processing while reality testing is intact. Reality testing may be
hard to actualize, as when a dyslexiC with poor spatial orientation is looking
for something and the reality testing process is functioning. "I know I had
it!" The concept of preservation of matter remains as a part of reality
testing, but nonetheless the darn thing has disappeared.
Considering the problem some children have with social and physical
processing, it is amazing how intact reality testing processing is. This makes
one wonder about localization of autonomous, complex ego functions.
These dyslexic problems of reality experience predispose, I believe, to
psychotic and near psychotic forms of comorbid illnesses such as
maniC-depressive disease. Dyslexics therefore have an increased incidence
of hallucinations, pseudO-hallucinations, delusions, and pseudo-delusions
during their depressive episodes.

Observing Ego
Observing ego also varies. One of the horrors of gradual, chronic senility is
the self-observation of it. Acute, severe, diffuse organic brain syndromes may
be without observing ego, although there is usually some.
Because dyslexics are born so, there may be little observing ego or
recognition of deficit. In addition, because self-esteem is often damaged
secondarily, powerful character defenses, usually narcissistic, often block
observing ego sentience.

Integrative Capacity
The failure to integrate complex, new information is often the earliest sign
of organic brain syndromes. This is because recognition and storage
functions of the brain are impaired. In addition, the integrative functions
may also be directly damaged. This is especially true once higher conceptual
functioning is impaired, because then rapid data sorting, already damaged,
cannot be compensated by generalization. As memory failure sets in, the
5. Psychiatric Illnesses and Mental Structure 173

integration problems increase, because data important to integration

patterns and strategies are missing.
Dyslexics have characteristic integration problems. Linear occurrence
sequencing is interrupted in a variable, somewhat unpredictable way, and the
interruption is often unobserved by the patient. Letter reversals, word
reversals, category reversals, and concept reversals are typical. Together with
perserverations, repetitions, and aphasic blocks, secondary process
integration is disrupted, mildly and intermittently to severely and
continuously, varying from patient to patient, with phase of development,
and with severity of illness. Subjunctive syntactical links may be missing
either because of inattention, trouble with sequencing, or category fusion.
This plays havoc with linear cause-effect and modifier relationships and
hence with secondary process integration.
Difficulty with linear sequencing may be extensive, affecting linear
memory, linear repression barrier, and linear personality development and
life growth. Linear integration may be extensively affected (see also Voeller,
1991). The ego and its secondary processes may not be smoothly integrated
at the cognitive level or at the emotional level.
Difficulty in distributing attention cathexis gives the whole machinery of
cognition a lurching rhythm, sometimes dragging, sometimes leaping. Self-
image and self-presentation are affected.

Example:
Teacher to a dyslexic child, "I don't know whether you are stupid or a genius!"

Also peculiar to the dyslexias is the difficulty in appropriate level of

abstraction. This may be due to concept block, often at the level of second-
order abstractions. "I can go from one to three, but I can't go from one to
two to three." Very intelligent patients compensate by developing the highest
levels of abstraction. However, sequential knowledge and learning remain
difficult, especially of less abstract material. Such people learn best by
pattern recognition and not by sequence of detail. This method is ultimately
functional, because experienced performance is pattern-based. But such
patients seem stupid during the early learning phase.
With so much trouble in secondary integration, it is no wonder there are
shifts to primary processing, which is surprisingly intact. When there can be
a shift to tertiary processing, the rewards are so great that some dyslexics
"move into" this realm lock, stock, and barrel, producing one variety of the
"absent-minded professor" syndrome.
It is crucial that these ego strengths and weaknesses be understood for
effective treatment. (Kafka, 1984; Rothstein et aI., 1988).
174 Psychosis and Near Psychosis

Rea lity Experience-Emotiona I Experience

A crucial integration domain that is affected is the relationship between

reality experience and emotional experience. Because secondary process,
which is dependent on memory and organization of percept, has so many
lapses, reality experience processing is uneven. Primary process, breaking
through an uneven repression barrier, captures reality experience in an
uneven way. Where the capture occurs--<:onscious, preconscious, or third
space-will determine, in part, the level of phenomena, whether psychotic,
near psychotic, or creative. The other aspect of structure is, of course,
whether condensation has occurred in one of these areas. Some mergers in
organic brain syndromes and dyslexias are coincidental overlaps of primary
process symbols with reality perceptual details. There is then a lag while the
sputtering secondary process sorts it out. The accompanying feeling is one
of anxiety. These contents are fleeting because secondary process eventually
sorts out the overlap. When a stable content exists over time, near psychotic
or psychotic condensation processes should be suspected due to a comorbid
affective illness or severe personality disorder.

Day Residue

The day residues for organic brain syndrome overlaps and mergers are
complex reality experience percepts that are only slowly secondary-processed.
When true condensation occurs in a stable psychotic or near psychotic
production, the day residue is similar to that of manic-depressive illness in
type and location. A reality loss is typical in organic brain syndromes. The
loss may be of a thing, a person, a situation, or a recognition of a loss of
brain function. Change of familiar location is a common day residue as is
increasing level of cognitive demand.
We do not know if there is also a tendency to psychotic and near
psychotic processing of upsetting emotional day residues that do not involve
cognitive vulnerabilities. If there is, we do not know if this is a problem of
repression barrier and of cognitive processing of affect or whether there is
a comorbid factor. However, this level of etiological certainty is fortunately
not required for successful treatment.
One pathognomonic aspect of the day residue in the organic brain
syndromes, induding the dyslexias, is the disruption of the sequential
ordering of the day residue event occurrence. Sequencing is disrupted at
both conscious and preconscious levels. At the same time, because context
is a pattern, there may be preservation of context memory of day residue
occurrence. When these day residues involve intense conflicted emotional
areas, there is high likelihood of a shift to primary process organization as
affect rushes in to organize what cannot be organized in a secondary process
5. Psychiatric Illnesses and Mental Structure 175

mode. Because of the failure of secondary process, intense affect cannot be

organized along secondary process lines for the day residue occurrence. It is
disruption of the sequencing of the day residue that also makes the dyslexic
at risk for the misdiagnosis of schizophrenia, in which the therapist mistakes
disordered sequencing for fragmentation.

Example of primary processing of day residue in a patient with organic brain

syndrome:
An elderly patient with multi-infarct dementia, totally dependent on an
attendant for orientation, tasks of daily living, and self-esteem support, is told the
attendant is planning a week's vacation in Europe. The patient does not respond
even to acknowledge receipt of this information. The next day she reports a
frightening dream in which she and the attendant are on a boat going to Europe.
Every detail is anxiety-filled and she experiences confusion.

The dream clearly seems to contain the day residue of the impending
vacation of the attendant. It also seems to contain the wish to be with the
attendant, as well as the already triggered anxiety and premonitory
confusion.
Of interest is this patient's past history. When she was four years old, her
family was abruptly driven out of Europe. She was smuggled across borders
in a trunk and came to this country by boat. The patient had to leave her
own culture and language, and start over with few orienting cues.

Thing Presentation

Thing presentation structure in organic brain syndromes is the same as in

manic-depressive illness except for affect intensity. Thing presentations are
even more likely to involve trans modal processes, especially to somatic
symptoms and to percepts. Boundaries of thing presentation phenomena may
be affected by the boundary problems of the brain disease (e.g., people
coming through the wallS), and thus characteristics of brain disease will
appear in thing presentation organization. This feature helps diagnosis.
Concrete cognitive processes, either globally, as in organic brain
syndromes, or focally, as in the dyslexias, may serve to reinforce and reify the
concrete thing presentation experience. Other non-thing presentation-
affected ego areas cannot process thing presentations into word
presentations. They can only be processed as real, concrete experience.
There may be difficulty going from thing presentations to word presentations
because secondary abstraction, generalization, and application are poorly
functioning. There may be difficulty translating visceral experiences of
metaphor to words, and if these are translated, they may not be able to shift
the affect experience. Dyslexic patients may resist word presentation
translations, therefore, because they experience word presentations as
176 Psychosis and Near Psychosis

reductionistic. Some very bright dyslexics experience affect validation at

either concrete thing presentation level or at hyperabstract levels of concept,
and not at intermediate, second-order abstract word presentation levels.
However, some dyslexics with aphasia and some organic brain syndrome
patients with stroke have the concept vailidity but cannot put it into clear,
verbal categories.
Some of the most rigidly resistant thing presentation experiences, even of
a non psychotic nature are in this broad category of patients. When such
experiences are diagnOSed, dyslexia should be suspected. There is a high
incidence of this illness therefore in anorexia nervosa or in rigid obsessive-
compulsive patients.
Also typical of these thing presentation experiences is their occurrence
across a range of affect intensity due to damage to the in-out boundary and
to the repression boundary.
Another characteristic of these thing presentations is sexualization.
Increased stimulus intensity, affect fusions, boundary fusions between self-
representation and Object representation, transmodal processing to physical
sensation, and ease of evocation by intense stimuli, all predispose to
sexualized thing presentations. The cortical integration of sexuality is a
developmental process that some dyslexias interfere with and some organic
brain syndromes obliterate as part of their cortical degenerative processes.

Symbols and Symbolic Alterations of Reality

The keys to these symbols and their symbolic alterations of reality are (1)
the variable intensities, especially of affect, (2) the particular boundary
problems within the symbol structure, and (3) the uneven variability in levels
of abstraction. These are due to the patchy ego function based on patchy
brain function of the symbolizing and translating processes.
The primary process may be the best preserved and most integrated of
mental processes, but primary process shows the above three characteristics.
In addition, characteristic, but not pathognomonic, is the symbol's
perseverative, "sticky" occurrence quality.

Object Relations

A key to the Object relations of this category is the real self-real Object
confusion. The characteristic boundary confusion is at this point.
Distinguishing this from schizophrenia is the frequent preservation of the
real self, the intact integration and organization of the Object (no
fragmentation), and the synchronicity and appropriateness of associated
affect. In dyslexia this real self-real Object confusion may be minimum to
5. Psychiatric lllnesses and Mental Structure 177

mild and only present in high affect states. The high affect state may be in
the real object. Some of these patients are therefore marvelously intuitive.
The real self-real object boundary problem is a type of in-out problem
that may possibly predispose to the double identifications that occur in
depression. Particularly with a depressed, hypercritical real object, the danger
is an intense, unintegrated double identification triggering an affective
episode.

Example of real object-real self confusion without increased affect intensity:

Patient: "You made a mistake on my bill. You need a new bookkeeper!"
Doctor: "Yeah, myselfl"
Patient: "I warn you, I don't know triage!"

This sequence seems to make sense if the patient is experiencing, and

complaining about being, the doctor as well as himself. "Myself" in the
quotation is an ironic statement by the Object in reality doctor referring to
his own mistaken bookkeeping. That becomes an ironic statement about the
real self humorously experienced by the patient, who claims he "doesn't
know triage," meaning that he is not a physician. It is as if the "myself'
became for the patient a statement both about the real object and about his
own real self. Any intervening steps, if present, were not stated by the
patient.
Problems integrating complex Object relations are also a cardinal feature
of severe dyslexias.

Defenses

Personality development and functioning, like intellectual development and

functioning, are not linear in the dyslexias (Samberg, 1985). Common
defenses mobilized by this group of illnesses are paranoid, obsessive-
compulsive, narcissistic, and masochistic. They especially relate to self-
esteem issues and depend on core character. These defenses can be rigid, can
block observing ego, can protect against recognition of day residue and of
cognitive deficit, can guard against secondary depressions triggered by
insight, and so may make psychoanalysis and psychoanalytic psychotherapy
difficult. Self-esteem, any comorbid affective illness, and defenses against
self-denigration must be analyzed before full day residue recognition of
cognitive deficits can be achieved. But when this point is gained, further
progress in psychoanalyzing core character defenses is rapidly and profoundly
achieved. This is true of mild dyslexics all the way along the spectrum to
severe degenerative brain disease. Psychoanalytic psychotherapy with these
patients can be most rewarding and satisfying to both patient and doctor.
Once the cognitive deficits are recognized and accepted by the patient, the
patient is much better able to allow intact cognitive processing to compen-
178 Psychosis and Near Psychosis

Table 5.1
Summary of autonomous ego characteristics of the dyslexias

Boundaries: porosity
In-out
Repression
Subject and object

Secondary process confusions

Horizontal, linear sequencing interruptions and reversals

Category reversals and gaps
Category fusions
Topic intrusions
TOpic incompletions
Topic perseve.ations
Concept gaps and reversals
Memory gaps for categorical and sequential information

Vertical cognitive hierarchies

Gaps in ordering of abstract concept
Reversals of concept ordering
Resultant, patchy difficulty in translating and integrating word
presentations from thing presentations

Affect modulation
Patchy loss of integrity with decreased impulse control or rigid impulse
control

Table 5.2 Summary of defenses in the dyslexias

Shift to primary process

Shift to thing presentation
Shift to concrete representation
Shift to rigid defenses with gaps in repression
Shift to chaotic defenses

sate. This can result in a most satisfying improvement in cognitive

functioning! On special treatment considerations in this group see Rosen
(1967) and Kafka (1984).
5. Psychiatric Illnesses and Mental Structure 179

Character Disorder
Introduction

Severe character disorders are also common psychiatric illnesses in psychotic

and near psychotic structures. Character disorders have a level of severity,
i.e., neurotic (see Glover, 1926; Reich, 1945), borderline (see Kernberg,
1975), and a type, e.g., narcissistic, paranoid, hysteric (see Kernberg, 1976).
There is frequent comorbidity with manic-depressive illness, schizophrenia,
organic brain syndrome, and early trauma. The exact mix of early trauma
(Hendrick, 1936) or comorbid psychiatric illness varies from case to case
making differential diagnosis crucial. Comorbid psychiatric illnesses intensify
and influence the organization of character and character conflicts.
Therefore, the more severe the character disorder, the more likely it is to be
a comorbid state (see Marcus and Bradley, 1987).
I make no distinction between character and personality; general psychiatry
tends to ignore any subtle academic distinction (see Campbell, 1989).
Character structure involves characteristic reaction propensities of
temperament, characteristic concerns, and characteristic conflicts, organized
in characteristic ways by characteristic attitudes used as defense and as
expression. These emotional attitudes affect many areas of ego functioning.
These emotional attitudes are conscious, preconscious, and unconscious.
Major portions are unconscious. They organize and are organized by Object
relations scenarios that are diagnostic of character type. An inner script thus
exists which imposes itself on the experience of social reality to a greater or
lesser extent. The "sicker" the patient, the more this inner emotional script
imposes itself on reality experience. See Freud (1916) and the recent reviews
of the psychoanalytic concept of character in Liebert (1988) and Baudry
(1984). For general psychiatry see Lion (1974). For a combination of
psychoanalytic and general psychiatry views see Shapiro (1965) and
MacKinnon and Michaels (1971).
In symptom neurosis, there is a symptom organization defended and
expressing unconscious emotional conflict, repressed and dissociated. There
is therefore conflict but no emotional solution. In the normal, there is an
unconscious primary process solution to conflict that is not dissociated in
the repressed unconscious but is a dynamic part of personality, mental life,
change, and growth. In symptom neurosis, there is unconscious dissociation:
still anxiety and avoidance, and the rupture of primary process symptom
formation into focal areas of emotional symptom experience. When this
eruption is into global character attitudes it is definitional of character
disorder (see Alexander and Isaacs, 1963; Compton, 1987). Then there is no
boundary between the symptom and the rest of personality functioning (see
Lampl-de Groot, 1983).
180 Psychosis and Near Psychosis

Boundaries

The main boundary crossing is a conscious and preconscious one. A

boundary between symptom experience and self experience never sOlidly
develops. The more "ill" the patient, the more fluid this interchange. The
result is character conflicts rather than symptom conflicts. If the character
conflicts and constellations are intense or if a comorbid illness is also
present, other boundaries may be affected directly or indirectly, depending
on the comorbid illness.

In-Out Boundary
The in-out boundary is said to be breached in severe character disorders by
behavior. This is not a true in-Gut boundary problem, since the mental
experience of the boundary is intact. It is, rather, a condensation of reality
experience-emotional experience in Object relations that is then enacted
behaviorally into reality across an intact in-Gut mental boundary. It is really
an affect-behavioral ego boundary and not an in-out stimulus boundary.
One key is the direction of the boundary problem, in this case, in to out,
rather than also out to in.

Percept, Concept, Affect Boundaries

Percept, concept, and affect boundaries are affected variably depending on
the severity. Neurotic patients show condensations in the unconscious.
Sometimes the quality is experienced. Near psychotic patients, especially
borderline behavioral types, show many of these affect-percept and
affect-concept condensations through their behavior. This is especially seen
in the phenomenon of action, in which a behavioral attempt is made to
change the day residue in reality to bring the percept of it into better accord
with the representation of it. In addition, the behavior of such patients may
display their own attempts to convey their affect and affect concepts in
behavioral actions influencing other persons' percepts (cf. Frenkel-Bruns-
wik, 1974).

Affect Boundaries and Modulation

Affect boundaries and modulation are often affected because so much of the
ego's dynamic content is involved with emotional conflict. The entire ego
structure, defenses, and autonomous ego may act as a rigid modulator. Ego
functions of affect malleability, flexibility, and adaptive capacity may be
interfered with along with the affect intolerance of conflicts. Obsessive-
compulsive characters, paranoid characters, certain narcissistic characters,
and rigid hysterical characters are obvious examples.
Narcissistic-sociopathic or sociopathic characters may have a form of fluid
structure in which hypermalleability and flexibility along a continuous,
5. Psychiatric Illnesses and Mental Structure 181

analog, ever-changing, ever-adaptive stance of all self-representation creates

a kind of "as ir character. Often hidden beneath is the rigid avoidance of
basic aspects of human functioning and object relations (love, work
responsibility, trust, truthfulness, honest achievement, rage, etc.) that is
characteristic of this character type.
Any comorbid affective illness will exaggerate modulation problems.

Reality Testing

Because of these problems, reality testing is under strain all along the
severity spectrum. This is especially so with near psychosis, where reality
testing is suspended. In the psychoses, it is lost. I do not include brief,
apparent psychotic losses of reality testing lasting a few seconds which are
not rare in all people if under great stress.

Example of apparent loss of reality testing in an otherwise neurotic level

character:
The scene is the cemetery at the burial of the patient's mother.
Patient: "Mother, mother! Don't leave me!"
Action: Tries to jump into the grave.

Observing Ego

Observing ego capacity in character disorders varies, but not according to

severity of illness. Some "healthier" but rigid neurotics have less observing
ego about their character attitudes than some "sicker" midlevel or borderline
patients. Because there is no clear symptom experience line in the ego,
because self-representation and self-esteem are so dependent on the
character attitude defenses, because superego condensations and compromise
formations are part of character defenses/attitudes, and because all these
functions are involved in self-sentience, the observing ego has a hard time.
It may not objectively experience pathological character attitudes and lacks
an experience of validity about this pathology. Much early work in
psychoanalysis or analytic psychotherapy must be done to achieve the goal
of a relatively dispassionate observing ego. Often, life milieu and Objects in
reality provide the confrontation. For techniques of psychoanalysis and
psychoanalytic psychotherapy that focus on and mobilize observing ego see
Fenichel (1941), Reich (1945), Greenson (1967), Masterson (1972), and
Kernberg (1975); for hospital treatment, see Kernberg (1976) and Marcus
(1987).
182 Psychosis and Near Psychosis

Integrating Capacity

Integrating capacity varies greatly from fuIl secondary and tertiary capacities
to major interference by primary process defensive structures along the
neurotic-near psychotic-psychotic continuum. The particular
cognitive-defensive organization of character integration style is beautifully
described by ShapirQ (1965) according to particular character disorders.
These characteristic styles may affect many areas of ego function (see
MacKinnon and Michaels, 1971). The most obvious arena to see this in is
the relationship between reality experience and emotional experience where
characteristic defensive processes of emotional experience impinge on or
capture reality experience. Intense paranoid eruptions, extreme controlling,
compulsive behavior, or hysterical affect storms are all typical examples.
Their capture of social reality experience varies depending on type of stress,
level of ego organization, and presence of comorbidity.

Day Residue
The day residue varies in potency depending on meaning for the patient.
Different character types have different vulnerabilities in this regard. This is
one of the reasons psychoanalysis and psychoanalytic psychotherapy are so
important in character disorder patients. This is true even, and perhaps
especially, with comorbidity. The day residue becomes processed by a
character style and character defense providing stimulus for character
regression and character conflict. Symbolic elaboration may condense with
the day residue experience and then be played out directly in behavior.
When the day residue seems to justify or confirm established character
attitude defenses and/or when they strike at basic fears underlying such
defenses, or when they just shift the balance of compromise formation
contained in character attitudes, the behavioral reaction can be surprisingly
intense. The conflict may trigger an affective episode.

Thing Presentations and Qualities

The resulting intensity may condense into thing presentations and qualities
which are expressed as intensely felt validations of character attitude. The
thing presentation organization and content appears as a validity and
veracity quality of certain attitudes and behaviors. When these concrete thing
presentation qualities become very intense, they override social reality and/or
inner reality testing, condense with reality experience, and become near
psychotic or psychotic defenses. This is structurally why basic character
defenses can be seen in the themes of many near psychotic and psychotic
5. Psychiatric Illnesses and Mental Structure 183

phenomena. The ability to translate to word presentations depends on

autonomous ego assets and abilities involved in word presentation
translation, formulation, and application. It also depends on the strength of
thing presentation experience.

Symbols and Symbolic Alterations of Reality

Symbols, therefore, in character disorders are subtly intertwined in the

character attitudes and are expressed as attitude themes in words or
behaviors. Symbolic dramas are played out, either in behavior or on the
mental stage, as part of the organization of quality and content of object
relations. I call such material character symbols. Sometimes we can see these
coalesce in likes and dislikes of other people. The basic transmodal
processing is from interpersonal reality experience, through affect, attitude
and behavior, back to social reality perception.
Character attitudes are prone to symbolically alter reality, because these
attitudes guide ego strategy of data collection, data organization, and the
experience of meaning and significance. This can set up a response and a re-
response that make the symbolic alteration of reality a self-fulfilling
prophecy. When intense enough, these symbolic alterations of reality
responses can become the day residue triggers for decompensation, especially
with comorbid affective illness.

Object Relations

The overall outlines of these Object relations dramas are thus typical of the
various personality disorders. Their content stereotypy is their cardinal
feature. The level of severity will be determined by the level of abstraction,
the degree of capture of real object and real self and of object in reality and
self in reality, and condensations with other reality experiences. The
relationship of the genetic past object relations to the derivative present
Object relations varies along the severity spectrum. Therefore psychoanalysis
is variously indicated and techniques within psychoanalysis differ. This has
led to much "Sturm und Orang" within the psychoanalytic literature about
the "correct" way to treat these various disorders. When ego function is
taken into account, many of these arguments disappear because analysts are,
in fact, talking about different levels of severity.
184 Psychosis and Near Psychosis

Defenses

Defenses in character disorders are attitude organized Object relations

themes and contents. These character defenses manifest as resistances in
treatment, especially resistances in the transference. Characteristic defenses
are characteristic of the character disorder type. They reveal themselves as
defensive attitudes and especially guard observing ego, conflict with reality
day residues, self-esteem and ego deficits. They mediate many boundaries
and condensations. This is why an ego-exploratory, psychoanalytically based
treatment is so revealing and so helpful with these patients. Because these
basic character defenses are so intermeshed with all ego functioning, they are
critical to patients, and hence they tend to be rigidly unyielding. The sicker
the patient, the more rigid these defenses. The sicker the patient, the more
intense, aggression-filled superego tends to be part of the system, both
defending and defended against (see Coen, 1988).
In comorbid affective illness, defenses intensify and rigidify even further
(see Shapiro, 1981; Marcus and Bradley, 1987), to cause affect rigidity, affect
simplicity, affect reductionism, and affect disjunction, all to avoid deeper
integrated affect states where intensities may trigger a mood cycle.

Notes
1. This in-out boundary accounts for confusion about the Schneiderian first
rank criteria for schizophrenia. Pope and Lapinsky (1978), in describing
stage 4 mania, describe Schneiderian first-rank signs in mania also.

2. That these illnesses belong in the larger category of organic brain

syndromes is shown phenomena logically by neurological soft signs
(Tupper, 1987), by focal hard signs like aphasias, which are common in
some dyslexias, by memory problems, which are also common in dyslexias,
and by spatial and social processing problems, which are also common
(Voeller, 1991). These then have effects on the autonomous ego functions
mediated by these brain functions and, therefore, on treatment (Rothstein,
1988). Geshwind (see Galaburda et a\., 1985) believed he demonstrated
changes in neuronal cytogeography in the childhood dyslexias.
6
Medication and Mental Structure

Introduction
Freud wondered if brain mechanisms were involved in psychotic illness. Now
we have powerful medications that act on the brain to affect the ability of
the mind to interact with reality. It is clear, then, that the brain and its
physiology are important in mental functioning, at least in the area of the
intersection between mind and reality. Psychoanalysis has, in Hartmann's ego
pSYChology, a description of the areas of mental functioning that engage
reality. Medication affects the same areas of mental structure that are
affected by psychotic and near psychotic illnesses. These areas have their
own developmental lines and autonomies from emotional dynamics, and
therefore it is tempting to say descriptively that a known intersection
between neurological functioning, reality, and mental functioning is through
the area of the autonomous ego apparatuses and functionings.
What is now needed is a description of medication effects on the
psychological organization of the mind-how medication effects psychic
structure. Different medications have different speCific effects on ego
functioning, and therefore impact in specific ways on the structure of severe
mental illness. This chapter will describe observations about the exact locus
of different medication effects on different ego functions, and therefore on
psychic structure in the different illness structures of psychosis and near
psychosis. For early work in the area of medication and psychoanalytic
treatment see Sarwer-Foner (1960), and Ostow (1962).

Psychosis and Medication-N euroleptics

Antipsychotic drugs are called neuroleptics and share the common
neurological property of dopaminergic blockade. They are not medications
for any specific illness. They are medications for a specific structural

185
186 Psychosis and Near Psychosis

organization of the ego. They work in psychotic states regardless of etiology.

This is because neuroleptics specifically help ego organization by acting on
certain boundaries. They are extremely helpful in treating hallucinations and
to a significant extent in treating delusions. The neuroleptics may increase
the integrating ability of the ego by decreasing fusion and some
condensation experiences and by increasing reality testing. The medication
does this by increasing structural boundary integrity and stability.
The neuroleptics have their most dramatic effects on the experience of
reality. Because they reinforce the boundary between reality experience and
fantasy experience, neuroleptic medication enables the untangling of fusions
and condensations that have allowed emotional experience and primary
process to capture components of secondary process and conscious
perception. The reality experience-emotional experience boundary has many
components: in-out, primary process-secondary process, affect-percept,
concept-percept, reality testing-reality experience, unconscious-conscious,
and repression-stimulus boundaries. These will affect, and are components
of, the boundary between Object relations. They are also part of the
boundary of the day residue. They are also part of the location boundaries
and use boundary of thing presentations. When boundaries are intact,
symbolic alterations of reality can remain in the conceptual domain with a
separately experienced reality day residue. When these boundaries are
stabilized, the relationship of reality experience to emotional experience
reorganizes away from psychotic condensation experience and assumes more
normal, balanced, secondary process, integrated forms.

In-Out Boundary

Neuroleptics rapidly stabilize the in-out boundary, dramatically decreasing

fusion experiences within hours to days. Perceptual stimuli, their intensities
and qualities, no longer flood emotional experience or logical, conceptual,
secondary process thinking. Percepts can once again be relatively confined
to perceptual experience. In that role, they can once again be used to make
judgments about the external world of people, events, and the body. Feelings
and thoughts can again be about perceptual information rather than fused
with perceptual information.

Concept-Percept

Percept can be used to experience concept. When percept itself is initiated

by concept, the phenomenon is usually psychotic. (When percept is triggered
by reality stimuli but colored, altered, and used to express concept, the
phenomenon is usually near psychotic.) Neuroleptics quickly reinforce the
6. Medication and Mental Structure 187

boundary of the sensorial ego apparatus responsible for experiencing

percepts so that they are no longer triggered by concepts or affects. Sensory
causality once again moves to the experience of external stimuli. Concepts
can be experienced directly as abstract ideas. This means they can more
easily be generalized, modified, and applied. Obviously, this makes
psychoanalytic treatment easier, although it may make psychoanalytic
understanding by the analyst less immediate.

Affect-Percept

The affect-percept mergers in psychosis may be either fusions resulting from

in-out boundary damage or a phenomenon resulting from condensation
occurring inside an intact in-out boundary. The former is dependent on
external stimulus intensity, and the latter is determined by internal affect
intensity and psychological meaning (the affect content). Neuroleptic
medication rapidly reduces affect-percept fusions and more slowly but
definitely reduces affect-percept condensations. The reduction occurs
because neuroleptics repair ego containment barriers of percepts.
Neuroleptics thereby reduce transmodal experience of percept as affect and
affect as percept. The conscious mind can once again experience reactions
to percepts rather than reactions in percepts.

Reality Testing-Reality Experience

The content of reality testing ego experience should be potentially different

from the content of the rest of reality experience. This is due to the normal
boundary that exists between these two domains which draw on different
resources and validities for their contents. In psychosis this boundary fails,
and reality testing contents and processes become merged in the psychotic
condensation. Neuroleptics restore this boundary in days to weeks. The first
aspect to return is the secondary process logic of reality testing. This helps
separate reality testing processes from those processes in the psychotic
condensation. Later, the content itself is restored as separate.
With reality testing once again a relatively separate mental faculty,
psychoanalysis and psychoanalytic psychotherapy can proceed more rapidly
to work through the upsetting concepts and affects formerly merged in the
psychotic condensation.
188 Psychosis and Near Psychosis

Unconscious-Conscious

Neuroleptics reinforce the primary repression and stimulus barrier so that

some aspects of perceptual intensity, evoked affect, and recruited affect
content no longer flood consciousness. Together with the boundary repairs
already described, external stimuli can become internal percepts. Evoked
fantasies can be contained, unconscious in location. A hallucination will
become a fantasy, and then an unconscious fantasy, which may appear clearly
only in a dream or disguised in psychoanalytic free association.
Latent content once again is established as a relatively clear and coherent
layer in the preconscious and conscious. This has further benefit in clearing
conscious mental function for secondary process logic and self-observation.

Boundaries of Object Relations

Because of the previous boundary repairs, the mental experience of people

and their stories becomes more coherent. The boundary between reality-
experienced real Object, real self, and emotionally experienced Object
representation and self-representation can once again function in
consciousness. This helps the inner Object world regain coherence, causality,
and proportion. Real object and real self are no longer perceptually altered
in reality experience, and the emotional life can once again be
psychoanalyzed because the affect-object domain is a separate ego
experience. This enables a more classically useful treatment. Generalization
and application of the emotional principles can be used by the patient for
treatment, because the reality-experience building blocks are now free for
use by these ego functions.

Boundary of the Day Residue

The perceptual boundary of the day residue is strengthened, allowing

discrimination of percept from emotional response. The result is a decrease
in condensation between day residue and symbolic alteration of reality. This
enables a more flexible use of the day residue by both the primary process
and the secondary process. There is also a resulting decrease in vertical
dissociations between the day residue and context-sequence, between the day
residue and concept, between the day residue and evoked affect, and between
the day residue and generalization-application.
6. Medication and Mental Structure 189

Thing Presentation

The stabilizing of boundaries stabilizes thing presentation experience so that

affect and concept no longer transmodally flood into conscious percept and
the resultant experience of real things. Thing presentation experience can
once again be contained in the unconscious. Thing presentation quality
moves, therefore, out of conscious reality experience, further aiding the use
of reality testing. As perceptual verification fades, thing presentation quality
fades and fantasy can revert to an emotional experience.

Patient example:
A 50-year-old man was brought to the hospital emergency room because he
tried to get into the White House. He believed there was a crown waiting for him
there. He was admitted to the hospital and treated with neuroleptics. After
several weeks he was no longer convinced there was a crown waiting for him in
the White House, but he had a wishful fantasy that there was one. After further
treatment with medication and the exploration of the emotional dynamics
contained in the fantasy and crown symbol, the patient was free during most of
his waking hours of this preoccupying fantasy. Periodically, he had a dream that
there was a crown waiting for him in the White House.

Symbolic Alterations of Reality

Neuroleptics thus move symbolic alterations of reality out of conscious

condensation between itself and the day residue, between reality experience
and emotional experience, and between real object-object representation
and real self-self representation. Symbolic alterations of reality in conscious
experience become symbolic alterations in emotional experience, symbolic
alterations of reality in unconscious experience, and/or symbolic alterations
of reality in conscious creative experience, thereby not contaminating
conscious reality experience. The ego's symbolizing function is released from
perceptual and concrete experience. A true psychoanalytic process can then
ensue, because a psychoanalytic mental domain is again available.
Interpretations can be given in the abstract and emotional rather than the
concrete and the reaL

Hallucinosis

Neuroleptic medication is dramatically and quickly effective in hallucinosis

because of the inside-outside boundary problem that is so diagnostic of this
condition and so effectively treated by phenothiazine-type medication. Visual
190 Psychosis and Near Psychosis

hallucinations disappear within hours. Auditory hallucinations, when present,

respond more sluggishly but within days. Because these states are so often
complications of toxicities, infections, and withdrawal states, a search for
etiology is mandatory and medication must be used carefully.

Delusionosis
A delusional state, with awareness that it is caused by illness but belief in
the delusional idea anyway, is, strictly speaking, perhaps not psychotic. This
is, however, a distinction without a difference as far as medication is
concerned. As far as medication is concerned hallucinosis and delusionosis
are treated exactly like the full psychotic equivalents. Neuroleptic medication
is effective, although as in all deluded states, the medication may take
several weeks to be effective. Again, the boundary between real
object-object representation or real self-self representation, and between
primary process and secondary process cognition, is greatly strengthened and
stabilized by the medication.
Both hallucinosis and delusionosis may deserve to be classified as
psychotic states. It may be better to understand them as having observing
ego rather than reality testing intact. However, this is probably a spectrum
phenomenon. There are certainly patients who have bona fide and
describable visual hallucinatory phenomena, carrying describable sensory
qualities without reality stimuli, who know full well that they are mental
products but are not quite able to test the reality of the percept as opposed
to the reality of the concept. With the equivalent delusional state, these
distinctions are often less clear.

Integrating Capacity
Integrating capacity refers to several subfunctions. The neuroleptics greatly
help the cognitive integrative capacity of ego functioning. Neuroleptics help
the ego's integrating ability because the secondary process integrates well-
boundaried and categorized mental experiences. With boundaries clearly
reinforced and affect-percept flooding removed from conscious reality testing
and conscious reality experience, secondary process integration is again
possible.
Logical thinking is greatly strengthened as reality testing returns.
Hallucinations disappear. The cognitive boundaries between inside and
outside and between percept and concept return.
Because of these increasing stabilities, integrated ego islands begin to
appear and are stabilized. An acute, constantly changing psychotic condition
becomes more fixed.
6. Medication and Mental Structure 191

The other extremely important integrative phenomena in very ill patients

are the dissociations that appear between different areas of mental
experience. These dissociations are helped somewhat as reality testing
returns and as logical integrating capacity of cognition improves. However,
there are many patients who are left with dissociated states in spite of
medication, because a specific dissociated area serves defensive functions
that have to do with the dynamic psychology of the material dissociated.
Medication does not affect dynamic psychology. This is a crucial area for
psychoanalytic psychotherapy to attend to in the patients who show these
dissociated areas, and almost all very ill patients do. In fact, it is the sicker
patients who do not, since they tend to have their psychotic material
infiltrate the entire personality structure.

Modulating Capacity

The neuroleptic drugs do not affect the modulating capacity of the ego to
a great extent. Modulation of affect requires, apparently, some control of the
intensity of affect, which is intimately linked to the modulating capacity.
Neuroleptic changes in affect are via sedation. Neuroleptics do so across the
board of mental functioning. They swing the modulating capacity over to the
extreme of frozen rigidity, so that one gets an apathetic state long before
one gets a well-controlled state. This may be better than wild, uncontrolled
emotional storms and dangerous behavior, but it is hardly a specific repair.
It is not an ideal result.
Boundaries between affect and affect are stabilized poorly by neuroleptic
medications. To the extent that they help much at all, they do so by a
sedative effect that dampens affective intensity throughout all areas of
mental functioning. The affect-affect fusions become less apparent. This
specific boundary is better helped by mood-stabilizing medication.
Thus, neuroleptics reduce psychotic phenomena by seeming to affect
boundary phenomena of autonomous ego functioning. (cf. Karasu, 1982;
Beitman and KIerman, 1984; KIerman, 1984; Bradley, 1990.)

Neuroleptic Medication Effect on Defenses in Psychosis

As long as the concept of psychotic defenses was confused by equating them

with the psychotic condensation itself, and as long as reality testing loss was
considered caused by defenses against underlying emotional conflict,
medication was viewed by psychoanalysts as either ineffective or dangerous,
because medication might bury the etiologic conflicts. More recent views, my
own included, hold that autonomous ego function is directly damaged. That
damage, while perhaps sometimes triggered by emotional conflict, involves
192 Psychosis and Near Psychosis

a biological mechanism aside from psychic conflict. The biological effect is

on autonomous ego apparatuses (see chapter 1). The emotional conflict then
erupts in illness-typical ways (see chapter 5). The result is a psychotic
condensation that involves aspects of reality experience. The psychotic
condensation (see chapter 2) involves defenses in several different ways. I
will now review those ways and describe medication effects.

Defenses Against Reality Experience: Reality Experience Defenses

The first situation is defenses that directly cross the reality
experience-emotional experience, conscious-unconscious-preconscious, and
secondary-primary process boundaries and capture an aspect of reality
experience via some condensation mechanism. Examples are delusional
mechanisms such as psychotic projection, psychotic denial, psychotic
compulsions, etc. Other examples are psychotic sensorial phenomena (see
chapter 4). Defenses that cross the reality experience boundaries become
part of the psychotic condensation (see chapter 2). Such defenses are
involved in the actual boundary crossing between reality experience and
emotional experience.
Neuroleptics, because they reinforce the reality experience-emotional
experience boundary and also the unconscious-preconscious-conscious and
secondary-primary process boundaries, resolve condensation crossings from
emotional experience which capture reality experience. Defense mechanisms
will then no longer primary process conscious reality experience. They will
be confined to emotional experience and tend to move out of consciousness
and into the preconscious and unconscious.
The content of the defensively altered material does not change, although
once freed from a reality experienced thing presentation, the underlying
concepts may be more layered and flexibly experienced. Affect may then
appear in more complex, varied, layered, and applicable ways. Concept
flexibility and affect complexity may, however, not appear after neuroleptics
have reduced the psychotic reality experience intrusion, because of other ego
problems in the generalizability function and affect modulation function.
However, if all the medication does is strengthen the reality experience
boundary, a crucial gain, even a life-saving one, has been achieved.
Neuroleptics do not affect the layering of affect contents within defensive
structures. The following example, an elaboration of the example just given,
will demonstrate this.

Patient example:
A middle-aged homeless man is brought to the emergency room after being
stopped by police as he was trying to enter the White House. He was convinced
that there was a crown waiting for him there. After a short course of
neuroleptics, he became quite sad because he felt his previous belief was not
true, although he still felt there should be a crown waiting for him at the White
House. A psychoanalytic psychotherapy ensued, revealing the following layers of
6. Medication and Mental Structure 193

affect content within the defensive wish to be crowned. At first the crown was
there. Then the crown was not there but should have been. Then the patient
understood that he wished it was there and that he felt entitled to it. He felt
entitled to it in order to help himself with an underlying despair that he felt
about himself, based partly on a highly traumatic childhood of violence and
abandonments. His sadness about the missing crown helped him understand that
if it was not there he felt he was nothing and was filled with despair and
hopelessness. This despair and hopelessness validated his anger, which defended
against his belief that common work and hope were useless for him.

Analyzing these layered defensive experiences was crucial in untangling

the complex interrelationship between traumatic deprivation and
pathological character attitudes, both of which were used as defense.
A most interesting aspect of this case was that treatment for the delusion
was begun by the United States Secret Service. One of their agents, after
detaining the man and hearing the story, said if there was a crown waiting
for him, they would be the first to know about it and since they did not
know about it, there couldn't be a crown waiting for him. This is the reverse
of the epigram at the beginning of this book. As a result the patient began
to feel sad, and the feeling was already conscious by the time he was in the
emergency room.

Layering Defenses
This example demonstrates not only the intrusion of defenses into reality
experience, but also the other way that defenses appear in psychotic
phenomena, namely, in the layering that occurs in the psychotic
condensation or in any complex psychological experience structure.
Neuroleptics do not affect this substructural layering of affect-content,
because interlayer boundaries are in emotional experience, even though the
entire structure may have psychotically moved into reality experience.
Therefore, psychoanalysis and psychoanalytic psychotherapy may be used.
They will be vastly better applied by the patient once reality experience has
been cleared. Reality testing, reality experience, and secondary process
attention cathexes can then all be used by the ego in service of the
therapeutic alliance and the therapeutic situation, i.e., in being able to
analyze and understand the primary process with secondary process
containment.
The defensive layering may be more accessible to analysis once the
intense, dense, unyielding truncation in the psychotic thing presentation
condensation is freed from entrapment in conscious perceptual reality
experience. Remember that percept and physical details inevitably truncate
concept and affect complexity. Once the thing presentation is in emotional
experience, layering tends to become more available, more flexible, more
complex, and more integrated.
The issue of "sealing over" inevitably comes up in discussions of
194 Psychosis and Near Psychosis

medication and psychosis. What is usually meant is the worry that dynamic,
layered defense systems will be repressed without other change of internal
relationships, especially affect relations. The rigid, defensive layering will
remain a point of vulnerability in the unconscious. This vulnerability, it is
feared, will manifest itself as a trigger point for psychotic relapse when
provoked by certain reality events and/or will manifest itself in the rigidity
of character defenses.
This worry is not without substance. However, the situation varies from
case to case and according to whether analytic psychotherapy is available
along with medication. Sometimes the course described above occurs.
However, withholding medication is not the answer. This will have the
greater danger of prolonging the psychotic state, and perhaps watching it
expand. Psychotic states carry a fatality rate (Stone, 1990). Chapter 7
describes the treatment needed to help the ego use the content in the
layered psychotic symptoms rather than seal over. However, this use is often
impossible without medication to stabilize the boundaries of reality
experience. Without medicine, therapeutically uncovered layering in
emotional experience will immediately condense with reality experience,
leaving the patient, if anything, more psychotic. When reality testing has not
established itself as a separate entity, when reality experience and emotional
experience are fused, the patient does not experience insight for emotional
change but rather an evolving psychotic experience.
Sometimes medication alone can help the ego integrate with insight,
achieving a rapid resolution rather than a sealing over. This depends on the
maturity, flexibility, and organization of the nonpsychotic ego.

Vertical Defenses
Vertical dissociations around psychotic condensations and conscious
experience are often mediated by basic character defenses. They are
nonpsychotic because they are preconscious emotional experience and
because they are not condensed with the psychotic thing presentation.
Neuroleptics may allow greater flexibility in these vertical enabling
defenses once the psychotic thing presentation moves out of reality
experience and into emotional experience. Sometimes that is all that is
necessary for the rest of autonomous ego to integrate and/or repress across
the dissociation and any enabling defenses. In this way, psychotic defenses
integrate with character defenses as thing presentations move into emotional
experience.
If the mediating defenses are rendered more flexible by neuroleptics, it is
because validity has been taken from thing presentation perceptual
experience in reality and moved into affect and affect-content in emotional
experience and into concept in secondary experience. This interrupts
intensity summation cycles between affect and percept, between character
defenses and psychotic defenses, between emotional experience and psychotic
6. Medication and Mental Structure 195

defenses, between emotional experience and reality experience, and between

psychotic condensation and psychotic behavior into reality that intensifies all
defensive operations including mediating defenses.
Often, however, psychoanalysis and psychoanalytic psychotherapy must
deal with these defenses, either the simple dissociation defense or its
mediating character defenses. This is especially true for those patients with
character pathology where character defenses rigidly block affect and affect
content even in nonpsychotic areas and times. In fact, this situation is the
most common one.
Interpretations in psychoanalysis and psychoanalytic psychotherapy can be
made even more effective with medication for boundary stability in order to
better understand enabling defenses, their content and process. Symbolizing
processes for affect can again use primary processing and emotional
experience rather than percept and reality experience.

Reality Testing and Defenses

Reality testing is part of the psychotic condensation (see chapter 2). Because
neuroleptics reinforce the reality experience-emotional experience,
secondary process-primary process, thing presentation-affect-concept
boundaries, reality testing, and secondary process and a separate reality
experienced percept-content can all separate from psychotic condensation.
This is enough to free reality testing as an autonomous ego functioning
unless mediating (enabling) defenses are also involved (usually not). If
enabling defenses are involved, exactly the same principles apply about
neuroleptic and psychoanalytic psychotherapeutic effects as apply to the
enabling defenses of vertical dissociations.

Observing Ego and Defenses

Observing ego is a separate ego function from reality testing and is usually
not part of the psychotic condensation (see chapter 2). Interferences with
observing ego are usually non psychotic character defenses. Neuroleptics do
not help except insofar as they shift the psychotic condensation-thing
presentation experience out of reality experience and into emotional
experience. When this happens, the observing ego has less sense of validity
to support its misalliance. Psychoanalysis and psychoanalytic psychotherapy
are very important in undermining defensive mechanisms blocking observing
ego. Therapy does this by rallying secondary processes through interpretation
(see chapter 7). The psychotherapeutic interpretive process can often be so
effective by itself that observing ego is separated clearly in experience from
the psychotic contents even without medication. This can help the
therapeutic alliance greatly, and even reality testing to some extent. But
when observing ego is blocked, it is almost always by character defenses.
This is the usual reason that psychotic patients stop taking their medication.
Many patients complain about side effects, but they are not the most
196 Psychosis and Near Psychosis

common reason for stopping. Some patients are delusional about their
medication, but this is actually rare. The denial of illness and the
psychologically mediated refusal to accept and deal with the illness are
almost always aspects of character pathology that are readily apparent to all
who know the patient well. In fact, even a beginning discussion with the
patient easily reveals these psychodynamics. It is a clear indication for
analytic psychotherapy in the psychotic patient, and medication alone will
not help. Expecting medication alone to free observing ego may be doomed
to failure. Patients treated this way may leave the psychotic episode without
insight into its psychotic nature, and therefore without motivation to take
maintenance medications or even to continue in psychotherapy. The relapse
rate in such cases seems to be high.

Object Relations and Defenses

In sicker patients, defenses and object relations are one phenomenon at the
same level of consciousness (see chapter 2). The term defenses focuses on
the mechanism and function, while the term object relations focuses on the
content and affect. Neuroleptics, acting at the inside reality experience-
emotional experience boundary, act on the real object-object representation
and real self-self representation boundary. Also, fusions between object in
reality and self-experience or vice versa are reduced because of the
reinforcing effect neuroleptics have on the in-out boundary. To the extent
the repression barrier between unconscious and preconscious/conscious is
reinforced, the intensity of emotional experience representations flooding
real object and real self is reduced. When and if vertical dissociations ease,
the integration of the object world can proceed both within reality
experience and within emotional experience and in the relationship between
the two. Superordinate ego functions again organize the Object world-in and
out, real and representational. Defensive use of object relations shifts back
to emotional experience.

Defenses in the Day Residue

The experience of the day residue precipitating event is both altered by
defenses and used defensively when altered by autonomous ego apparatus
damage.
The autonomous ego boundary problems allow placement of the symbolic
alteration in the same mode (reality experience) and level of consciousness
as its day residue Object. A symbolic alteration of reality then appears in
conscious reality experience, which is a condensation between the reality
event and the emotional feelings that have symbolically altered the
perceptual idea of the event.
Vertical and horizontal dissociations may then separate sequence and
context from the symbolic alteration of reality. This prevents contradicting
evidential reality experience from confronting the thing presentation
6. Medication and Mental Structure 197

symbolic alteration. Such confrontation could, if successful, destroy the

emotional logic of the symbol and start to release the affect the thing
presentation both contains and defends against (Le., crown and sorrow).
Neuroleptic medications that reinforce boundaries will allow more
flexibility in the day residue's relationship to its own symbolic alteration.
Affect will become more available in direct affect experience.
The vertical and horizontal dissociations and the more elaborated
enabling character defenses guarding them may become more flexible as
intense thing presentations fade. Usually, if there are elaborated character
defenses guarding simple dissociations, psychoanalytic psychotherapy is
required. But interpretation can have a much greater effect if medication is
concurrently used, because until emotional experience is out of reality
experience, interpretation will be seen as irrelevant to the reality-experienced
psychotic condensation.
The defenses against integration arc reduced with psychotherapy after
medication has established the separation in reality experience between the
day residue and its symbolic alteration. The day residue no longer stands
reified in perceptual-ideational reality experience. In this way, integration
between day residue object and its sequence and context is achieved. When
this is not achieved, the psychotic condensation freezes affect, enabling
defenses dissociate sequence and context, and the psychotic condensation ties
up all available attention cathexes, priorities, and validities, thereby
paralyzing remaining islands of intact autonomous ego apparatuses.

Other Defenses
Neuroleptic medication has an effect only on the defenses that involve the
use of reality. Psychosis as a defense and capture of specific areas by fantasy
is treated by neuroleptic medication if such capture is mainly the result of
boundary problems that neuroleptic medication affects. It will not affect, in
any case, the content or mechanisms of character defenses not involving the
capture of reality. What this means is that a patient who is paranoid about
his wife as part of a delusional system may, upon recovery, be found to have
similar contents and projective mechanisms involving his wife, if not
consciously then preconsciously and unconsciously. This is why the use of
medication within a psychoanalytic psychotherapy does not cloud the
psychological understanding of the patient, nor does it impede the progress
that insight can bring to the patient. Medication can help the patient
distinguish real from unreal and thus allow treatment to pay more attention
to deeper layers of fantasy structures. The ability of reality to help the
patient work through his or her psychological life is limited by the mostly
secondary process organization of the available real world. So when
emotional dynamics are trapped in paranoid projections onto reality,
understanding is limited.
198 Psychosis and Near Psychosis

Thymoleptic Medication Effects on the

Ego in Psychosis
Thymo/eptics are drugs that affect mood disorders. As in neuroleptics, their
effects on psychotic structure (psychotic depressions and manias) are mostly
on the autonomous apparatuses and functions.
Antidepressants or lithium stabilize mood (see Loeb and Loeb, 1987) by
stabilizing affect intensity, spread, and recruitment. They also stabilize
fluctuating, autonomous, massive affect discharge propensities. Thymoleptics
stabilize and prevent the circular feedback between affect/mood and content,
and hence between mood and the triggers of mood in reality via affect-
content evocation. They also stabilize and prevent the triggering of affect
linked regressive content. This can have a very beneficial and stabilizing
effect, not only on the level of ego organization in general, but also on
defensive structures. There are patients who regress to lower levels of
defensive structure under the influence of intense mood disturbance.
Autonomous ego is shielded by thymoleptic medication more effectively
than defenses because of the decreased intensity of affect allowing repressive
barriers greater effect. The affect intensities that do escape the repressive
barrier now, because of their decreased intensity, may be discharged with
secondary process content, with adaptive behavioral actions, with
sublimations, and with contained fantasy experiences. It is this decreased
intensity that seems to remove a functional block to both the autonomous
ego pathways and the functional repressive abilities.
Antidepressants seem to have a specific ameliorating effect on the
discharge of aggression, whether the discharge is directly from id reservoirs
into the outside world behaviorally or into the superego and back onto ego
structures, as in some severe depressions. Lithium will calm psychic
discharges of aggression in manic patients. It will also work on libidinal
intensities in erotomania.
Because mood stabilizers work especially on affect, they can help not only
the ego's reality testing, observing ego, and integrative capacity, but also the
intensity, frequency, and domination of primary process experiences. Thing
presentation quality can decrease and the separation between perceptual and
fantasy channels of experience can once again be restored. This increases the
possibility for integrating and generalizing. An abstraction can then be
cognitively and not just affectively experienced by the patient. This has the
most dramatically beneficial effects for enabling an analytic psychotherapy
to proceed. It dramatically increases secondary process use of the primary
process layers of intensely affect-ridden preconscious and unconscious
material. This material can then be integrated as the therapy uncovers.
6. Medication and Mental Structure 199

Thymoleptic Medication Effects on

Autonomous Ego Structures in Psychosis

I will now cover some specific ego functions, and then I will discuss specific
defenses in affective illness as affected by medication. The ego functions
listed will be the same as in the section on neuroleptics (p. 185), because
these are the ego functions that are crucial to the organization of psychotic
experience. Most interestingly, they are also the ego functions that these
medications affect the most.

In-Out Boundary
When the in-out boundary is affected by affective illness so that
environmental stimuli arriving along perceptual channels fuse with the inside
experience of bodily perceptions, of affect, and of concept, and when the
Object in reality is fused with self- and Object representations, one is almost
always dealing with mania. Lithium will reinforce this boundary in a week
to 10 days. Neuroleptics will do so in hours to a few days. Both are usually
given at first.
Neuroleptics seem to directly reinforce the in-out boundary in all
psychotic states, regardless of etiology. Lithium probably does this by
decreasing affect intensities because lithium works only in affective psychosis.
Lithium also works well in the mild form of manic in-out problem, where
only affect is crossing the in-out boundary, both from the environmental
object in reality to the inner affect experience of the patient and from the
patient to the experience of the real Object.

Primary-Secondary Process Boundary

Because the primary process is an affect-processing system, intense increases
in affect will change the content and range of primary processing function.
Increased intensity will also shift the primary process location. The intensity
increase and the resulting spread of primary process and the increased
intensity of its content-imaging will begin to dominate preconscious and then
conscious, logical, and then perceptual experience. Recruitment of memory
and of present perceptual experience will be based on affect and associated
affect-contents. As intensity increases, this recruitment, which occurs
according to primary process rules and emotional experience, will cross
secondary process boundaries into logical consciousness. Primary process will
then dominate in that location. This is true whether the affect is primarily
depressive or euphoric/irritable. Thymoleptics will greatly reinforce this
boundary indirectly, by decreasing intensity, and directly, by decreasing
spread of affect into mood.
200 Psychosis and Near Psychosis

Affect-Percept
As affect intensity falls and primary processing modalities fade below the
level of consciousness, affect no longer contaminates conscious percept.
Affect of lesser intensity can be contained by the ego within affect
experience. This dramatically reduces sensory psychotic phenomena. Again,
the neuroleptics act directly and quickly on this boundary, the thymoleptics
more slowly and indirectly via affect intensity, spread, and modulation.
Affect-percept relationships are crucial to thing presentation experience
and therefore to psychotic condensation experience. As the affect-percept
boundary strengthens, affect can be experienced directly and thing
presentation experience can be repressed once again to the unconscious.

Concept-Percept
As affect separates from percept, affect-determined, affect-expressive, and
affect-contaminated concept can be freed from perception. Ideas, even those
associated strongly with affect, can be utilized by the ego in secondary
process ways. Ideas can once again be subject to Aristotelian logic, to
generalization, and to application. This step greatly helps regain reality
experience. With this boundary once again functioning, a psychotic patient
with a mood disorder is once again rational.

Reality Testing-Reality Experience

As affect intensity falls and affect recruitment no longer dominates reality-
experienced categorization, reality testing can reassert its independent
content and function. Thymoleptics will gradually, therefore, allow the
reappearance of reality testing. Reality testing not solely determined by
either reality experience or emotional experience can again function once
the contamination of its content and processes by affect determined reality
perceptual experiences is reduced.

Unconscious-Conscious; Repression and Affect Intensity Barrier

As intensity of affect comes under control, the repression of affect can again
function as a percept-affect stimulation barrier. Primitive primary process
contents expressing affect relationships and intensities can again return to
unconscious mental life. Environmental evokers of affect must once again
reach a certain stimulus threshold before affect breaks through into
consciousness, into secondary process, and into behavior. This dramatically
decreases psychotic condensations and behaviors. Therefore, thymoleptics
greatly help the functional repression barrier by decreasing intensity of
affect. Thymoleptics may also act directly on the repression and stimulus
barrier, as do neuroleptics.
6. Medication and Mental Structure 201

Object Relations
Because the ego functions just described are once again functional with
thymoleptic medication, the real object world can once again be organized
categorically in consciousness. Psychotic condensations can resolve/dissolve.
The object in reality, the real object, and the object representation of
emotional experience can be separately experienced in consciousness. The
affect connections between the representational world and the perceptual-
reality object world return to relationships rather than to conscious
condensations. The same, of course, holds true for self-experience and for
self-object relations. This brings secondary coherence once again to the
conscious object world. 1

Day Residue-Symbolic Alterations of Reality

Increased stability of affect intensity and mood stabilizes the ability of the
ego to maintain the day residue in reality experience and its affect evocation
in emotional experience. Reality evokers, emotional reactions, and resultant
symbolic alterations are no longer linked by affect intense primary process
condensations in consciousness. Sequence and context, so important as
precipitants of affect, can once again be tolerated in relationship to the real
Object or real thing event.
This separation of emotional experience from reality experience frees
conscious symbolic processes for abstract concept, generalization and
application. It also frees symbolic experience for third space (tertiary
process-Arieti, 1976) functioning in organizing new day residue reality
relationships and emotional adaptations required by the changing real world
and by emotional growth. The new integrations required can once again be
processed because it is in this area (creative area) that such integrations are
first processed (Winnicott, 1953, 1971).

Thing Presentation
As ego functions return, the intense, dominating, highly affect-charged
perceptual thing presentation will decondense, ease in intensity, fade back
into the unconscious, and release its grip on secondary and tertiary process
functions. Percept and concept will again be available for an uncontaminated
reality experience. The secondary defenses, avoidances, and floodings will
disappear. A psychotic patient will become nonpsychotic. The major
suffering of psychosis has to do with the dominating terror of this
overwhelming thing presentation experience. Its rigidity, locus in
consciousness, truncation of affect complexity, and content are all primary
process results of affect intensity symbolization. Thymoleptics dramatically
change this. Neuroleptics, by contrast, will contain the thing presentation so
that reality testing returns, but in affective illness only thymoleptics will
202 Psychosis and Near Psychosis

return normal relations and flexibility to conscious symbol functioning.

Thing presentation translating mechanisms of abstraction, generalization,
and application, no longer flooded by affect intensity and content
recruitment, no longer rigidified and truncated, can once again function.

Thymoleptic Effects on Defenses in Psychosis

Thymoleptics affect not only autonomous ego functions but also defenses.
They seem to do this indirectly by their effect on the intensity and spread of
affect states. It is intense affect which plays a crucial role in the triggering
and organizing of defenses.

Defenses and Reality Experience, Including Reality Testing

Defenses capture reality experience, the real Object, and/or the real self in
mood disorders when affect can no longer be contained, repressed, and/or
dissociated. Instead, affect contaminates the perceptual experience of reality
in sensations or ideas. 2 Affect and affect-recruited ideas are then usually
projected. They thereby condense with reality experience. But affect can also
be defended against by denial of reality evokers of fact, sequence, or context.
This is denial of factual reality. Intense affect can also be defended against
through dissociation of affect from affect, of affect from idea, or of affect
from reality. When reality testing is lost as an independent process 3 and its
contents condensed with emotionally captured reality experience, a psychotic
condensation in conscious reality experience is formed. Thymoleptics
function in mood disorders to decrease the intensity of affect and to increase
the autonomous ego's capacity to modulate affect. This allows affect
experience and expression along secondary process lines of organizational
experience. Affect can then be contained in emotional experience.
Projections onto reality experience, denials, and dissociations no longer
capture, deny, or separate factual reality. Validity criteria will shift away
from thing presentation experience back toward secondary process
organizations, data, and abstractions.
Defenses are preconscious, primary processors of affect. They use
organization by emotional association and recruitment of idea via associated
affect to symbolize, express, and repress affect. They operate in a hierarchical
way to spare self-experience from the worst affects in a series of less to more
painful. They also serve to protect reality from behavioral disruption due to
impulse affect discharge.
As mood disorders progress, one can watch the shift toward increasing
intensity, primary processing, content saturation, content starkness, level of
consciousness, and disruption of reality experience and reality testing.
Likewise, one can watch the shifts back when treating with increasing doses
of thymoleptics.
6. Medication and Mental Structure 203

Patient example:
Fifty-year-old man with depression. Without medication: "I can see my soul
coming out from my stomach to be stolen by other people."
With thymoleptics: "My self-esteem leaks au!."
Increasing medication: "I project my perfection fantasies and feel small by
comparison."

Defenses and Observing Ego

Observing ego, the capacity to view oneself dispassionately and logically and
to understand that one is ill, is often blocked by defenses. These defenses are
not part of the psychotic condensation. Basic character defenses are usually
involved. These defenses can intensify, spread, and rigidly block observing
ego in mood disorders. Thymoleptic medication can dramatically decrease
the rigidity of those defenses and shift them back toward emotional
experience. When affect leaks link intense emotional experience and reality
provocations, the observing ego may ally with defense experience validity
rather than observational validity. This can be, and usually must be,
interpreted analytically. Thymoleptic medication can also be very helpful in
achieving a more plastic and less intense defensive structure which will
enable interpretations to be more effective and useful.

Defenses and Vertical Dissociations

Vertical dissociations are of two types. Some separate oppositely valenced
affect (splitting). Others separate affect and content (ideas) from other
affect-contents. Thymoleptics, by decreasing the intensity of affect, help the
ego integrate splitting. Intensity reduction also helps decrease other vertical
dissociations by lowering the affect component, and thereby easing primary
process recruitment across vertical boundaries. Affect intensity both
mediates dissociation defenses and motivates them. Affective experience can,
with thymoleptic treatment, return to an emotional locus. Affect blending,
complexity, layering, and neutralizing can reappear. Complex affect
experiences, composed of many affect components, reappear and regain a
modulated and flexible relationship to reality provokers contained in real
objects, real self-experience, real things, and their sequences and contexts.
Affect discharge can then return to sublimatory, secondary process, socially
appropriate channels. Even more importantly, emotional discharge can
return to the complex integrated emotional discharge for change we call
satisfaction.

Thymoleptic Effects on Defense Content in PsychOSis

Thymoleptics may on occasion shift the content of primary process fantasies
contained in defensive operations. Thymoleptics can do this because
decreased intensity decreases the primary process function of containing
intense affect in symbolic content (ideas). The primary process operates to
204 Psychosis and Near Psychosis

express and contain affect in primary process fantasies. The content of those
fantasies is in part an attempt to express intensity factors. Such defenses are
on a continuum, e.g., narcissistic-paranoid, obsessive-paranoid. These labels
attempt to convey the information that certain character types will shift
defense content and mechanism depending upon the effect of stress on their
emotional equilibrium. When reality confrontation interferes with grandiose
fantasies, many narcissistic patients, in a last ditch attempt to avoid
contemptuous rage turned upon the self, will project this rage in a paranoid
attack upon the confronting reality person or stimulus. Failures in their
perfection image cannot be their fault or depressive disaster may ensue. It
is, therefore, the fault of the reality intervention or intervener. The
employees of such people know that they cannot be the bearers of bad news.
Thymoleptics can reverse progression along such a defensive content
spectrum or block the progression, greatly stabilizing both character
structure and psychotic illness.

Patient example:
A patient experiences the reality evoker of less attention from a lover (the
lover does not call when expected). This triggers a fear of loss, which in turn
causes hurt pride, anger, and a projected jealousy fantasy that the lover is with
someone else. Thymoleptic medication can stop the progression at this point. If
it is not given or if the patient does not take it, in this particular patient the
progression proceeds to feelings of being a loser, a failure, and projection of
blame onto the experience of the real self. The patient, tearful, feels unworthy,
is flooded by the recruitment of memories of past failures, and has an intense
and validated experience of worthlessness. Self-blame intensifies in an attempt at
expiation, resulting in the failure of this expiation and therefore of hope. A
suicidal despair and an impulsive gesture then follow.

Other Effects of Thymoleptics

Thymoleptics have two other effects that do not have to do with the ego.
The first has to do with aggression. Thymoleptics, when they work, seem
especially to ameliorate the intensity of aggression, whether it is directed
externally, as in mania, or internally through the superego to the ego, as in
depression. This diminution of aggressive malignancy allows shifts in
defenses.
The second is the effect on rhythmicity. Thymoleptics prevent the cycling
of mood disorders. This is a primary effect they have on the brain, and the
mental locus is presumably the id. 4
6. Medication and Mental Structure 205

Medication Effects on
Near Psychotic Ego Structures
Near psychosis is characterized by a particular kind of condensation in the
preconscious between reality experience and emotional experience (see
chapter 3). A number of autonomous ego dysfunctions and types of defense
mechanisms organize the structure. I will now list them and describe
medication effects for each.

Boundaries

The boundary between reality experience and emotional experience suffers

the condensation crossing in the preconscious. This involves a number of
subsidiary boundaries (chapter 3).
The boundaries between inside emotional experience and inside reality
experience in the preconscious, and between conscious reality experience and
preconscious affect, are crucial. Condensation crossings result in a poorly
boundaried preconscious experience of the affect distinction between real
object and Object representation, between real self and self-representation,
and sometimes between self-representation and real object.
Neuroleptics do not reinforce preconscious boundaries except insofar as
they sedate all of mental functioning and thereby sedate intensity of all
affect. If the near psychotic condensation is related to a near psychotic form
of schizophrenia with fragmented conscious cognition and fragmentation
crossings of boundaries, neuroleptics will help the conscious, and sometimes
the preconscious, aspects of that integrative problem.
The wiser choice of medication is usually a thymoleptic. By acting
especially on affect and mood, thymoleptics can affect preconscious boundary
function. Decreasing affect intensity results in decreasing primary process
dominance. The affect capture of reality percept experience and reality idea
experience in the preconscious fades. The distinctions between real Object
and object representation, real self and self-representation, and self-
representation and real Object all increase. The boundary functions resume
because affect flooding, affect recruitment which crosses boundary lines,
affect spread, and affect veracity all decrease as intensity falls. In addition,
phantasmagoric primary process content decondenses and shifts to less
dramatic content that can be more easily integrated and/or repressed.
Thymoleptics help the usual near psychotic state because the usual
structure involves "affect leaks" across boundaries whenever affect is too
intense and too easily triggered. This is a hallmark for certain types of
affective illnesses. Affect leaks, condenses, and/or mixes without integration
206 Psychosis and Near Psychosis

into other affects. This is the typical affect storm of near psychotic states.
Affect contaminates concept. Affect alters percept shading, quality, evocative
ability, and significance. Affect spreads quickly into mood and recruits affect-
associated contents. Affect shifts secondary process logic to primary process.
It leaks into behavior and judgment. All these affect boundaries are affected
by thymoleptic medication and improve in function. Affect and mood
modulation return. The ego can then better control intensity of evocation
and spread of affect. There can once again be boundaries between affect and
the rest of mental experience. Reality experience can be held relatively
separate from affective emotional experience, even in the preconscious.
Crucial to this separation is a decreased intensity of thing presentations.
Word presentations again are able to contain and express affect. As word
presentations reappear and regain validity quality, integration capacity in
secondary process can reappear. Abstraction, generalization, and application
processes' again function along secondary process lines instead of along
affect-primary process lines and thing presentations.
As thing presentation experience fades, decondenses, and shifts to word
presentations, the day residue can decondense from the symbolic alteration
of reality. Affect and resulting validity then move away from the symbolic
alteration of percepts toward words and concepts.
What happens in those near psychotic states where the boundaries
themselves are weakened directly? Schizophrenia is such an illness and may
take a near psychotic form. Near psychotic schizophrenia has fragmented
near psychotic condensations. The near psychotic preconscious location is
due to fragmenting of the preconscious-conscious and unconSCious-precon-
scious boundaries. Affect is usually muted. The characteristic fragmentation
of secondary and primary process thinking (Bleuler, 1950) is diagnostic.
Neuroleptics will help. How much they help varies. Intraconcept cohesion
and interconcept integration may improve.
A bigger pharmacologic dilemma is those patients with neurological
dysfunctioning of boundaries, as in certain types of minimal brain
dysfunction-dyslexias with or without attention deficit disorder. Here,
concept fusion, concept reversals, higher order abstraction hypertrophy to
compensate for lower order abstraction concreteness, rigidity, and inability
to shift and modulate abstraction levels may be operative and make flexible
word presentation use and containment of affect difficult. Category fusion
and reversal is a kind of boundary defect that looks like primary process, and
because of fusion, intense affect expressed along primary process can easily
leak across a defective category boundary. Category fusion and reversal is
not true primary process, which is based on condensation rather than fusion,
but the two look so much alike that it takes an experienced clinician to tell
the difference.
If affective illness is present, thymoleptics will help. If attention deficit
disorder is present, psychostimulants may help. If neither is present, it is not
clear that any medication will help. Learning disability training may help,
6. Medication and Mental Structure 207

depending on intelligence and intactness of higher order abstracting ability.

This can be part of and/or an addition to an informed psychoanalytic
psychotherapy (see chapters 7 and 8).

Reality Testing

Reality testing is an aspect of secondary process ego function with reality

experience content. In near psychosis it suffers a condensation alteration of
content but has its process preserved, although suspended. The alterations
in reality testing provide the rationale for neuroleptics. This is not a good
rationale. Neuroleptics will not change reality testing in near psychosis,
because the process boundary is intact in consciousness. If this boundary is
particularly fragmented, as in forme fruste schizophrenia, the neuroleptics
will help. But the usual near psychotic is a forme fruste of affective illness
(with or without minimal brain dysfunction). Thymoleptics are much more
effective, because they reduce the affect leaks, recruitments, and primary
process shifts caused by poor affect modulation. Reality testing content can
then separate from the near psychotic condensation, especially with the help
of concurrent analytic psychotherapy which challenges and reinforces the
reality testing secondary processes. Further gains in reality testing are made
as the preconscious near psychotic condensation decondenses, the intensity
of the thing presentation experience fades, and preconscious symbolic
alterations of reality separate from reality day residues. A huge shift in
veracity experience then occurs and reality testing is returned to normal.
(Remember that reality testing compares reality experience, logic and
percept, with emotional experience. When emotional experience is so intense
that percept is contaminated, reality testing processes this even if secondary
process is intact.)

Observing Ego

Observing ego is usually at least blocked and may be actually part of the
near psychotic condensation. This is another rationale for neuroleptic use.
It is a poor rationale. The link between observing ego and near psychotic
condensation is through emotionally experienced defensive structures.
Neuroleptics do not affect this unless the sedation effect on affect intensity
is sufficient, which it rarely is. If it is, there are safer sedatives than
neuroleptics. Observing ego is better liberated through psychoanalytic
psychotherapy (see chapters 7 and 8). Thymoleptic use may, if it causes shifts
in defensive organizations, help liberate observing ego by moving primitive
projective and denial experiences away from observing ego.
208 Psychosis and Near Psychosis

Thing Presentations and Symbolic Alterations of Reality

NeuroJeptics do not dramatically change the thing presentation experience

nor its condensation of day residues with symbolic alterations of reality in
near psychosis, because neuroleptics do not dramatically affect the
preconscious. Thymoleptics will bring dramatic change, because as affective
intensity/spread decreases, thing presentation intensity decreases and
symbolic alterations of reality separate from reality day residues, which can
then be processed along secondary process channels.

Medication Effects on Defenses in Near Psychosis

The analyst hopes that medication in near psychosis will affect defenses by
(1) shifting the process away from reality experience capture and (2)
affecting defensive contents. Neuroleptics do neither job well. Capture of
reality experiences occurs in the preconscious, which neuroleptics do not
specifically target. Content is unaffected even if the patient is sedated by
neuroleptics.
Thymoleptics, on the other hand, may have dramatic effects on both
aspects of defense. The first is the shift away from primitive processes that
capture preconscious reality experience. As intensity decreases and
integration shifts to secondary process, there is a preconscious release of the
capture of percept. Concept meanings and emotional validities are freed.
Projective identification can shift to higher-level projections and move away
from real self- or real Object experience to object representations or self-
representations. Likewise, preconscious denials of fact can shift to denials
of significance of fact, i.e., emotional experience.
Content, too, can change under the influence of thymoleptic reductions
of specific affect intensities (rage, arousal, etc.) and spread. Primary
processing of affect varies in content, in part according to intensity. So-called
primitive contents are reflections not just of specific condensed conflicts but
also of intensities. Shifts in intensity, therefore, can have dramatic effects on
preconscious defense contents (ideas). This shift toward higher-level contents
is particularly dramatic after the near psychotic thing presentation
experience has dccondensed and near conscious perceptual qualities fade.
(Remember, in near psychosis the conscious percept itself is not captured.
Only the qualities sensory percepts have in reality experience are captured
in the preconscious (see chapter 3).)
Another dramatic effect thymoleptics have on defense is on rigidity. The
fixed relationship between defense mechanism, defense content, superego
content, near psychotic thing presentation, and autonomous ego functions
6. Medication and Mental Structure 209

eases as affect experience eases in intensity. The condensation between

defenses and near psychotic thing presentation causes a rigid, preconscious
reification experience filled with validity, which causes a preconscious
certainty experience of projective identifications and denials. Without this
reification and certainty quality, integration and amelioration are possible.
It is often astounding to see what this shift can do to personality function,
and hence to availability in analytic psychotherapy. Observing ego can free
up. Personality organization can shift back along the spectrum of processes
and contents toward the more neurotic. Rigid, paranoid, hysteric patients
can shift to more flexible, predominantly hysterical processes. Rigid,
obsessive-masochistic-depressed patients can shift back to primarily
obsessive mechanisms. Rigid-narcissistic-paranoid-depressed patients can
shift toward the narcissistic, grandiose instead of deflated, paranoid, and
despairing (see Marcus, 1990). These shifts are most helpful to
psychoanalysis and to psychoanalytic psychotherapy, since rigidity of
structure is usually the most rate-limiting step.

Thing Presentation Quality

Neuroleptic medication has a quite variable effect on thing presentation

quality in near psychosis. Neuroleptic medication mayor may not be helpful,
depending on whether the quality emergence is due to cognitive boundary
structures that are affected by the neuroleptics. Affect intensity, integrating
incapacities, and generalizing incapacities are all causes of thing presentation
thinking that will not be dramatically affected by the neuroleptics. Mood
stabilizers will help the affect intensity problems, and stimulant drugs will
help those patients with minimal brain dysfunction who cannot focus
integrating attention. These categories of drugs are much better suited to
those categories of illnesses than the neuroleptics. In addition, patients differ
not just in the ability to experience thing presentation quality but in the
ability to use the experience of thing presentation quality for secondary
process purposes. That functioning can be greatly helped by an analytic
psychiatrist who understands that the experience and the use are two totally
separate mental abilities. Patients can be greatly helped by the experience of
analyzing a thing presentation quality experience and understanding that it
is a way of thinking that they can use. This is, after all, a hallmark of
creative thinking.
210 Psychosis and Near Psychosis

Mood Stabilization

Antidepressants and lithium work by stabilizing mood in all its aspects. They
stabilize cycles of fluctuating mood discharges. They stabilize and prevent the
cirular feedback between affect/mood and content, and hence between mood
and the reality and personality triggers of mood. The affect intensities that
do escape the repression barrier are now, because of their decreased
intensity, able to be discharged along autonomous ego pathways with
secondary process, with sublimations, and with contained fantasy experiences.
Lithium alone, antidepressants alone, or the combination of both may be
needed to prevent cycling.
Antidepressants seem to have a specific ameliorating effect on the
discharge of aggression, whether directly from id reservoir into the outside
world behaviorally, as in borderline conditions, or into the superego and
back onto ego structures, as in near psychotic depressions. Lithium will calm
psychic discharges of aggression in out-of-control bipolar affective illness and
will work on libidinal intensities in erotomania.

Modulating Capacity

From what has been said, It IS apparent that the mood stabilizers have
dramatic effects on the modulating capacity of the ego. Again, the
medications seem to work on this capacity by decreasing the intensity of
affect and its spread. However, they may also act directly on the modulating
capacities.

Integrating Capacity

With a decrease in affective valence, the cognitive integrating capacity of the

ego is strengthened indirectly because the intensity of the emotional
experiences, and hence their paradoxes and contradictions, are less dramatic.
Therefore they are more integratable cognitively.
However, the dissociated mental experiences, while reduced in intensity,
are still often unintegrated. Psychotherapy is needed to provide the
integration in this area. However, the decreased intensity through medication
greatly aids the analytic exploration of the defenses mediating the
dissociation and the emotional reasons for these defensive structures. For a
recent study on the efficacy of medication and psychotherapy in the
treatment of depression see Weissmann et al. (1979). Such studies are
needed for psychoanalysis and medication.
6. Medication and Mental Structure 211

Object Relations

The threshold of the affect-triggering mechanism is raised by thymoleptics.

Affect no longer so easily disrupts the distinction between real object and
object representation, real self and self-representation. Affect no longer
clogs perceptual channels. As long as affect is incoming via percept as well
as concept, and as long as there is a too easy flow between fantasy and
percept and between percept and concept, the distinction between real
object and object representation will be difficult. The same is true for real
self and self-representation.
Medication can be very useful in near psychotic states, but it must be clear
for what purpose the medication is used. Medication affects certain types of
near psychotic states and not others. For those that it does benefit, it is
beneficial only for certain aspects of near psychotic structure. The accurate
choice and dose of medication require the utmost care.

Near Psychosis/Pseudo-Delusional Type

The pseudo-delusional patient is usually a higher-level near psychotic patient

and the diagnosis of affective illness is usually relatively straightforward if a
specific search is made. The usual drug of choice is one of the antidepressant
drugs, which are so effective in decreasing the intensity of aggressive affect
particularly, and in the case of the pseudo-delusional type of near psychosis,
ending the intense outpouring of aggression into superego functioning. The
repression barrier is enormously stabilized, and self-esteem mechanisms, no
longer flooded with recriminatory superego aggression, begin to modulate
the real self-experience more realistically once again.
The cyclothymic mood swinging patient almost always has
behavioral/borderline features. because the grandiosity and irritability are
harder to contain. Lithium is the treatment of choice, and the only key to
its use is to understand from the dynamic psychological material that the
irritability is (1) present and (2) part of grandiosity rather than depressive
agitation. Agitated depressions and irritable hypomanias may be confused in
diagnosis. However, although both can be flooded with aggression and both
can project this aggression, the agitated depressive tends to have a large
component of that aggression directed against the real self in the form of
failure and despair, while the hypomanic has almost all of the aggression
directed against the Object, real and representational. It is important to
realize that if one does choose to use a neuroleptic rather than a mood
stabilizer, one must not use as the endpoint of medication treatment the
pseudo-delusional idea, since it is already a non psychotic phenomenon.
212 Psychosis and Near Psychosis

Reality testing and inside-outside boundaries are intact. The neuroleptic,

therefore, will not eliminate the idea which is based on content and intensity
of affect. A similar situation occurs in medicating a delusional state with a
penumbra of pseudo-delusion. The delusional state will be medicated and
the pseudo-delusional penumbra will not.

Near Psychosis/Borderline or Behavioral Type

The main boundary problem that is so damaged in borderline/behavioral

states is the boundary between affect and behavior. This boundary is mildly
to moderately helped by medication to the extent that the pressure of
intense emotional experiences is lessened, and therefore the behavioral
action is less pressured, less urgent, and less extreme. However, behavioral
action as an ego style and as a defense remains, even in medicated
borderline patients, although it is obviously less dangerous. Psychotherapy
is crucially necessary to "stuff the patient's life back into his or her mental
experience" and then analyze it. The dangers of medicated borderline
patients with mild to moderate improvement and untreated by analytiC
psychotherapy are that the subtle problems remain and the life stalemates
persist. Growth, development, and self-actualization remain stalemated. The
dangers of activating primitive defenses remain.
Because the mediating locus of pathology is in the preconscious, reality
interventions from the point of the transference relationship of the analyst
can have ameliorative effects on these conditions even in the absence of
medication. When the cycle of reality and psychology, each affecting, inten-
sifying, and triggering the other, is interrupted in the transference, the
psychology of the near psychotic states can be analyzed and integrated by
many patients. They may then either never require medication or be able to
come off the medication. Many, however, will need maintenance medication.
In summary, psychotropic medication in mental illness strengthens the ego
for conflict repression, conflict integration, conflict adaptation in reality, and
conflict resolution in psychoanalysis. It further widens the "widening scope"
(Stone, 1954) of psychoanalysis. Medication wilh psychotherapy or
psychoanalysis makes mutative treatment available to otherwise treatment
resistant patients (see Marcus and Bradley, 1990). The use of medication to
overcome technical difficulties in psychoanalysis was first described by Ostow
(1957). For overviews of combination treatment see Sarwer-Foner (1960,
1983), Ostow (1962, 1966), Karasu (1982), Beilman and Klerman (1984), and
Marcus (1990). See Table 6.1 for summary of medication effects in pscyhosis
and near pscyhosis.
6. Medication and Mental Structure 213

Table 6.1 Effects of medication in pyschosis and near psychosis

I. Neuroleptics and autonomous ego functions in psychosis

Reinforce reality experience boundaries to increase distinction between:

In-out
Primary process-secondary process
Percept-concept
Percept-affect
Reality testing-reality experience
Unconscious-conscious (repression & stimulus barriers)
Real object-object representation
real self-self representation
real object-self representation
Day residue-symbolic alteration of reality
Thing presentation-affect/concept generalization, abstraction and
application

II. Neuroleptics and defenses in psychosis

Defenses that cross into conscious reality experience:

Reinforces reality experience boundary, unconscious-conscious

boundary, secondary process-primary process boundary, real self-self-
representation boundary (Result: defenses shift back to emotional
experience)

Layering of defenses within psychotic condensation:

Reinforces percept boundaries (Result: frees affect and affect/concept

from thing presentation condensation and concrete reification)

Mediating defenses:

Reinforce emotional experience validity as thing presentations shift

away from reality experience (Result: reduces rigidity of enabling
character defenses)
214 Psychosis and Near Psychosis

Table 6.1 continued

III. Thymoleptics and autonomous ego functions in psychosis

Increase ego ability to regulate and modulate affect:

Intensity
Spread
Emotional stimulation threshold; ease of evocation
Repression ability
Cycling of mood and subsequent "regression" (and thereby slowly
increase functional ego boundaries; see section I)

IV. Thymoleptics and defenses in psychosis

Increase:

Plasticity
MObility
Repression effectiveness

Decrease:

Rigidity
Dissocia tions
Captures of reality experience

Shift:

Level of integration
Content spectrum

V. Neuroleptics and autonomous ego functions in near psychosis

May increase preconscious boundary function due to sedation

Decrease fragmentation in those near psychotic states caused by

schizophrenia

VI. Neuroleptics and defenses in near psychosis

Nonspecific sedation effect only

6. Medication and Mental Structure 215

VII. Thymoleptics and autonomous ego in near psychosis

May dramatically and effectively improve preconscious boundary functions

by decreasing affect: intensity, recruitment, and spread.

Thymoleptics:

Decrease:

Preconscious capture of reality experience of real object and of

real self

Dominance of primary process condensation of affect qualities

with percept qualities of day residue with preconscious symbolic
alteration of reality

Cycling of mood and consequent "regression"

Increase:

Affect modulation
Secondary process
Thing presentation shift to word presentations
Affect-behavior boundary
Reality testing
Observing ego

VIII. Thymoleptics and defenses in near psychosis

By increasing affect control, thymoleptics may rapidly stabilize the ego's

defensive functions to:

Increase:

Effectiveness of defense (binding of affect) (integrations of affect)

Shift in major locus of character defenses to higher levels of

contents and processes
216 Psychosis and Near Psychosis

Table 6.1 continued

Decrease:

Capture of preconscious reality experience

Of real object and real self
Of reality testing
Of observing ego

Phantasmagoric content

Notes
1. Edith Jacobson (1964, 1967) was a pioneer in this area but never clearly
distinguished conscious, preconscious, unconscious, or real Object and real
self components of psychotic condensations. This is because she was
writing about Object relations experiences rather than focusing on ego
functions of autonomous ego as it organizes the object world.

2. An idea can be a perception when concept is expressed in perceptual or

sensory symbolic alterations of reality. An idea can be a perception, also,
when an idea is experienced as having reality qualities and validity
experiences typical of sensory perceptions.

3. Reality testing is a special, usually protected, and separate aspect of

reality experience.

4. Dr. Mortimer Os tow (1964), working with medication and concepts of

drive and energies, began as early as the 1950s to write about medication
and its effects on psychic structure from this point of view. He remains
the one who has written extensively on the problem of medication and
drive.
7
Psychoanalytic Psychotherapy and
Psychoanalysis of Psychosis

Introduction
Psychoanalysis and psychoanalytic psychotherapy have been used to help
neurotic patients by enlightening them about their unconscious psychology,
its dynamic content and process. This same theory of treatment holds true
for the psychotic states except that attention must be paid to the ego
structure of the patient which organizes these dynamics. In pSYChosis, that
organization is severely distorted. There is a structure to psychotic
psychological phenomena that must be understood by both patient and
therapist for treatment to be helpful. This is because without the analyst's
attending to structural aspects of ego dysfunction, the uncovering of more
unconscious material is not usable to the patient whose particular ego
deficits make it impossible to use uncovering for integrated enlightenment
and Change.
I will leave out most modifications of technique necessitated by specific
psychotic illnesses. I will describe only the general principles and
modifications of so-called classical technique applicable to all psychotic
illnesses. On treatment of schizophrenia see Fromm-Reichman (1948,
1959), Freeman et al. (1958), Searles (1964), Chiland (1977), Pao (1979),
Boyer and Giovacchini (1980), and Stone et al. (1983). On
manic-depression see Fromm-Reichman (1948), Lewin (1951), Greenacre
(1953), and Jacobson (1971); cf. Brenner (1976), Stone (1986), and Milrod
(1988).
This Chapter is meant as a guide and not as a formula. Every patient is
different, and what aspect of the illness experience is most available varies.
Clinical work involves careful observation and intervention and is best done
by an experienced clinician with good judgment based on that experience

217
218 Psychosis and Near Psychosis

and on long-practiced clinical skills (see Fromm-Reichman, 1955; and

Szalita-Pemow (1955).

Theory of Treatment
The treatment of psychotic states is different from that of neurotic states,
because the psychoanalytic psychotherapy and psychoanalysis of psychotic
states must deal with ego dysfunction (for papers on the relationship of
structure of the ego to technique see Hartmann, 1951; Eissler, 1953, 1958;
Lowenstein, 1958, 1972; and Blanck, 1966). There are two aspects of this ego
dysfunction: (1) the autonomous ego deficits and (2) the psychotic structure
(psychological content and experience of psychosis) as organized by those
ego deficits.
Integration of dissociations, increases in observing ego, increases in reality
testing, shifts of thing presentation to word presentation, decondensation of
psychotic symbol experience, and reinstitution of effective boundaries must
all be achieved for real insight and change to be possible.
Analysis does not mean only uncovering the unconscious or discovery of
the psychogenetic origins of symptoms in childhood. It also means describing
very carefully and specifically how the mind is organizing its experiences so
that the conscious ego can gain mastery of those processes. It is this aspect
of the theory of psychoanalytic treatment that is so important in working
with psychotic patients. The description of ego dysfunction so that it
becomes conscious can be as helpful to psychotic patients as the description
of unconscious emotional conflict is to the neurotic patient.
I realize that the description of unconscious conflict in the psychotic is
also important. As in any mental state, the analytic treatment involves
engaging the psychology of the patient and progressively unfolding the
unconscious conflicts. However, the ego dysfunction of the psychotic and
near psychotic imposes an additional task on the therapist-a task of
integration of this psychodynamic material with ego function. For other
cognition problems and techniques see Rosen (1967), Renick (1972), Kafka
(1984), and Rothstein et a1. (1988).
Integrating the new material has two aspects. The first is integrating the
mental experience within the mind. The second is the integrative application
to life, growth and change. Both are a problem in very ill patients because
there are psychotic links between reality, psychopathology, and psychological
structure. These links are in the ego and all psychoanalytic psychotherapy
works mainly with the ego. In neurotic patients, these relationships are
neurotic and the ego's flexibility to use analysis of them is assumed. With
very ill patients, there are linkages which are part of the psychotic structure.
7. Psychoanalytic Psychotherapy of Psychosis 219

Therefore, interpretation is important, but together with techniques of

bridging, strengthening, and integrating the relationship between the three
areas: reality, psychopathology, and psychodynamics in the psychotic
structure. This is called "working through" by psychoanalysts treating
neurotic patients. It has the same meaning for those of us who work with
psychotic and near psychotic patients, except that it means applying
psychodynamic information not only to different life areas and to different
aspects of the neurotic symptom but also to the experience areas within and
between psychotic and non-psychotic ego structure. Doing this in
psychotherapy depends on the structure and function of non psychotic ego
areas.
The goal of technique in the psychoanalytic psychotherapy of psychotic
states is to enlighten non psychotic areas of ego function so that they can
intervene and resolve the areas of psychotic process (see also Basch, 1981).
One does this technically by confronting intact but dissociated autonomous
ego functions and by analyzing defenses against intact ego function,
especially dissociations. Intact secondary process ego areas can, when
mobilized, take over the function of damaged ego areas which mediate
psychotic processes.
Crucial to this goal of psychotherapy is the use of medication which
directly strengthens secondary process ego function (see chapter 6; Sarwer-
Foner, 1983; and Marcus, 1990b; cf. Ostow, 1957, 1966).
Because of the complexities of the theory and teChnique of treatment, I
will summarize this chapter now, before going into detail, rather than at the
end. I will then return and cover specific points in detail. The basic theory
could be restated briefly as follows: analyze what needs to be uncovered,
support what needs to be supported, and integrate what needs to be
integrated. Pay attention at all times to reality testing, observing ego, and
integration. Stay in technical neutrality unless forced out and then return as
soon as possible. In order to do this:

1. Specifically diagnosis ego dysfunction;

2. Specifically analyze the psychodynamics of psychotic and near psychotic
systems;
3. Put together the ego dysfunction and psychodynamics of psychotic and
near psychotic systems.

This treatment chapter, thus, focuses on those aspects of treatment

determined by psychotic ego deficits rather than only content dynamics. (For
excellent reviews of content dynamics in psychotic illnesses see Freeman,
1988; Yorke et aI., 1989; Frosch, 1990; Gabbard, 1990.)
220 Psychosis and Near Psychosis

Table 7.1 Summary of psychoanalytic psychotherapy of psychotic states

1. Diagnose ego dysfunction by accurately observing:

A. Autonomous ego, especially:

1. Boundaries
2. Reality testing
3. Observing ego
4. Integration

B. Observe changing contours of these ego apparatuses:

1. Acute psychosis by definition means rapidly changing contours of

ego islands
2. Chronic psychosis by definition means stable ego island
boundaries, hence, stable psychotic material, even if fragmented

II. Treatment interventions based on these diagnostic observations:

A. Support autonomous ego with medication; use specific

medications for specific ego problems:

1. To stabilize boundary between inside experience and outside

experience, thereby decreasing fusion
2. To increase reality testing
3. To increase stability and secondary process integration of ego
islands
4. To stabilize the relationship between reality experience and
emotional experience in the direction of conscious secondary
process dominance
5. To decrease the intensity of affect and the spread of affect into
mood, thereby easing rigidity of defense

B. Support autonomous ego psychologically:

1. With structure of hospital routine and rules

2. With object constancy of therapist in reality
3. By recruiting and engaging unimpaired ego
(Le., memory, secondary process logic, reality testing in
non psychotic areas)
4. Use this recruited unimpaired ego to engage psychotic areas so
that conscious, cognitive dissonance about the psychotic areas is
experienced, acknowledged, and actively used by the patient
7. Psychoanalytic Psychotherapy of Psychosis 221

Table 7.1 continued

5. Interpret resistances to this therapeutic process (interpret
mediating character defenses against observing ego and of vertical
dissociations)
6. Support and encourage nonmediating defenses, integrations and
sublimations of dynamic affect content conflict as it is released
from psychotic condensations
7. Support and engage observing ego
8. Support self-esteem by interpreting superego attacks of shame and
failure

C. Interpret, analyze, uncover:

1. Mediating defenses and resistances to treatment

2. Mediating defenses against observing ego and against vertical
dissociations
3. Then analyze delusional and hallucinatory psychotic condensation
systems by interpreting:
a. Character defenses and resistances within the psychotic system
(repeats the psychoanalysis of mediating defenses)
b. Affect-content of psychotic dynamics, making sure to translate
thing presentation contents and qualities into word
presentations and affects
c. Day residue and reality Objects; derivatives in the present
linked with the psychogenetic day residue and reality Objects
of the past
d. Character conflicts of nonpsychotic areas; origins in the past

III. Summary of psychoanalytic therapy of ego deficit itself:

A. Empathize, especially with the quality of thing presentation experience

(in the beginning, sometimes this is all that can be done, but it is
crucial)

B. Observe ego deficit

C. Describe ego deficit

D. Allow intact autonomous ego functions to take over functions of

damaged areas; crucial to this is to:

1. Analyze any mediating defenses of the ego deficit

2. Analyze any defensive functioning and use of the ego deficit itself,
as part of conflict analysis
222 Psychosis and Near Psychosis

Table 7.1 continued

3. If secondary process systems are damaged, such as second-order
abstractions, remedial help with this function may be required
4. Challenge intact but dissociated secondary processes

A summary of purely interpretive technique, in the usual order of

importance would be (1) empathize with the thing presentation quality of
psychotic experience; (2) locate and clear observing ego; (3) martial intact
secondary processes; (4) interpret dynamics of the symbolic alterations of
day residue reality, thus revealing the primary process pattern linking the
psychotic content, the dissociated character conflict content, the dissociated
day residue, and the newly freed real Object or real self. This will result in
a decondensing of the psychotic experience into layered affect-contents,
reality day residues, and the psychogenetic past.
I will now give a patient example, but first I would like to say something
about such examples. Clinical examples can be crucial to understanding
mechanisms, but they have a problem in illustrating treatment with this
group of patients. A long and detailed treatment report is best equipped to
show the complexity, depth, psychogenetics, and progress ofa treatment. But
I would have to annotate a lengthy case to describe the intervention
rationale at each step, making the case report quite long. I have used short
reports of verbatim therapeutic dialogue to illustrate particular points of
technique. This can sometimes seem facile, superficial, and reductionist. This
is especially so because the initfal descriptive interpretations of thing
presentation condensations may appear to use metaphor (see Reider, 1972;
and Arlow, 1989) or be a clever pun or play on words. Actually, word
presen'tation channels and translating ego mechanisms are so blocked or
damaged that the patient cannot conceptually experience even these
superficial layers. This is why these interventions "work." The release of
affect and of greater complexity of content is proof that the validity and
veracity of certainty are correctly captured at the proper beginning level by
the interpretation. The emotional effect on the patient is easily observed if
the interaction is accurate. It is difficult or impossible to convey this in print,
especially if for the reader, seeing is believing. Nonetheless, I will proceed
with such brief examples in the hope that they will suffice to illustrate
certain technical points. (For descriptions of standard psychoanalytic and
psychotherapy technique see Greenson, 1967; or Langs, 1973.)

Example:
A woman in her mid-80s suffered several cerebral infarctions (strokes) and
several heart attacks, leaving her in chronic heart failure; confused, mildly
disoriented, and with memory defects. She complained that the people in the
neighborhood were talking about her. They say she didn't pay taxes after World
War II. Why would they say that? She doesn't steal. Once she was accused of
stealing money when she first started working, but it wasn't true. Now they say
7. Psychoanalytic Psychotherapy of Psychosis 223

she's a shoplifter. She feels that her maids and her sister are stealing from her.
She then said to the analyst, "You work in this neighborhood. You must have
heard them saying this."
The first session was spent taking the history, including the details of her
delusional system. Because of her medical illnesses, psychotropic medication was
dangerous. At the end of the session, when the patient reiterated to the analyst
that he must have heard this, the analyst said, "I have not heard this. It may not
be true that they are talking about you. It may not be true that they are accusing
you. I have not heard it." In addition, her husband, who brought her to the
session, was instructed not to support the delusion anymore with reassuring and
calming statements about paying no mind to what other people say. On the
contrary, he was to reiterate that he had not heard such things and feels they are
not true.
Session 2: The patient says she is feeling better. Now her worries bother her
only at night, when she awakens at 1:00 a.m. with a low feeling. They accuse her
of stealing.
Analyst: "You have a low feeling about yourself."
Patient: "I always had a high feeling about myself, maybe too high. I was
always a leader at work. Then I retired four years ago and they began talking
about me." (The day residue precipitating event has just appeared! It is not the
strokes, as the analyst first thought, but the retirement! Why has retirement
affected her so?)
Analyst: "You had a high feeling about yourself, but underneath you felt your
feeling about yourself was too high. Then you stopped work, which had helped
maintain your high feeling about yourself, and now you feel low, as if your
former high feeling about yourself was undeserved-6tolen! (This integrative
interpretation ties together manifest content statements that she has made and
the delusional content.)
Patient: "I used to be a leader in the neighborhood association. I urged my
husband to go to the meetings. He would have no part of it. Now he's president
of the association. I don't go anymore. They might say something bad about me.
But I'm not sad. My memory's no good anymore. This makes me feel bad. I
used to keep my work in my head."
Analyst: "Did you keep all the business in your head?"
Patient: "No, I had index cards."
Analyst: "So, you didn't keep the business in your head. You had index cards."
Patient: "Why are they saying bad things about me?"
Analyst: "It's your feelings about yourself. Your mind is looking in the past
for your bad feelings about yourself. The problem is now."
Patient: "What is the problem now?"
Analyst: "After your strokes, your memory went bad. You feel you relied on
it. Now at association meetings, you're not a leader anymore."
Patient: "My job! I kept it all in my head."
Analyst: "No, you had index cards."
Patient: "So what?"
Analyst: "So your memory was never perfect. The memory loss now is also a
symbolic loss attaChing itself to a newly revealed low feeling about yourself which
really began when you stopped working."
Patient: "Not being able to do! I feel guilty about not being able to do! As a
224 Psychosis and Near Psychosis

little girl, I made all my own clothes for myself and my brothers and sisters."
Analyst: "Almost as if you were the mother, an honor which you felt you stole
and made up for your guilt by working hard. Now you can't work."

That was the end of the second session. In followup by phone a few days
later, the patient and her husband said she was greatly improved. She was
sleeping again. She said she was troubled in her mind but now she was over
it.
In this two-session supportive and uncovering treatment, I supported
observing ego, reality testing, memory, logical secondary process, self-esteem
via interpretations geared to increase understanding of the patient's
problems with self-esteem. I did this by integrating manifest elements:
delusion, history, current events, behavior, associations, affect, all put in an
integrated secondary process statement by the analyst-an integration
indicated by the primary process and the structure of the psychotic symbol.
This treatment process rapidly resulted in insight-an understanding of the
relationship of feelings to reality to psychotic symptom.
I will now describe the techniques of treating specific ego deficits.

Boundaries
The most distressing boundary that is frequently lost in acute psychotic
states is the boundary between inside experience and outside experience.
Loss of this boundary is a conscious, cognitive dysfunction. There is much
confusion in the literature which ascribes this cognitive deficit to an
unconscious fantasy. It is much more than a fantasy, however. Some authors
go so far as to say that there is difficulty telling this fantasy from reality. In
fact, the deficit is far worse even than that. It is a true inability of the mind
to contain its own experience separate from percepts of outside stimuli.
Percepts that would ordinarily be contained in outside experience seem to
be part of the inside experience. With the mind a totally open system, no
treatment can take place, because there is no coherent, stable experience of
oneself or of the therapist. An example is shown when the therapist
scratches his leg and the patient says, "Why are you scratChing my leg?"
The treatment for loss of the inside-outside boundary is medication.
However, before medication was available, and even nowadays while the
medication is taking effect and in those for whom medication is ineffective,
an attempt to connect with and enlighten the patient about this experience
can be made. (The pioneers in this area were Sullivan, 1953; Fromm-
Reichmann, 1953; and, more recently, Searles, 1964; and Pao, 1979. Cf.
Boyer and Giovacchini, 1980; and Stone et aI., 1983.)
The late Dr. Harry Albert (see Stone et aI., 1983), an extraordinarily
gifted therapist with psychotic and near psychotic patients, used to offer the
following example: He is sitting in his office with a new patient who is
7. Psychoanalytic Psychotherapy of Psychosis 225

talking word salad. There is no coherent sentence structure. Dr. Albert lifts
his two hands and clasps them together intertwining the fingers. "See?" he
says to the patient. "There are really two but they seem as though they're
one." He opens and reclasps his hands, several times. "It seems as though
they're one, but they're really two." He demonstrates this again several times.
Patient response: "This is the only sensible thing a psychiatrist ever said to
me." (It was also the first time that she used a syntactically intact sentence!)

Another example:
While sitting for my PSychiatry specialty board examination, I was asked to
interview a young man in the presence of an examiner. The patient entered the
room agitated, excited, and fearful. His thinking was obviously fragmented, but
he managed to convey his great anger that he was being tested and that he might
fail the test and lose all possibility of a weekend pass. To make matters even
worse, he said, I was trying to confuse him by not making sense. His rage was
close to physical assaultiveness. Attempts at reassurance and denial did
nothing, and so I told him that if I was trying to confuse him, it was too bad for
me, not him, because the examiner was examining me, not him, and if I was
confusing him I would fail, not him. He calmed considerably, sat down in his
chair, and asked if I was sure the examiner was examining me, not him. I said I
was sure and asked the examiner to verify this. He did so. The patient then asked
the reason for the examination. I said it was for my certification as a psychiatrist.
He said I was in a lot of trouble because I was confusing him and therefore I
would probably fail the exam, and could he help me out in any way so that I
might pass the exam! I thanked him and asked my next question: had he ever
thought he was confused. He got angry and said I was again trying to confuse
him because he had just said I was confused, not he. I said I wasn't trying to
confuse him and asked him if other people had said to him that he was confused.
He said yes, and I empathized with him about how difficult this must be for him,
since he felt he wasn't confused but they were saying that he was. In this way, we
both got through the 3D-minute interview.

Even more common than the totally open boundary of acute psychotic
states are lesser degrees of this same dysfunction. Emotions which can enter
from experience outside directly into experience inside disrupt self
experience, even when the boundary to reality factual event stimuli is
maintained. Similarly, ideas that other people (Objects in reality) have may
be immediately incorporated into the self experience and verbalized as if
those ideas had originated in the person himself. Both affect and ideational
boundary porosity are easier to work with than a total loss of inside-outside
boundary in which all perceptual stimuli are blended in a fused
inside-outside state.
In all these patients, there is some degree of fusion, with inability to tell
the therapist object in reality from the real Object from the Object
representation from the real self or the self representation. Technique
involves immediate and active intervention at the boundary of in-out to
delineate a difference, at least in the object in reality.
226 Psychosis and Near Psychosis

Example:
Patient: "The voices are threatening me again. I'm fed up. They sound
somewhat like your voice, doctor!"
Analyst: "I have nothing to do with those voices!"
(For a discussion of psychotic transference see Reider, 1957; Searles, 1963; and
Little, 1981.)

In-out boundary problems, whether or not they capture the therapist in

reality, are often highly distressing to the therapist. Countertransference
confusion and panic can result. Sometimes active interventions are needed
to help the therapist as much as to help the patient. Each of us has his or
her own tolerance limits. With experience, those limits grow more secure.
Hospitalization during acute episodes helps both patient and therapist in
this regard. A physical boundary is drawn between patient and therapist. A
schedule boundary is drawn between the patient's disorganization and social
reality. That schedule boundary is both sequential and multidimensional
(space, time, logic, behavioral). Multiplicity of staff provides instant relief
and support to the solitary therapist and to the in-out boundary.

Reality Testing
Reality testing, lost in both acute and chronic psychotic states, is usually lost
around condensations of real object and object representation or of real self-
experience and self-representations. It is along this boundary that therapy
can be so helpful. The submerging of day residue in emotional material
which is organized along primary process lines due to the capture of reality
by fantasy further impairs reality testing. Therapy can also, therefore, help
reality testing along the boundary of the day residue-symbolic alteration of
reality.
Reality testing is also helped by liberating observing ego. The description
of day residues and reality niduses contained in events and in real Objects as
revealed in the primary process organization of the pathological phenomena
enables the observing ego to understand that the condensations are
occurring as a mental process. This challenges intact logical processes and
therefore buttresses reality testing.
It is relatively easy to do this, particularly in the acute phase, because all
real objects, including the psychotherapist, are day residues that become
immediately incorporated into the psychotic experience. If one observes and
is aware of this happening, it forces an intervention by the therapist that
validates real Object distinction. This is extremely helpful to the patient.
Because the delusional patient has reality testing outside of the delusional
content area, the therapist need not necessarily tell the patient what reality
is. He has to get the patient to tell the patient from the vantage point of the
secondary process ego. Although this is easier said than done, it enables the
7. Psychoanalytic Psychotherapy of Psychosis 227

therapist to maintain technical neutrality and therefore to allow the patient

to observe, thus building more effective ego. The advantage in technical
neutrality is that it maximally mobilizes the patient's intact reality ego.

Example:
A 75-year-old man who lives with and is taken care of by his 50-year-old son
presents with a two month history of feeling infested with worms in his intestines.
He feels them "thrashing" around. He feels that he passes a lot of flatus, is
swollen, and smells bad. His flatus, the worm flatus, he can feel them and smell
them. Others can smell them too, and think he's repulsive. The worms keep him
up at night and bring him to tears. He looks in his stool for them but never sees
them. Once he found a white kernel but it was only undigested corn.
Therapist: "What do you make of the fact that you feel them but you don't
see them?"
Patient: "Oh, no! It's not in my mind! They are really there!"
Therapist: "What do you make of the fact that you feel them but you don't
ever see them?"
Patient: "Could it be in my mind? I don't believe it. Maybe a doctor could see
them."
Therapist: "Have the doctors seen them?"
Patient: "My son says I should go to a doctor."
Therapist: "Your son?"
Patient: "Yes."
Therapist: "Tell me about him."
Patient: "He's sick, too. He had a heart attack two months ago. He's only 50
years old."
Therapist: "That has been very upsetting to you."
Patient: "I am very agitated."
Therapist: "You feel like you're thrashing around."
Patient: "He's my last child and only son. I didn't really want another child but
we became very close."
Therapist: "He wormed his way into your affections."
Patient (laughing): "He was a very cute baby. Very active."
Therapist: "Like a wiggly, thrashing worm."
Patient: "And eager to please!"
Therapist: "Although you didn't want him around at first, the thought of
losing him now is eating away at you."
Patient: "I feel terrible."
Therapist: "You feel repulsive."
Patient: "I do (tears)."
Therapist: "You feel your initial rejection of him was a repulsive thing and
now you feel you deserve to be treated like a worm."
Patient: "I don't know what I'd do without him."
Therapist: "Is he very sick?"
Patient: "Yes, he's going downhill right in front of my eyes (tears)."
Therapist: "And your health?"
Patient: "I had cancer of the bowel two years ago but I'm fine now."
Therapist: "When was your operation?"
228 Psychosis and Near Psychosis

Patient: "About this time of year."

Therapist: "Any new symptoms?"
Patient: "Yes, I haven't felt well and I've intermittent diarrhea."
The therapist called the patient's internist and sent the patient to the internist.
A stool culture for worms was done that day. Haloperidol (neuroleptic) was
given, 0.5 mg once at night. The stool culture came back the next day-negative.
The patient asked the internist if he had ever seen patients who thought they had
worms but it was all in their minds. The internist said yes. Two days after that the
patient returned to the therapist and said it had all been in his mind. He never
knew such a thing could happen. He discussed his feelings about his son again
and stopped the medication, saying he was feeling better. A week later, blood
tests came back, and cancer of the bowel metastasized to the liver was diagnosed
by the internist. The patient has not been psychotic again, now one year later.

In this example there were multiple condensed day residues: the son's
being ill, the recurrence of diarrhea, etc.. All were eating away at him at an
unconscious level. These day residues were eating away at him literally in
reality (the metastatic cancer, the son's heart attack) and also emotionally.
The treatment sessions challenged observing ego and used that observing ego
to challenge reality testing. This was done by using the fact that he never
saw the worms to confront the delusion and to challenge intact logical
processes. This was also done by elucidating relevant psychodynamics and by
relating those dynamics to the uncovering day residues, thus decondensing
the psychotic symbol. The worm symbol seemed to be a condensation of his
experience of his real self, of his self-representation, and of the Object
representation of his son. It symbolized how he felt about himself in his
depressive guilt and how he felt about his son in his aggression and fondness
for that son. The condensation of self-representation and Object
representation was at an unconscious level. The condensation of real self-
experience and self-representation in the repulsive feelings about himself in
the worm symbol was conscious. At no time was there an actual fusion
between real self and real Object.

Observing Ego
The fact that patients can have an observing ego about their psychOSis leads
to the hypothetical distinction between observing ego and reality testing and
the hypothesis that observing ego and reality testing are two separate ego
functions. Because analytic therapists are used to having patients with the
ability to distinguish the treating physician from their conscious ideas about
the physician, who have some understanding that they are ill and even some
understanding of the problem they would like to begin to focus their
attention on, the fact that observing ego is obliterated in sicker patients is
often overlooked or its implications are not fully appreciated. A true
7. Psychoanalytic Psychotherapy of Psychosis 229

treatment alliance in which a patient and a physician are working together

in order to help the patient with the patient's problems is really possible
only when an observing ego exists so that there can be some beginning
agreement about what those problems are. The true therapeutic alliance is
attached through the receiving locus of the observing ego (Sterba, 1934).
Therefore evaluation and treatment of this mental faculty are crucial in
psychosis and near psychosis. To help a delusional patient to the point
where he or she says, "I understand that what I believe is part of my illness,
but I believe it anyway" is a monumental step forward, because true mutual
work on the illness delusion can now occur. When observing ego is able to
view illness, it is a hair's breadth away from being able to observe day
residue and real objects. This is a step on the road to viewing self- and
object representations in reality experience and moving them back into
emotional experience.
Such distinctions are the difference between ego syntonic psychosis and
ego dystonic psychosis. The dispassionate discussion of the patient's illness,
and therefore the examination of observing ego, take place from the very
first contact with the patient when the analyst is able, one way or another,
to say to the patient, "What's wrong?"
A differential diagnosis of absent observing ego must be explored
immediately upon observing it. The differential diagnosis is made by the
verbal observation and engagement of the psychology of this issue with the
patient. The differential diagnosis includes psychosis with severe boundary
disturbance obliterating observing ego, or delusional inclusion of observing
ego. These two are actually not common. More commonly, a third problem
exists. This is the barrier to observing ego due to character defenses that are
intensely mobilized, either by the psychotic phenomenon itself or as part of
the character defense environment of the illness. It is these basic character
defenses that must be engaged and interpreted early so that observing ego
may then be possible. The therapeutic query "I notice you don't tell me
about your illness" is followed, in those patients with defenses against
observing ego, by a patient response that expresses the defense. These
defenses include simple denial, projective paranoid rage, omnipotent control,
negative evaluation of the therapist, narcissistic self-aggrandizement, and
hysterical emotionality. The defenses chosen as resistances are often
characteristic of the basic character organization in specific mechanism and
thematic character type. These basic core defense resistances are testimony
to the emergency experience that psychosis is. The emergency defense
reaction hides the discomfort that could help the illness be ego alien, but
also extremely painful. In addition, because exploration of observing ego
leads to rapid diagnosis of character problems and their interdigitation with
psychotic illness, the work can focus early on central issues that in a
healthier patient might take years. As with much of the analytic treatment
of very ill patients, there is opportunity in crisis.
One problem is that these character defenses are along an axis of neurotic
2..10 Psychosis and Near Psychosis

to borderline to psychotic. The technique of dealing with them will vary

depending on their location along this health-sickness axis. However, it is
amazing how often in psychotic patients the character resistances to
observing ego are at a neurotic level of organization.

Example of separating observing ego from reality testing:

Therapist: "Hello. I am Dr. X. How may I help you?"
Patient: "The rays are entering my body and destroying my brain. I must get
out of here. Please open the door."
Therapist: "I am a doctor. I help people who have iIInesses."
Patient: "Can you help me?"
Therapist: "Could it be that you have an iIIness?"
Patient: "Perhaps I do. But the rays are entering my body and ruining my
brain."

This early intervention has begun to separate a bit of observing ego away
from its merger with the psychotic process. It easily separates, as we can see,
with a simple noninterpretive statement of fact by the therapist. This is
because observing ego function may not be condensed in a primary process
attachment to the psychotic process. In this patient, no basic character
defenses were mobilized that prevented observing ego from separating, and
therefore no interpretive statements about character defense are necessary.
If the intervention by the doctor had elicited character defenses, those would
have been interpreted.

Example:
Patient: "X-rays are destroying my brain!"
Therapist: "I am a doctor. How can I help?"
Patient: "A doctor can't help me, you idiot!"
Therapist: "When I talk to you about being iII, you get very angry. Your anger
may be because were you to acknowledge that I am a doctor, you would logically
have to realize that you are iII. This could be very devastating to you. Perhaps
you fear you would then feel helpless and totally vulnerable, like an idiot."

Integrating Capacity
Most important in working with psychotic and near psychotic patients are
the vertical dissociations of one mental experience from another. Again,
basic character resistances may be involved in the separation. These are
engaged and interpreted when the dissociation is pointed out. This can be
done by simply asking, "And what is the relationship between experience A
and experience B?" The response may be an early attempt at integration or
it may be a dispassionate observing ego discussion. Either of these is good.
Even "I don't know" is a step forward, since it is a statement by a
nonpsychotic observing ego. More commonly, one gets the same basic
7. Psychoanalytic Psychotherapy of Psychosis 231

character resistances that got in the way of an exploration of the observing

ego function. These must then be interpreted, even if it is very early in the
treatment and even if the patient is still psychotic. It is particularly helpful
to interpret the dissociations that occur between psychotic and non psychotic
content and any character resistances between the two. The worry that this
will incorporate non psychotic areas into the psychosis is balanced by the
opportunity that psychotic areas may become more reality-oriented and
integrated with nonpsychotic areas. The key is to take the risk of doing it
and to observe very carefully the immediate results of the intervention:
whether it leads more toward the loss of secondary process integration and
reality testing or more toward the gain. If it leads more toward the loss,
point this out. Reinterpret any character defenses that appear. If this leads
still further into loss of secondary process, then back off, readjust
medication, and start again at some later time. Almost always, however,
interpretation in this manner improves things considerably, even if only for
the period of time of the analytic interview with the therapist. Once again,
this is because the integrating capacity of the ego is not entirely lost in all
areas of a psychotic patient's ego functioning; the intact areas have been
separated from the delusional areas.

Modulating Capacity
The modulating capacity of the ego is severely damaged in acute psychotic
states and may be somewhat damaged in chronic psychotic states. This
means that evoked affect easily and explosively increases in intensity and/or
affect is rigidly frozen and unavailable to self and Object representation
experience. The first is the most frightening and the second is the most
trying for the therapist. Comments about explosive affect and its evocation
must be made immediately, before the eruption spills over into behavior.
Great care must be taken in the interview not to free affect or affect-
triggering experiences into the damaged ego. Anything can be said by the
therapist if it is said calmly and with great concern, respect, and empathy for
the patient's ego dysfunction. Preparation of nonpsychotic areas of ego
function can be made so that the exploratory engagement of psychotic
material is with the patient's permission, cooperation, and planning. In those
patients with rigidly frozen and unavailable affects, this too can be noted
with the patient, and the appropriate affect supplied by the patient'S
secondary process logic. This is not an experience of the affect. It is an
intellectualizing defense. But it is a higher-order defense than denial and
extreme affect isolation. The intellectualizing step may allow the
understanding before insight that permits less anxiety and more available
affect experience. The defenses against affect in rigidly frozen patients,
including paranoid patients, are best engaged early, since they will lead to
232 Psychosis and Near Psychosis

emotional experiences that can integrate with, and dilute the power of, the
aggression that these patients may be experiencing. Once again, it is
important to realize that even the more tender emotions may carry, for
paranoid patients and others, humiliation experiences that are even more
painful than the frightening retaliation fantasies they suffer because of their
aggression.
The bottom line of defense analysis in psychosis is that defenses are
interpreted that serve as resistances to treatment and provide barriers to
higher-level ego integrations by blocking observing ego and permitting
vertical dissociations. These are interpreted because they must be. Higher-
level neurotic defenses that help contain affect and organize experiences,
such as intellectualization, may be encouraged early in treatment. They are
not interpreted early unless they are used as resistances to treatment. One
is, therefore, working with a graduated series of defensive structures from
psychotic to borderline to neurotic, even in many psychotic patients. The
psychotic defenses are layered in the delusional system, the borderline
defenses usually surround the delusional material in the gap of vertical
dissociations, and the neurotic defensive structures are farther away in stable,
non psychotic character areas. The diagnosis is made by the sickest areas.
Although it is confusing, it is the very spectrum of ego defenses in most
psychotic patients that makes treatment possible.

Object Relations
Remember that the usual crucial problem in Object relations,
pathognomonic for psychosis, is the condensation of real Object with Object
representations or the real self-experience with self-representations in
conscious cognitive experience. There are often other boundary problems as
well, such as the inside-outside boundary problem. But all stable psychotic
states show this problem in Object relations. Exact configurations will vary
from illness to illness and also from patient to patient, depending on the
psychic structure before the illness intervened.
Psychoanalytic psychotherapy and psychoanalysis attempts to help the
patient separate the real Object from the object representation and the real
self from the self representation. An attempt is first made to liberate enough
observing ego to engage concern about this condensed experience. The
patient must be helped toward the separation. This takes place in the
observing ego at first, from the transference and from outside the
transference. The therapist remains in technical neutrality unless reality-
based interventions are required. Sometimes all this is to no avail, and the
analysis of thematic content must proceed even though the condensation of
the Object world is occurring and perhaps becomes transiently worse with the
analysis of thematic content. It is helpful to have such patients in a hospital.
7. Psychoanalytic Psychotherapy of Psychosis 233

The point is that although defenses against observing ego and integration
may be rigid, very often defenses against deeper layers of object relations
material are not so rigid. The analyst should proceed cautiously, but deeper
analysis will uncover recurrent Object relations themes, recurrent
coincidences with objects in reality, recurrent content of the patient's past,
and crucial present day residue events with their sequences and contexts.
This will help the potentially available secondary processing of object
relations, because the psychological organization of the psychotic object
relations structure becomes clearer and clearer in contrast to Objects in
reality. This makes it harder and harder for observing ego to ignore the
difference and for defensive structures to prevent the recognition of
psychotic objects by nondelusional secondary process areas of mental
functioning. This statement describes a crucial aspect of the theory and
tactics of analytic, that is to say uncovering, treatment of psychosis. It is the
reason the analytically trained therapist has so much to offer the psychotic
patient. However attention to ego synthesis is required, and this means
constant vigilance by the therapist. Analytic treatments that uncover but do
not use this material to help the patient with non psychotic integrative
capacities may make the patient worse and lead to the chronic
psychotization of more and more ego areas that prior to treatment had been
nonpsychotic areas. It is for this reason that psychoanalytic treatment of
psychotic states in the past got such a bad name (Wallerstein, 1986). This
was especially true when medication was not used. However, awareness of
vertical dissociations, of observing ego lack, and of reality testing loss will
enable the analytic therapist to avoid the pitfall of ignoring integration and
synthesis.
At what points unraveled layers of deeper emotions and repressed factual
experiences should be used for integration of partially separated psychotic
objects is a constant question. Clinical judgment is most difficult because it
involves a constant measure of the plasticity of the psychotic condensation
and the integrative capacity of the autonomous ego. The guideline is,
however, really quite simple. Every time new object relations dynamic
material emerges that makes sense to the therapist and that is not utilized
for synthetic integration by the patient, this must be inquired about and the
resistances to this process interpreted. This is especially true when a glaring
coincidence of thematic material emerges or when a factual detail emerges
that was previously unknown or disputed but that is now seen clearly by the
patient and that throws secondary process doubt on the primary process
psychotic story. A simple question by the therapist "What do you make of
that?" is usually enough to start the integrative process. One is asking the
patient, therefore, not to lead into more dynamic material but to consider
the significance of the material exposed. In this way, intact areas of
secondary process can be mobilized for integration along with any mediating
defenses which can then be interpreted. (For other approaches see Jacobson,
1964, 1967; and Rosenfeld, 1965.)
234 Psychosis and Near Psychosis

Thing Presentation
It is important to comment on the thing presentation experience in psychosis
and its treatment. If one remembers that thing presentation experience is the
experience of feelings condensed with the experience of perceptual things,
with the quality of reality binding the emotional experience of affect, one
can understand that the treatment of the thing presentation experience is to
translate it into word presentation experiences, including descriptions in
words of the affects. The therapist must describe thing presentation
experiences in words. The patient is helped to describe that experience in his
or her own words. The affect experience can be deduced from free
associations of the patient, empathic resonance in the therapist of the
psychotic symbol, more available similar affect in derivative symbols, and
free-floating affect in the patient when it occurs. The affect can then be
experienced in the patient's self-experience of affect.
The ego functions involved in word presentation processing for affect are
impaired in psychotic patients. Which ones are impaired depends on the
psychiatric illness. The translation of emotionally contaminated percept
experiences into higher-level, verbally organized conceptual and affect
experiences allows for greater separation of complex condensations involved
in the thing presentation experience. The translation function is a higher ego
function. It may be damaged by acute illness or it may be an ongoing
problem for patients, especially some of those with dyslexia.
Patients understand the power of the therapeutic translation process and
express their understanding in their resistances. A non psychotiC example is
sexualized thing presentations, because the quality of erotic affect experience
is condensed in the perception of the reality thing. "Telling it in words ruins
it." But although the statement is not totally false, it is not totally true. The
statement represents despair about the capacity of higher-level ego
functioning to (1) contain, (2) express, and (3) experience real self and real
object integrated with ambivalent, complex, layered affect. In fact, word
presentation mental experience evolved presumably because of the power it
gives to organize reality in ways that are beneficial not just for dealing with
reality but for satisfying one's own emotional desires and reassuring one's
own fears.
Changing thing presentations to word presentations involves some level
of interpretation, because the thing presentation condenses present and past,
concept and affect. As the interpretive word presentation statement is made,
the patient will experience and provide confirmation: often a startle reaction,
often an affect reaction, always a process of elaboration that reveals new
material (Langs, 1973). This is because the thing presentation experience is
decondensing as word presentation processes provide discharge and
conceptual pathways (Sarnoff, 1976). Therapeutic facility and accuracy in
7. Psychoanalytic Psychotherapy of Psychosis 235

catalyzing this process comes with practice and with the intuitive familiarity
that experience with very sick patients gives.
It is crucially important to diagnose the reason for the predominance of
thing presentation experience. It may be due to the disorganization of
thinking permitting the emergence of primary process material. It may also
be due to the oveIWhelming affect that condenses in thing presentation
experiences to provide a containment barrier to intensity and spread. Word
centers in the brain may be damaged, as in neurological illness (remember
that dyslexia is a neurological illness). A treatment plan based on the proper
diagnosis can then be planned.

Thing Presentation Quality

One crucial aspect of the thing presentation experience is the peculiar
quality of the experience. It is a condensed affect-percept experience and
has the qualities of both affect and percept. Therapeutic empathy with this
quality is important in early treatment. Such empathy helps patients feel
their psychotic experience is understood by the therapist and therefore that
they can get help from the therapist. An empathic statement about this
quality should be part of the first intervention. Tone, gesture, and attitude
of the therapist can all convey this empathic concern. But the beginning
attempt to decondense and psychoanalyze involves expressing this quality in
words.

Example:
A young woman who lives in her own apartment in the same building as her
father, and who left her mother, grandmother, and stepfather one year ago,
presents to the emergency room with a two-week history of acute psychosis. The
world is coming to an end. God is killing all the people by burning them because
of their sins. She believes she is Judas, who betrayed Christ. God's voice says she
can fly. If she opens the window and jumps, she can save the world and get
forgiveness for sins. God told her to jump and she smelled the burning building.
Therapist: "You must have been terrified!"
Patient: "I was!"
Therapist: "And sin?"
Patient: "The sin of lying."
Therapist: "How so?"
Patient: "I didn't speak up."
Therapist: "How so?"
Patient: "A boy recently kissed me and I couldn't tell him I didn't want him
to do that."
Therapist: "But sin is Judas, and God burning the world?"
Patient: "Well, sex."
Therapist: "How so?"
Patient: "My stepfather molested me from age 8 until age 12. He fondled my
236 Psychosis and Near Psychosis

breasts and vagina. 1 kept a knife and wanted to murder him. 1 told my family
but my grandmother and mother didn't believe me."
Therapist: "You felt betrayed by your mother and grandmother who didn't
believe you and didn't stop your stepfather from sexually molesting you. They
allowed it to continue. You feel frightened and guilty because you are so angry
about it and because the sexual activity was frightening to you then. You suffer
from this now. It interferes with your sexual relations with men now. The guy
trying to kiss you stirred all this up again. You badly need treatment."
Patient: "But 1 shouldn't have allowed him to kiss me."
Therapist: "But maybe you were sexually attracted to him."
Patient: "I hate sex!"
Therapist: "You hate your sexual desire because it reawakens all the anger
and fear of what happened back then. But it isn't back then now. You couldn't
say no then, but you can say no now. The problem is will you ever be able to say
yes! Now when you sort of say yes, you feel terrible."
Patient: "I do!"

Notice the progressive affect decondensation into emotional experience

and expressed in words as the exploratory interchange progresses. Affects of
anger, sadness, and guilt are moving out of the perceptual, other-worldly
experience of percept into words and into the direct experience of affect.
Psychogenetic day residues of the past are separating from present day
residue reality precipitating events.

Analysis of Psychotic Structure

Now we are at last ready to proceed to discuss analysis of delusional content.
Analytic therapists should be quite comfortable with this aspect since it
involves the same uncovering work with much the same technique as with
neurotic patients. It requires only a greater observational attention as the
unraveling of the dynamiC system of the delusion occurs so that attention
can be paid to the liberated day residues, real Objects, and recurrent
dynamics which intact ego areas must integrate and work through. Working
through is left to the intact neurotic ego of neurotic patients, by and large,
and requires little effort on the part of the analyst other than to point out
the recurrence of the dynamic themes. The analyst of neurotic patients may
consider the working through aspect as part of the patient's job and
abstinence in this area as part of technical neutrality. However, even in
neurotic patients, working through requires attention to the same dynamics
in other areas at other levels, and some neurotic patients require a good
deal of this therapeutic attention. Psychotic and near psychotic patients need
help in this area in particular, through the analysis of enabling defenses of
vertical dissociations and/or through an understanding of the autonomous
ego deficits of generalization/abstraction. They need help not just in
7. Psychoanalytic Psychotherapy of Psychosis 237

uncovering similar themes in different areas but in integrating and applying

this knowledge.
Remember that around every delusion is an area of pseudo-delusion: an
area of the same dynamics with slightly different application in which reality
testing seems to be gone but is in fact present. Technique in this content
area can be freer and more engaging than in the delusional area itself,
because reality-testing processes are potentially intact in these areas. The
goal is to free the delusion from associated psychological areas of pseudo-
delusion and, in that way, reduce the delusion to its essential core.
In order to do this analysis, one must maintain technical neutrality unless
forced out of it by the pressure of behavior or of imminent behavior. This
is because in the area of pseudo-delusion, reality testing is possible and the
patient's own reality testing must be challenged rather than replaced by the
therapist's. In psychotic patients, the therapist may actually have to provide
reality testing. But do not expect this supplied reality testing to immediately
change the reality testing of psychotic structure. Psychotic condensation and
its capture of reality testing is usually quite rigid. The technical intervention
should, however, increase observing ego and increase secondary process
logic, and these two newly freed and recruited autonomous ego areas can
begin to help reality testing and to decondense the psychotic symbol. The
movement out of technical neutrality that is required is usually a statement
about reality or about the real object. It is important to return to technical
neutrality as soon as possible so that potentially available aspects of the
patient's own ego functioning can be engaged.
Technical neutrality in psychotic and near psychotic states, however, does
not mean passivity or failure to interact. On the contrary, the therapist must
be very active in challenging intact ego areas by pointing to the primary
process logical inconsistences of delusional and pseudo-delusional material.
It is only in this way that intact ego islands can be recruited for therapeutic
benefit.
The next important issue is to use free association. Consider as free
association all of the communication stream of words, of affect display or
lack of display, of behavior, and of psychotic symptomatology. Many
psychotic patients can, in fact, truly free associate and free associate more
freely than many neurotic patients. These psychotic patients are those who
are only somewhat unintegrated and in whom primary processing has not
dominated all of cognition. The diagnostic question with psychotic and near
psychotic patients is whether there are true free associations or whether you
are really dealing with loose associations. Loose associations are primary
process intrusions, unwanted, into secondary process communication. Loose
associations, like free associations, will enable the therapist to follow affect
content themes to guide interpretation. But patients with loose associations
have an ego deficit and the therapist must be clear that patients can use
such information. If not, some diagnosis of why not must be made and some
treatment plan within the analytic therapy provided.
238 Psychosis and Near Psychosis

There are many frozen delusional patients who do not truly free associate.
Nor do they have loose associations. However, their verbal streams, which
go from content of delusion to content of character dynamics to statements
about the condensed real object-object representation, are a type of
dynamic information. This type of free association involves a verbal stream
in which latent and manifest contents are condensed with each other and in
which the relationships between vertically dissociated aspects of mental
experience are demonstrated to the therapist by their contiguity in the verbal
stream. That they are related is hypothesized, and their exact relationship
requires analysiS. Sometimes the relationship is quite clear to the therapist,
because a dissociated or displaced affect experience is observed which links
them. This does not mean that the patient is aware of this link or able to
use the link. That requires some analytic help. Once again, basic character
resistances may need to be analyzed. Again, ego deficits of secondary process
integration need to be diagnosed.
In unraveling delusional systems, all analytic therapists have struggled with
the rigid loss of reality testing and rigid denials of fact that many psychotic
patients suffer. The delusion, therefore, does not unravel. Often, however,
delusional systems unravel, but the analyst does not recognize the unraveling
because the elements are dissociated from each other or are in the
transference. Alternatively, the analyst may recognize the unraveling but
does not know how to help the patient use this unraveling. However, in
some patients the delusional system truly does not unravel in a verbal
stream, despite engaging the material and analyzing basic resistances. This
may be because of the rigidity of cognitive deficits, or because of the rigidity
of defenses within the delusion, or because of rigid character defenses
blocking observing ego and secondary processes. Proper diagnosis and
analysis of blocks may be necessary. Hospitalization for these rigid patients
is extremely helpful because then some of the reality day residue triggers to
increased psychotic symptomatology can be observed by the staff and used
by the analytic therapist to understand the structure and linkage points of
the psychotic symbol. Presenting this information to the patient may result
in a reaction and subsequent verbal productions that elaborate the
delusional story and progress the treatment toward unraveling the delusion.
If all of this fails, then the technique is to deal with the same dynamics in
character pathology, both manifest and latent, and with their associated
reality triggers. Once the unraveling of this related material is clear, a new
attempt can made to deal with the same dynamics in the delusional system.
This enables the progressive unraveling and understanding of the dynamic
material in areas not blocked, as it is in the delusion. It allows the patient
and the therapist to gain access to unconscious areas inaccessible in the
delusional area. This information can then be used in integrative
interpretations to help the patient understand and unpack his or her
delusion by showing the similarity of dynamic content.
7. Psychoanalytic Psychotherapy of Psychosis 239

Example of analyzing a delusion:

A young woman is convinced that her two children have tuberculosis, in spite
of the fact that the doctors have reassured her that this is not so.
Patient: "They are coughing."
Therapist: "But the x-rays are negative."
Patient: "The doctor says they don't have it but I know they do. Because I am
their mother and I see them every day."
Therapist: "But the tests are negative. The x-rays are negative and the doctor
says no. Most mothers would be relieved."
Patient: "I am relieved. But I still know they have tuberculosis and the doctor
hasn't realized it yet. I don't let the kids visit. Other children might get the
tuberculosis. I do let them go to school and parties because I don't want to jail
them."
As therapy progressed, more of the reality history was revealed. Her boyfriend
had tuberculosis, and now she has a positive skin test for tuberculosis. The
children have negative skin tests. The children were both born out of wedlock
with different fathers. The woman now does not date. She has no sexual life. She
has never told the pediatrician that the boyfriend lived in the house. He had not
only a positive skin test but also a positive x-ray. She saw him coughing and losing
weight. She broke up with that boyfriend because he had tuberculosis. He got
angry, broke into the apartment, and raped her. She then started feeling sad. She
cries all the time and has trouble sleeping.
Antidepressant medication was begun and therapy sessions continued. With
the therapist empathizing with her difficulties with men and with sex, she said
that she had lied about the boyfriend raping her. She was out drinking and found
herself in bed, naked, with her boyfriend tOUChing her vagina. She was furious
and wanted to kill him. She expressed her anger, but he just laughed and said she
better not do anything. She was afraid. She also said that she had sex after this
episode with a male friend whom she doesn't love. He came into the house and
saw the tuberculosis pills and asked what they were. She said it was asthma
medicine. She wants the therapist to call the pediatrician and tell him about her
boyfriend who had tuberculosis. The therapist commented on the guilt she felt
about not telling the pediatrician about the boyfriend with tuberculosis, maybe
because she felt embarrassed about their sexual relationship. She responded that
she first got pregnant when she was fourteen. Her father said, "Disgusting." Her
boyfriend at the time contracted gonorrhea and passed it along to her when she
was two months pregnant. Her older brother said, "You are a woman now. You
can't stay in this house." So she left and lived with the boyfriend who had
contracted gonorrhea. She moved in with her grandmother just before the baby
came. Her grandmother taught her how to take care of the baby. This daughter
is now the patient's father's favorite. Both of her children do have asthma, with
many hospital emergency room visits. The younger child has a chronic cough.
The elder daughter is 11 and starting to develop physically.
As this information came out over the next few sessions and her guilt and
shame were interpreted, the patient began sleeping, stopped crying, and began
dating. Her worry now became reversed. She was afraid that the children would
give the man some disease.
Therapist: "Your children, two girls, now approaching adolescence, have, like
240 Psychosis and Near Psychosis

you yourself, what you believe to be an illness-female sexuality. It infects men

and then it comes back to infect the woman."
After the session in which this interpretation was given, the patient felt very
much better. She felt so much better that she stopped her medication and had
sex for the first time in quite a while. Unfortunately, she promptly came down
with trichomonas vaginitis and became depressed again and worried that the
children would get vaginitis from her. The antidepressant was restarted and the
therapy continued with a rapid resolution of her worries that the children would
either be infected or would infect.

At a conscious level, the real object boyfriend with tuberculosis was

merged with Object representations of her children. Both had sexuality as the
common denominator. More latently, there was a condensation of real self
with self-representation: the tuberculous illness that she was positive for in
reality condensed with her own feelings about her sexuality as being dirty
and infectious. This latent self-representation infecting her real self
experience was displaced to the children's infection in the delusional system.
More unconscious was her gUilt over the tuberculosis infection coming from
the man and her sexual relationShip with the man and her anger that her
daughter had become her own father's favorite. Tuberculosis in the children
was punishment of both her and her attractive child rival who she feared
would soon be more attractive than she to her boyfriend. She felt very guilty
about this worry. (For an example of early work in this area see Sechehaye,
1951.)

Symbolic Transformations of Reality

In both neurosis and psychosis, analytic therapy analyses symbolic
transformations, but in the case of psychosis these symbolic transformations
are of reality. The symbolic alteration of reality is the manifest, conscious,
and easily recognizable manifestation of psychotic structure and its primary
processes. As the many examples in this chapter show, analysis of these
symbolic alterations of reality, if done with the technical recommendations
illustrated here, may lead to the decondensation of the day residue from its
primary process symbolic alteration.
The question always arises of when to analyze the delusional symbolic
transformation and when to avoid it and analyze the same dynamics in the
character structure. This is the same question as when to support and when
to analyze an aspect of ego function. The answer to these questions has to
do with the structure of the patient's ego. In fact, with most psychotic
patients one does different things at different times, depending on the
content areas and associated autonomous ego functions that have been
captured or not captured. The question is whether or not the patient's ego
requires this or that and whether or not the appropriate technique is used
7. Psychoanalytic Psychotherapy of Psychosis 241

to further the progressively unfolding description of the unconscious for the

purpose of integrated growth and change.

Day Residues
In the acute and disorganized psychotic state, real objects, but also real
events, their sequencing and context, are lost in the chaos of object
representations and self representations. Therefore, the day residues of
emotional experiences, the instigators and organizers, are lost to the mental
experience of the patient and to the purview of the physician. Logical
sequence of events is lost. One crucial advantage of treating such patients
in hospitals is the ability of the milieu to maintain, organize, and record
those sequences. The observations of these sequences will become crucially
important as the patient begins to organize and make a recovery. Linking
these sequences with emotional states and the interplay between reality and
psychotic symptoms is one of the overall tasks of the therapist in the
beginning phase of treatment.
As the dynamics of the delusional system unravel, it is the common
experience for day residues of the present to pop into view. Interestingly
enough, in adult psychosis the triggering reality genesis or aggravator is
discoverable because that genesis is so recent, reportable, and in a
hospitalized patient, observable. These triggering events may be surprisingly
parallel to reality day residue genetic events of the past. Sometimes these
genetic past events pop into view before the reality triggering events of the
present. Therefore, the analytic therapist uses this to confront reality testing
and observing ego. Improved observing ego and reality testing helps liberate
the present reality nidus from the psychosis where it is trapped by unraveling
the psychological dynamics of the symbolic transformations of that disguise.
Unconscious layers of delusional content and affect are uncovered. These
layers can then be related to conscious and unconscious here and now day
residues and to conscious and unconscious there and then day residues. This
uncovering technique is ego-supportive, provided that the therapist carefully
attends to reality testing, observing ego, and ego integration. The analyst
must use unimpaired autonomous ego in non psychotic areas. The analyst
must leave nonmediating defenses alone or support them but must interpret
mediating defenses as needed.
As the analytic therapist unravels delusional material, he or she must
make sure the day residue is not captured by primary process and reified,
but rather integrated in secondary process. This is done by observing the
capture of primary process, pointing it out to the patient, inquiring about
the reasons for this, listening to the associations to the engaging of this
issue, and seeing whether one is getting resistances to the analytic process
at that point or more information about the difficulty that the patient is
242 Psychosis and Near Psychosis

having in moving day residue material into secondary process. This difficulty
may be caused by character resistances, intensity of affect liberated,
unrecognized transference intensification, undiagnosed and condensed
attachment points to reality triggers at the core of the genetics of psychotic
phenomena, or severely damaged secondary process cognition which has
been unrecognizably present in all areas of ego function, psychotic and non-
psychotic. This is only a partial differential diagnostic list, no doubt, but it
serves to provide examples.
Sometimes, just as the day residue/precipitating event emerges in the
unraveling of the delusional system, great resistance seems to be engaged
because of the uncanny resemblance between psychology and reality, between
the present and the past. These attachment points of the delusional system
are very difficult for observing ego and reality testing to work with because
there is this uncanny overlap. This becomes especially problematic when
thing presentation quality is present in these focal experiences, and in
psychosis, it is. Thing presentation quality provides the precept verification
of the condensed experience and may be present in the elements of that
experience even after the decondensations.
Many therapists make the mistake of breaking with therapeutic ne~trality
and distinguishing the Object representation from the real Object and from
the day residue object in reality. This rarely works, because the therapist is
leading to reality testing, which is damaged, rather than to observing ego
which is intact. There is less of a problem if the therapist empathically
understands that the patient cannot experience the difference between the
delusion at that point and the day residue in reality. Instead, there is a
delusional attempt to organize elements of experience that have perceptual
thing presentation quality. When a patient says that the physician doesn't
understand, that the delusional thought is real, the only answer the therapist
can make is that it is more real than the patient can understand and admit
at this pOint! The analyst thereby comments on the use of psychotic reality
to defend against day residue reality and affect reality. The day residue
reality coincidence is crucial because its recognition and acknowledgment
would be the first decondensation from the psychotic structure. Needless to
say, patients are extremely resistant to acknowledging these present day
realities. Most delusions have a kernel of reality to them. The problem is
that there is also a condensed symbolic transformation of that reality. A
delusion is a symbolic transformation along primary process lines. The
patient cannot translate this primary process but the analytic therapist can.
In that way, the therapist ought to be discovering the day residue and affect
reality of the delusion before the patient. It is the descriptive explanation of
this to the patient that is so helpful. Ironically, the greatest resistances may
engage at the point where the therapist finally understands all aspects of the
reality of the delusion and attempts to help the patient understand it. This
ought to be expected in advance, since the rigidity of the delusional system
speaks not just to the illness attacking autonomous ego functioning but also
7. Psychoanalytic Psychotherapy of Psychosis 243

to the intense pressure of the psychological material involved. This is the

reason that the paradox expressed in the epigram to this book is used. The
question was, "Are you real or are you part of my imagination?" The answer
was, "Your imagination is real and since I am part of your imagination, I am
reall" I would go even further. Because the real experience is captured by the
delusional system, the delusional system contains the real experience as well
as the imagined experience (Freud, 1907). The problem with recognizing the
real experience is the affects generated, the conflicts evoked, and their
conscious condensation with reality experience. Hence, defenses of all types,
character and psychotic, within and approaching the delusional system are
intensified at the point this present reality starts to separate. Interpretation
of those resistances can be extremely beneficial, resulting in the final
decondensation of this present material and the liberation of affect
experience. The patient's intact secondary processes are then much better
able to see the difference between the reality day residue of the present, the
primary processing of that day residue of the present, and the reality day
residue of the genetic past. When these separate they will be seen to be
uncannily similar and at the same time remarkably different in crucial ways.
In summary, if psychodynamic material is exposed, help integrate it; if
hidden uncover it; if defended against, interpret the defense; if the defense
is unyielding, unravel the delusional system by seeking the same themes in
non psychotic character derivatives.
It is important to realize that for the psychotic patient clarification of
reality is a neutral confrontation, because the patient is condensing that
reality with fantasy. In this way, the condensation might separate and the
conflict contained in the two aspects can be clarified. The evocative
similarity of affect fantasy and of fact becomes apparent.
This process does not lead just to supporting intellectualization as a
defense but rather to secondary process integration. Psychotic and near
psychotic patients have a primary process that is dominating. Primary
process is an integrating mode, and in patients where secondary process is
too severely damaged, this is all the therapy has at first. The goal and the
usual accomplishment of treatment is to restore secondary process
integration capacity.

Timing and Sequencing of Interpretation

Patients vary as to when and how much affect, content, and transference they
can tolerate. This varies with illness, patient, phase of treatment, particular
transference content, particular affect, and associated particular captured
autonomous ego aspects. Clinical judgment is empathically sensing this
balance. Very ill patients are as unpredictable a priori as are neurotic
patients. This is because the specific autonomous ego functions captured by
244 Psychosis and Near Psychosis

specific affect and content are quite variable and quite unpredictable from
patient to patient and from layer to layer within one patient. Hence the need
for analytic technique, empathy, intuition, and clinical experience, the
combination of which is called clinical judgment. Timing and sequencing of
treatment make the most demands on this clinical judgment.
The variability of patients according to level of illness, type of illness, and
individually is given much lip service in psychoanalysis but poorly
appreciated at times. Much psychological argument about structure and
treatment is based on experiences with different patient populations who
have very different ego dysfunctions.
In any case, much working through must be done from the ego areas
which can tolerate the dynamic material. This will help those ego islands
grow, and they may be then used as dispassionate areas from which the
patient can consider the more difficult areas.

Self-Esteem and Technique

As therapy progresses, the relationship of ego to superego as it affects self-
esteem is often a crucial issue. It often triggers the most resistant character
defenses to treatment and to observing ego.
This leads to a brief discussion of sealing over versus integration as
psychosis remits. Of course, this theory of treatment would hold that it is
important for patients to integrate psychotic phenomena rather that to seal
over and repress them. A practical reason for this is that psychotic patients
often do not take their medication, and a revolving-door process of repeated
hospitalization ensues. It is very important not just for psychological growth
but for maintenance of remission that patients understand that they were
psychotic. As a patient seals over, if that is happening, and denials of fact
enter along with repression of dynamic content, vigorous attempts at
interpreting those defenses must be made, even though they are
nonmediating defenses. Almost always, these defenses have to do with the
self-esteem system and the defenses against the superego experience of
psychosis and past psychosis. When the defenses are successfully analyzed so
that the sealing-over process stops, the patient almost always feels depressive
affect. This is the confirming evidence that the self-esteem system was
involved and this depressive affect can then be analyzed.
It is important, however, to realize that sealing over is a complex
phenomenon that requires an accurate differential diagnosis. Some patients
are, in fact, still psychotic with delusional denial or denial of delusion. Other
patients are intellectually slow and have not cognitively grasped what has
happened. Only some patients are using neurotic and borderline defenses of
denial which buttress the self-esteem system in patients who have had an
acute psychotic episode.
7. Psychoanalytic Psychotherapy of Psychosis 245

Empathy with psychotic qualities is the crucial first self-esteem supporter.

Then one can, perhaps, be able to empathize with the observing ego of
psychotic experience. Next, it may be possible to empathize and analyze the
superego's reaction to psychosis as well as the superego condensations in
psychotic symptoms. This superego material is often found in character
defenses that have been lifelong in the patient.

Regression with Treatment

Analytic reconstructive treatment with psychotic patients always raises the
specter of making the patient worse. Making the patient worse involves one
of two common structural problems or both. The first is increased
integration problems. The second is a sinking into more and more primitive
psychological material in content and affect. From my point of view, the real
problem is the first complication rather than the second. If the patient is
integrating or intermittently integrating the unraveling of more primitive
content and intensities, then the therapy is useful, at first to the therapist
and then to the patient. Particularly in chronic psychotic states or in chronic
severe character disorders of near psychotic proportions, the regression
breaks a longstanding stalemate and is therefore a potentially progressive
regression! The problem is to make sure the regression is a useful one
rather than merely another stalemate. The decision about whether or not
regression, if it occurs, is a necessary evil is not made by the content and
structure of the regression but rather by the functioning of intact observing
ego and integration faculties of the ego. There are patients who are so
chronically ill, and some so dangerously so, that the risk of a regressive
experience is worth it. A quick example of this is the patient who is riddled
by psychotic phobias and secondary suicidal elaboration, who goes to the
hospital, becomes even more regressed, but finally breaks free of a symbiotic
reality relationship, has observing ego about his or her illness, finally accepts
medication, and moves on in analytic treatment to understand the dynamics
of his or her psychosis and associated character defenses. On
psychoanalytically based hospital treatment see Chiland (1977), and Marcus
(1987b).
Some patients are already in a very regressed state when seen. These
patients can be analyzed if attention is paid to integration and to
nonpsychotic derivatives in character structure. In sicker patients, much
psychological material is repressed in derivatives and much primitive
material is used to block existing higher-level ego functioning. In any case,
the reparative psychoanalytic technique is often greatly aided, and in some
cases only possible, in a hospital setting.
Regression is true of all psychoanalytic experience. The question is not
whether regression occurs and not whether the regression is theoretically
246 Psychosis and Near Psychosis

good or bad. The problem is in the control of the regression. All

psychoanalysis involves controlled regression, and all psychoanalysis thus
involves interventions to allow regression or to defuse or contain it. The
analytic therapist does this with silences and with interpretation at
appropriate times in the neurotic patient. The analytiC therapist must be
more vigilant and active with psychotic and near psychotic patients. The
analyst must be particularly vigilant about transference phenomena and be
prepared to interpret early and/or defuse them. In any case, the technique
of controlling regression is determined by the structure of the ego, as are all
other therapeutic interventions in very ill patients.

Psychoanalytic Psychotherapy Versus Psychoanalysis

The debate over psychoanalysis versus psychotherapy, what is which and if
there are two or if there is one, is extensive, ongoing and a little futile.
Semantics looms large in such discussions much to the detriment of the
progression of knowledge. These distinctions should depend on the ego
structure of the patient. In fact, there are varying degrees and varying
intensities of analytic therapies along an analog spectrum depending on
patient, therapist, and illness. The more fruitful issue is how one can help
a particular patient unravel and integrate his or her own psychology for the
purpose of symptom relief and personality growth in present day real life.
Different degrees of reality interventions, integrative interpretations,
transference intensities, and setting and frequency will be required,
depending on particular ego structure and phase of treatment. Such
questions are better answered in the specific than in the general (cf. Hoch,
1992; Morris, 1992; and McNutt, 1992).
Psychotherapy may be used in preparation for psychoanalysis (see Weil,
1973; and Bernstein, 1983). Important for the success of this technique is
specific diagnosis of ego problems and an active engagement of those
problems in the treatment.

Use of the Couch

The subject of regression and of psychotherapy versus psychoanalysis brings
up the issue of the couch. Psychoanalysts by and large have moved away
from the use of the couch with near psychotic and psychotic patients, for
good reason. Lack of visual feedback makes it more difficult for the patient
to separate real object and object representation in the transference. It also
encourages a passivity in the therapist that is inappropriate, considering the
ego dysfunction of the very ill patient. A silent therapist and a rambling
psychotic patient only lead to further psychotization. However, the couch
7. Psychoanalytic Psychotherapy of Psychosis 247

can be used for integration as well as for regression (see Khan, 1960), and
there are certain advantages in the use of the couch over the chair for the
task of integration with certain patients.
The following are some possible indications for the use of the couch in
psychotic states. Criterion one is a stable, chronic, organized delusional
system. Criterion two is that observing ego has already separated from reality
testing, and beginning interpretations increase reality testing. Criterion three
is that an increasing understanding of the dynamics causes an increase of
observing ego and a decrease in the psychotic symptom. Criterion four is
autonomous ego strengths of (a) intelligence, crucial aspects of which are
abstracting and generalizing abilities, (b) the ability to free-associate without
severe regression of autonomous secondary processes, (c) a firm behavioral
control, (d) boundaries between in and out, and (e) boundaries between real
and fantasy experience in the transference. Intact, albeit dissociated,
secondary processes is the fifth criterion. The sixth criterion is an accessible
overlap of dynamics in the delusion and in character, and that the character
is neurotically organized, rigid and needs psychoanalysis. Criterion seven is
that the delusional system needs greater intensity to be analyzed, free
association provides this intensity, and free association in this particular
patient needs a decrease of visual feedback. Criterion eight is that regression
can be controlled because of the boundary between the delusional system,
the character structure, and stable higher-level autonomous ego areas.
Criterion nine is that the transference has a lack of engagement and
intensity, so that the couch can be used successfully to increase intensity of
the transference but without causing psychotic condensation of the
transference. Criterion ten is that the autonomous ego is healthy enough to
make use of this transference material.
The couch works best with patients who are rigid, neurotic characters who
suffer an acute, time-limited psychotic episode. It is especially helpful if the
psychosis is rapidly brought under control by medication and by
psychoanalytic psychotherapy. Because the underlying dynamics of rigid
character are often clearly seen in psychotic eruptions, because
psychoanalytic psychotherapy often quickly localizes attachment points
between the two, and because this then opens derivative dynamic structures
in the character, the analyst is sometimes tempted to an early reconstructive
treatment in these patients. I have found this temptation well warranted
because such patients usually respond rapidly and well.
But great efforts must be made to avoid psychotic transference. Near
psychotic transference can usually be engaged and analyzed if done so
vigorously and consistently from the beginning. Transference elements are
also important because they may involve similar dynamics as the psychotic
material and mediating defenses.
248 Psychosis and Near Psychosis

Example:
A 28-year-old woman was seen in consultation because of increasing anxiety
over three months. She was afraid to be alone with her two year old son. Would
she be able to take proper care of him? Suppose she felt like killing him? A
psychiatric history revealed many depressive symptoms including insomnia, tearful
feelings, anhedonia, decreased appetite, and passive suicidality. There were three
previous episodes, two mild but one severe, which included a serious and nearly
successful suicide attempt. Mental status examination revealed that desperation
and panicky ruminations about her son had not yet reached delusional
condensation. Thing presentation quality, rigidity, and beginning confusion and
despair were evident. Although nonpsychotic ruminations, they completely
dominated her mental content and affect experience. Her involvement had a
conviction and certainty, especially about fears of killing her child, that seemed
to have strong thing presentation quality, and hence may have been an impending
psychotic episode if the intensity of the depression worsened, as it seemed to be
in the process of doing. Reality testing processes were intact. Observing ego was
excellent and impulse control strongly present. Defense mechanisms were higher-
level obses~ive with good integration and consisted of intellectualization, affect
repression and isolation, partial day residue repression with rationalization and
denial of significance, some displacement of affect, but no projection. Reality
experience was being flooded with depressive anxiety and condensation capture
of conscious self-representation; reality experience of failure was beginning to
occur. Further history revealed longstanding family, employment, and marital
problems, all resulting from and leading to chronic conflicts over assertion and
aggression. Crippling and frustrating moral scruple against assertion and
aggression was organized in a masochistic way with castration and abandonment
fears. Longstanding psychic conflict played out into the environment and created
repetitive, complex day residues from employment and the family. Both
summated in the patient's part-time work in the family owned business.
This, then, was a patient with a neurotically organized ego who was being
overwhelmed with a depressive episode approaching but not yet psychotic. The
depressive illness was erupting through character defenses. Antidepressant
medication was begun, resulting in a decrease in flooding intensity of depressive
anxiety. The patient was seen four times a week sitting up in an exploratory
psychotherapy.
After two weeks, the patient felt ready to move to the couch, and
psychoanalysis and medication were conjointly used. The depression rapidly eased
over the next two months. By six months the patient no longer required
medication. Dynamic issues quickly evolved and deepened in the psychoanalysis
in the context of a benevolent transference interrupted periodically by paranoid
depressive anxieties that were immediately interpreted before they were either of
intolerable intensity or began to capture reality experience in the transference.
Intense depressive affect was seen to have primary process content that both
made clear and was made clear by the day residue triggers. These triggers, past
and present, became more and more clear. This permitted a shift to secondary
processing of those day residues and several bursts of ego growth and life change.
7. Psychoanalytic Psychotherapy of Psychosis 249

Psychoanalysis became more and more classical as the intensity of the

affective illness eased and the repression barrier assumed its usual functioning.
The psychogenetics had preoedipalloss issues, but these were reorganized at the
oedipal competition level where guilt, fear, and loss were the main issues.

In summary, in almost all cases the couch is not used nowadays in the
psychoanalytic treatment of very ill patients. I support this. There are,
however, some patients who not only can use the couch but require it. I
have listed some criteria and shown a case example to help the analytic
therapist understand who those patients are. See also Waelder (1924),
Federn (1934), Namnum (1968), and Bellak and Meyers (1979).
8
Psychoanalytic Psychotherapy and
Psychoanalysis of Near Psychosis

Introduction
I divide nea!" psychosis into two categories: those who are near psychotic in
ideas and attitudes only, and those who are also near psychotic in behavior.
In addition, illness etiology of near psychosis varies from formes frustes of
schizophrenia, manic depressive illness, organic brain syndromes, severe
trauma, severe character pathology and its various subtypes, and
combinations of these etiologies. Because of this variation of illness
phenomena, the literature on psychoanalytic psychotherapy technique with
near psychotic patients varies a great deal as to relevant psychodynamics,
tactics of intervention, and types of treatment. The psychodynamic issues
range from focus on narcissism, aggression, and splitting defenses (Kernberg,
1975), to focus on separation anxiety (Adler, 1983), to focus on infantile
abandonment/depression (Masterson, 1972). The tactics range from
consistent confrontation (Kernberg, 1975), to empathic support (Adler,
1983), to limit setting (Masterson, 1972), to supportive psychoanalytic
treatment (Kohut, 1971), to so-called unmodified (neo)classical
psychoanalysis (Porder et al., 1983). (For a review of dynamics see
Gunderson, 1984; Frosch, 1990; or Gabbard, 1990.)
I have used each approach at various times, to varying degrees, with
different patients. This is because with different etiologies, the intensity of
a given dynamic system and the exact arrangement of ego problems varies.
But if there are commonalities of structure (see chapter 3), then there
ought to be commonalities of treatment. A summary of psychoanalytic
psychotherapy with this broad group would be:

1. Empathize with near psychotic thing presentation qualities of

perceptual affect in the near psychotic idea or behavior.
2. Separate observing ego from the near psychotic condensation.

251
252 Psychosis and Near Psychosis

3. Make near psychotic condensations fully conscious: contents and affects,

especially of object relations, especially of real self or real object.
4. Make reality-testing processes fully operative by confrontation of near
psychotic condensations with the patient's secondary processes and
memory.
5. Demonstrate how these contents and affects have condensed with and
influenced behavior, attitudes, and conscious ideas.
6. Deal with behavior early: feeling vs. impulse vs. action, of near
psychotic condensation.
7. Deal early with negative transference, reality experience altering
defenses, and dissociations.
8. Deal with here and now before ontogenesis, especially with behavior.
9. Look for, recover, and describe complexities of affect revealed in
associations, behavior and attitude, especially as manifested by
transference and countertransference.
10. Look for day residue event and help reassemble sequence and context.
Integrate day residue, Object relations content, and affect themes,
showing the relationship among all three that expresses itself in near
psychotic attitudes, behaviors, and relevant dissociations.

Because many autonomous functions are intact, the analytic treatment of

such patients can proceed provided the analytic therapist understands that
in the focal area of near psychosis the patient will soon, if uncovering
proceeds, appear to be delusional. However, reality testing is intact, and as
the material is uncovered and as the therapist makes active attempts to help
the patient separate real object from object representation or real self from
self representation, or real self affect from real object affect, the analysis can
often progress quite well. There is a momentary affect explosiveness as the
condensed material is entered and a momentary inability to integrate at the
point of the dissociation. The most primitive character defenses are now
often engaged. This has several dangers. One is that the therapist will be
captured by an intense affect-fantasy in a pseudo-delusional transference.
This always begins to happen. Active interpretive efforts are necessary at
that point to forestall a breach of the therapeutic alliance or, worse, the
treatment alliance itself. However, one can usually remain in the technically
neutral position because there are Significant areas of neurotic and of
observing ego available. If forced out of technical neutrality temporarily, it
is usually into clarification and affirmation of reality, usually the reality of
therapist affect in his professional role. Clarification, along with engaging
intact secondary process, is usually swiftly efficacious and permits the
movement back into technical neutrality. It is combined with immediate
analysis of what happened and the underlying fears and wishes that caused
the capture.
The other danger is that mobilized affect will trigger an affective episode
in those patients so predisposed. Again, quick interpretive intervention
8. Psychotherapy of Near Psychosis 253

about the fact, organization, and content of such experiences is crucial to

treatment. Such descriptive work can be most rewarding, as it often leads
back to the psychogenetic past. This may go a long way toward disassembling
these affect-triggering vulnerabilities and toward integrating ego function.
Medication is often necessary, especially during crisis points of the early and
midphase of treatment. One can anticipate and interceptively treat those
crises because of the predictability of their day residues and content
dynamics due to the stereotypy of their structure.
A premonitory sign of difficulty in analysis is the rigidity of defense. There
are some patients in whom the rigidity is so great, the affect contained in the
pseudo-delusion or behavior is so intense, and the pressure to capture the
therapist so relentless that the therapist decides, either after a trial of
directly analyzing the material or, through empathic intuition alone, to avoid
the matter. This is much like stepping around a fixed delusion. Just because
it is a pseudo-delusion does not mean that one can take it head on, directly
and early. Almost always one can, but not in every case. If the material must
be stepped around, the same rules apply as in psychosis. The dynamics are
explored in areas other than the transference, in more neurotically
integrated and repressed character derivatives. After months to years of
working through this material, the pseudo-delusional area and mechanisms
can often be reapproached. Medication often is very helpful at this point.
Again, it is not the content or structure of the pseudo-delusional states that
decides this indirect approach, but rather the intensity and rigidity.
Remember that rigidity is the best measure of severity of illness and of
prognosis. Extremely rigid defensive structures, whether psychotic, near
psychotic, borderline, or neurotic should be considered extremely serious,
and great care should be taken by the therapist to diagnose the reasons for
that rigidity. Many patients with subtle affective illness have very rigid
defenses because they are attempting to defend against overwhelming
intensities of affect that are easily evoked. The question then arises whether
or not a trial of medication might help make those defenses more pliable
(see chapter 6). It is worth such a trial. In some cases, the results are so
beneficial that an impossibly stalemated treatment is converted into an
evolving and ameliorative analytic process.
Although the experience of treating near psychotic patients is intense and
the sense of danger is never far, the sense of accomplishment at helping
them is large and the relief the patient experiences is gratifying.
I will now elaborate this summary in a detailed description of ego
functions and the implications for technique.
254 Psychosis and Near Psychosis

N ear Psychotic Patients

Near psychotic patients are those whose near psychotic condensation does
not emerge mainly in behavior. Their affect-behavioral boundary is good.
They tend to have higher-level ego function in general than the behavioral
type. Many have ego function organized along neurotic lines, with only one
breach through neurotic defenses of an intense, near psychotic area of
concern that condenses with and captures an area of reality experience in the
preconscious. The result is a near psychotic idea. The same can be true of
near psychotic attitudes, although those tend to express themselves more
broadly throughout the ego and in behavior, classifying the patient, usually,
as borderline. The context of near psychotic ideas is, however, often a
condensation of attitude defense. The level of pathology within that defense
varies from case to case and from time to time. Treatment of the attitude
may precipitate a near psychotic transference. The near psychotic potential
of the transference can be seen in other intense relationships the patient has
or has had.

Boundaries In-Out

The in-out boundary is, in my view, intact. There are no conscious fusion
experiences except in some near psychotic severe dyslexics or other organic
brain syndrome patients, and then not as a consequence of their near
psychotic condensations. The reason it seems as though the in-out boundary
is damaged universally in near psychotic patients is twofold. First, there is
capture of reality experience-the real Object or the real self-by emotional
experience. Then, in behavioral borderlines, the resultant condensation is
acted out into behavior which then has an effect on the Object in reality or
the self in reality. The treatment for the behavior problem is covered later
in this Chapter (pp. 264, 269). The point for now is that this is a
condensation acted out into reality, rather than a fusion state of stimuli from
reality entering, unmodified, into the self-experience.
The treatment for the near psychotic capture of reality experience by
emotional experience is to make that capture conscious. The transference is
often an especially useful vehicle, because the therapist has knowledge of the
fact of condensation, the reality event coinciding with that merger, the affect
display by the patient, and the therapist'S own affect. Therefore, the therapist
has information about all the elements of the near psychotic condensation,
at least as it is focused at that moment. This gives the therapist the ability
to engage, describe, interpret, challenge, refute, and empathize accurately.
This informational accuracy will help the therapist to help the patient make
the near psychotic condensation fully conscious and then analyze its
8. Psychotherapy of Near Psychosis 255

elements. Where one begins depends on what aspect touches the

transference with what degree of available intensity yet potential flexibility.
Technique also depends on which defense mechanism is used to condense
reality experience with emotional experience.

Defenses
There are many different defenses possible, including projective
identification, denial, affect storm, and rigid dissociations. The classic ones
are projective identification and denial.
The treatment of projective identification involves making the
condensation clear, especially in the transference. The therapist says, in one
way or another, that the patient acts as if the therapist has an attitude
towards the patient. Actually, the patient has an attitude towards the
therapist albeit the patient feels, in response. The correct labeling of the
attitude in the patient, pointing out the concomitant feared attitude in the
therapist, the primary process organization of the content of the attitude, the
affect expressed and defended against in the attitude, all are used to
challenge observing ego and reality testing. Sometimes it is necessary or
simpler to use refutation. It is crucial to pick up the projective identification
and its attitude-determined condensation of content when it happens, to
note with the patient what seemed to have triggered it, and to locate the
relevant affect states properly in the self-representation, the real self, the
Object representation, and the real object. The actual mechanism involved,
projection onto the real Object or the real self, must be part of the
descriptive interpretation.
Likewise, denial, when it occurs in treatment, can be focused on for the
dissociation it is. One can point out to the patient what he or she said or
did, that he or she did mean it, that it has meaning, and it has meaning even
in the present. This bridges dissociation of fact, of meaning, of time, and of
validity. A general statement of the use of this defense by the patient can
also be made. The affects and Object relations scenarios thus defended
against on each side of the dissociative denial must be part of the
interpretive work. The relevant psychogenetics of content and of defense
organization can then often be recovered.
Defense resistances to the interpretation of the defenses are crucial and
often, fortunately, involve the same defense mechanisms. Therefore, the two
often coincide in the transference, making this an opportune interpretive
time.
The main difference from neurotic patients in near psychotic defense
mechanisms is the near psychotic reality experience captures and the
resultant intensity and near perceptual veracity of conviction. Again, the
transference helps because the countertransference is known and, if
256 Psychosis and Near Psychosis

discordant to the patient's experience or accusation, can help the therapist

with therapeutic conviction which can help with therapeutic courage. The
tricky thing is when the countertransference is concordant (Racker, 1968).
Then one must remember that behavior or attitude in the patient provoked
this concordant countertransference (Kernberg, 1976b). One can then
describe the evolution and evocation of this experience. One can point to
the sequence beginning with patient projection, affirmed in patient attitude
or behavior, which then provoked the therapist'S feeling or behavior.
Because defenses operate in the preconscious, they are usually part of the
near psychotic condensation. This means that defenses will be "primitive," i.e.
capture reality experience in the preconscious. They often will also be basic
character defenses. These are the problems of, and opportunities for, defense
analysis in near psychosis.
Projective identification, denial, and dissociations are all readily available
as part of the near psychotic symptom, the resistances, and the transference.
They come quickly and often. This gives the opportunity to interpret
methOdically, consistently, and from a variety of therapeutic and empathic
contexts.
As defenses are interpreted, near psychotic transference clears, observing
ego increases, near psychotic condensations emerge into consciousness and
decondense, reality testing increases, and a complex affect experience
emerges, which can then be integrated as dissociative defenses are
interpreted. The psycho genetics, often all too apparent but without influence
except for justification of the near psychotic content, can now be more truly
and realistically integrated with present day affect evokers and symptoms.
The irony is that in just some of the illnesses where classical defense
analysis is seen as difficult or impossible, it is so helpful. But the therapist
must understand the peculiar nature of those defenses consequent to their
involvement with near psychotic structure-their near perceptual quality and
seeming capture of real object or real self-experiences. The stormy defensive
transference eruptions, if faced head-on with consistency and bravery by both
patient and therapist, can ease into a dramatic therapeutic progress.
Crucial to the analysis of defense in these states, therefore, is an
understanding of the near psychotic experience and the near psychotic ego
structure. This understanding will guide necessary adaptations of teChnique
toward ego deficits and "primitive" ego experiences. This is crucial if the
classical defense analysiS goal is to be achieved. Too much silence, ignoring
of structural problems, or failure to attend to observing ego, or reality
testing, or integrative processes can result not in a therapeutic process but
in disaster. Such disaster often manifests itself as a transference explOSion
and/or a serious suicide attempt.
Medication is also helpful in easing the rigidity, intensity, and chaotic
manifestations of near psychotic defenses (see chapter 6).
8. Psychotherapy of Near Psychosis 257

Preconscious-Conscious, Primary Process-Secondary Process

Analysis is greatly aided by the subtle intrusion of primary process into the
near psychotic story line as a consequence of the preconscious location of
the near psychotic condensation. This makes martialing and use of secondary
process obvious and effective. It is especially effective when the day residue
sequence and context are known or deducible. The primary processing of
near psychotic symbolic alterations of day residues then stands out clearly.

Affect Boundaries and Modulation

Because of the intensity, stereotypy, overlap, and rigidity of affect responses

that drown or mix affect with affect, considerable attention must be given to
describing affect states in words. Affect recognition by the analyst can
accomplish many goals. It addresses the translation problem, the veracity
problem, the chaos problem, the action problem, the dissociation problem,
and the contamination of the real Object or the real self. All of these
structural problems due to intense affect boundary crossings must be
described when appropriate. Doing so has the potential of greatly
strengthening the ego functions of containment, control and
verbal-conceptual expression of affect. Observing ego and reality testing
both dramatically improve when affect control improves and the real object
or real self is freed from affect-determined near psychotic condensations.
Medication may be crucial to treatment of modulation problems (see
chapter 6).

Reality Testing

Reality testing is suspended but potentially present in the pseudo-delusional

area of the near psychotic idea, in the behavioral enactment of the
borderline, or in both in patients with mixed features. Most patients do have
mixed features.
Consequent to the structural fact that reality testing contents are
condensed in the near psychotic symbolic alteration of reality, but reality
testing processes are not, is the technical recommendation of confronting
reality testing in the pseudo-delusional or behavioral areas that betray the
near psychotic condensation (Kernberg, 1977). Consistent reality testing
confrontation can aid in the decondensing of the near psychotic symbol.
The key to the technique, as with all psychotherapeutic technique, is
clinical judgment about when, where, with what degree of neutrality, and
258 Psychosis and Near Psychosis

with what degree of affect. Remember that confrontation is a technical term

meaning to engage the issue or to point out. It does not necessarily imply
countertransference aggression.
The interplay between reality testing confrontation and exploration of
psychodynamics is mutually reinforcing. As reality testing is challenged, more
of the near psychotic story emerges to buttress the near psychotic argument,
only to reveal primary processing which reinforces reality testing and other
secondary processes. Reality testing, which was flooded preconsciously by the
intense demands of the near psychotic condensation, can now function once
again independently.

Example:
Patient: "And then I heard music, somber funeral music, as if someone had
left the tape recorder playing."
Therapist: "That must have felt very spooky."
Patient: "It was! Do you think my wife could have purposely done that?"
Therapist: "It must have been very distressing to think so."
Patient: "Yes! (tears) To think she hates me so; to torture me like this!"
Therapist: "Did you look for the recorder?"
Patient: "I didn't."
Therapist: "How come?"
Patient: "I was afraid I wouldn't find it."
Therapist: "And then?"
Patient: "And then either I'd be crazy or ... "
Therapist: "Or your wife is a witch!"
Patient: (laughs) "She is a witch!"
Therapist: "Her anger stops at nothing! She's capable of anything!"
Patient: "Oh, she is a mean woman; and very angry with me."

One can also explore the percept condensation:

Therapist: "What comes to you about funeral music?"

Patient: "Like a funeral dirge; slow, low."
Therapist: "Somber, foreboding, sad."
Patient: (tears) "Yes, as if I were dying. I feel that way!"
Therapist: "Your feelings for her may be dying. You may feel that her feelings
for you are dying; the relationship is dying. To you, this may feel like you are
dying." (preconscious capture of real self experience)

Notice the progressive affect decondensation into emotional experience

and expressed in words as the exploratory interchange progresses. Affects of
fear, sadness, and despair are moving out of the near perceptual, other-
worldly experience into words and into the direct experience of complex
affect. In addition, this example indicates the avoidance of reality testing that
near psychotic patients characteristically demonstrate. The patient would
rather worry that it was true that his wife has supernatural powers or
purposely hid the tape recorder to play music to torture him than face his
8. Psychotherapy of Near Psychosis 259

feelings about his wife: that he feels she's a witch in the emotional sense. As
treatment progresses, he learns he is afraid to face this because of the
implications he feels it would have for the relationship, for his ability to
maintain the relationship, and for his self-worth.
The use of the word "witch" by the therapist is an attempt to summarize
the affect-content using a primary process concept "witch", an affect-rich
symbol. The therapist uses an Object representation to clarify the real Object.
Sometimes this primary process approach will work, if accurate or close to
accurate, when secondary process is blocked (see also Glover, 1931).
The psychogenetics in this patient involved intense attachment
ambivalences, traumatic attachments and abandonments, and depressive
superego reactions to loss and aggression. In repetition compulsion, it did
seem as though he had married an angry woman whom he then provoked.

ObselVing Ego
Observing ego may be free or flooded. In near psychosis, it tends to be
flooded and guarded by character defenses. Stubborn negation, haughty
grandiosity, and intense rage are all common character attitudes used as
defense against observing ego. These must be descriptively interpreted.
Observing ego is the aspect of ego function that recognizes the illness
state of the patient and the helper state of the therapist. This recognition
should hold in spite of patient apprehensions about helpers. Observing ego
absence usually makes itself known immediately in attitude or in the way the
patient treats the near psychotic condensation phenomena. It is also usually
immediately apparent in behavior and attitude toward the patient's own
illness and the helper. When observing ego is missing, the patient's total
experience of the illness and of the helper is captured preconsciously by his
or her fears or wishes. The psychotherapeutic approach to observing ego in
near psychosis is to confront it together with reality testing, at the same time
trying to make near psychotic condensations conscious. This approach is
taken because observing ego and reality testing are part of the near psychotic
condensation.

Integrative Capacity
The major integrative scheme in near psychosis is primary process in the
preconscious. This is aided by dissociative processes in the preconscious and
conscious. The major treatment strategy is to fully elicit the preconscious
primary process near psychotic story with its affect, so that integration can
shift into secondary process channels of concept which only operate in
conscious ego function, and into conscious affect experience linked to and
260 Psychosis and Near Psychosis

validating those conscious concepts. The techniques for doing this are
observations of associ ationa I verbal, behavioral, attitude, and affect material,
when spontaneous or in response to open-ended inquiries. The patient can
be invited to associate when associations do not occur spontaneously or
when they are too tangential.
Defenses that interfere with this process are interpreted, just as in
neurotic cases. In near psychotic cases, those defenses tend to be intense and
almost to capture reality experience, especially in the transference. But they
must be interpreted nonetheless.
Early, consistent attention to integration is a prerequisite for a useful
unfolding psychotherapy. It is as much a requirement as increasing observing
ego and increasing reality testing. Integrative capacity must increase
concomitantly with near psychotic decondensation, or an immediate defense
interpretive investigation of the reasons for failure to integrate must ensue.
Do defenses need interpreting? Is affect too strong? Are there undiagnosed
cognitive problems, especially of abstracton and generalization?

Relationship of Reality Experience to Emotional Experience

In shifting the near psychotic ego integration strategy toward secondary

process, one alters the near psychotic relationship of reality experience to
emotional experience where primary process dominates. Because the
organization of the relationship is primary processed and because the
location is in the preconscious, the infiltration into reality experience of
emotional experience has an almost real, uncanny quality that triggers
conscious anxiety even as ii triggers conscious partial conviction.
It is this anxiety and partial conviction that can be empathically engaged
with such benefit. The technique is to get the patient's conscious, secondary
process reality to do the engaging by labeling and empathizing with both
sides of the conflict, both the anxiety and the partial conviction.
Questions like "What do you make of it?" or "So what do you think of
that?" or "Does that logically follow?" can begin the dialogue between
conscious secondary process and preconscious near psychotic condensations.
Patients often respond by saying, "It may not make sense, but .. ." and then
repeating the near psychotic concern. The therapist then says, "But you just
said that it doesn't make sense." The patient agrees, says, "Yes, but," and
begins to reveal the elaborate details of his or her near psychotic
condensation which cause his or her near psychotic conviction. "And what
do you think about that?" says the therapist, to which the patient often
responds, "It doesn't make logical sense." The therapist can then say, "But
you feel it so strongly. This takes priority." The patient responds, "Right!"
"That's too bad," says the therapist, sympathetically, "because although it
feels satisfying to let those feelings dominate, that very domination causes
you anxiety because part of you still realizes the illogic, and hence the
8. Psychotherapy of Near Psychosis 261

danger to you and the injustice to the other. And your feelings remain
unresolved." This points out the dissociation of the price paid for the near
psychotic symptom from the symptom itself. This technique alternates with
open-ended questions which help open up new material. "What comes to
you about that?"
The alternating psychotherapy pattern of uncovering and integrating has
its own special rhythm with each patient. Following the patient's needs in
this regard involves the mastery of technique in timing, accuracy, and
empathy that experience teaches. This therapeutic skill is a crucial aspect of
the "analytic instrument" in work with very ill psychiatric patients.

Dissocia lioll
The vertical dissociations are usually apparent in near psychotic states. They
are so apparent because near psychotic states involve eruptions of primary
process content and affect that are not integrated with other areas of
conscious mental functioning. Pointing to these different areas can begin the
process of integration by engaging mediating defenses and also engaging that
which is defended against in the dissociation. Although analytic uncovering
of latent material and bringing it fully to consciousness along with the
condensations may result in easy integration, many near psychotic patients
need considerable help in working through this process of integration. This
is because translation of exposed or uncovered primary process material into
an understanding of its secondary process derivatives is an ego capacity. This
translation capacity may be blocked by character defenses and will improve
when those defenses are interpreted. But it is also a cognitive function which
people have to varying degrees. The diagnosis of innate capacity in this area
is crucial to treatment. Cognitive incapacity shows up on mental status
examination, with careful observation of the patient's spontaneous
generalizing and abstracting abilities, or on neuropsychological testing and
can greatly aid the therapist in understanding how active to be at points of
the treatment process when these ego functions are especially required. If a
cognitive disability in this area is present, it can be identified and spoken
about directly. Teaching other higher cognitive functions to be brought to
bear at these points can be extremely helpful. In addition, translation
capacity may improve with practice. What we are talking about essentially
is a subtle type of learning disability which is more common than has been
recognized in the near psychotic patient. These cognitive disabilities can be
one of the mechanisms mediating the vertical dissociation.
The summary of technical recommendations for treatment of the
dissociations of these states is:

1. Through observation and free association, evoke the full latent story with
the hidden real object and Object representation condensations or the
262 Psychosis and Near Psychosis

hidden real self and the self representation condensations on each side of
the dissociation.
2. Elicit the day residue in the present.
3. Elicit day residues of past genetic experiences that are thematically stirred
by present day residues and dissociated.
4. Integrate all vertical dissociations when fully conscious.
5. Integrate horizontally with the repressed affect as that affect becomes
conscious.
6. Consistently interpret defenses that mediate these dissociations. (The
matter is simpler when the major dissociation is of affect valence, as in
splitting. The matter is somewhat more complicated when the
dissociations involve mixtures and layers of affect, as in higher-level near
psychotic patients).

Day Residue

The reality of the day residue in near psychosis is usually heavily primary
processed. Therefore, it is very helpful when the therapist observes the day
residue, e.g., by incidentally walking into the ward common room at just the
right moment when two patients get into an argument. It is even better
when the day residue is a therapist action or inaction. The symbolic
alteration of reality in the transference and the sequence are clear to the
therapist, who can, with conviction and accuracy, interpretively describe this
to the patient.
Fortunately, most near psychotic patients soon enact in the transference.
For those high-level near psychotic patients who do not, progress toward
unraveling the day residue must await partial decondensation of the near
psychotic symbol and therefore report of the day residue by the patient. The
therapist must be alert to its emergence. Secondary process by the therapist
must be brought to bear, if even only silently, so as to make a hypothesis
that might allow technically neutral interventions designed to mobilize the
patient's secondary processing and conscious reality experience of the day
residue.
What happened can then be separated by the patient from the reaction
to what happened. Then one can get to why the particular patient reaction
occurred, and to why this type of reaction constantly happens.

Thing Presentation and Thing Presentation Quality

Near psychotic thing presentations emerge with conscious thing presentation

qualities. Ideas, behavior or both have the conviction of perceptual quality
validity and veracity. Such patients almost actually "see" it (see chapter 3; cf.
8. Psychotherapy of Near Psychosis 263

Frenkel-Brunswik, 1974). Therapeutic empathy with this perceptual quality

is crucial. Help the patient have empathy with this quality yet maintain his
or her observing ego about it. Only if the thing presentation quality is
viewed as its own affect justification but not logical justification will there
be a chance that it will no longer so intensely be both fought for and
partially repressed to protect it from conscious secondary process reality
function. Empathy about this aspect of near psychosis is, therefore, crucial.
The techniques used can be technically neutral by merely descriptively
pointing out the quality, the significance of the quality for the patient, the
use the patient makes of the quality, and the conscious fear of this quality.
This usually allows a more complete emergence into consciousness of the
preconscious thing presentation content. Once fully conscious, it tends to
disappear, sometimes quite abruptly.

Example:
An army captain is being driven in a jeep, part of a convoy of vehicles in a
motorized infantry division. The line stretches for miles and travels relentlessly
through heat and dust for hours. Gradually he becomes aware of funeral music
playing over the armed forces radio band. Panic ensues as he realizes that music
doesn't play over the armed forces radio band, only weather reports and encoded
troop movements. Furthermore, he doesn't remember turning the .radio on.
Before turning himself in to the division psychiatrist as "crazy," he decides to
check and see if the radio is on or off. He puts his fingers on the dial and finds
that the radio is off. The music instantly disappears.

Empathy with both the reality quality conviction and the secondary
process anxiety reassures patients that full elaboration in consciousness will
neither prove their worst fears literally true, nor prove their emotional
experience invalid (see "witch" example, p. 258). The army captain, of course,
was afraid of being killed. As the story unfolded, because he eventually did
talk to the psychiatrist, there was good reason for him to fear this. There
was also good reason for him to want to deny and partially repress that fear.
It was a fear of his own troops.
Thing presentation emergence into consciousness at the point of
decondensation when, for a moment, the near psychotic structure is in view
but undiluted by secondary process is a therapeutic moment of great
excitement and satisfaction for the therapists who like working with very ill
psychiatric patients. The dexterity required to "carry water on both
shoulders," to maintain both primary and secondary process tracks until they
meet at the transference or the day residue, is a gratifying act of mastery.
The relief of the patient seconds later is so great and the progress solidified
so helpful, the risks involved seem suddenly worthwhile to both patient and
therapist.
264 Psychosis and Near Psychosis

Agencies

Dynamic conflict of the agencies id, ego and superego is organized and
experienced as part of intense object relations condensations by the near
psychotic patient. Psychoanalyzing into agency elements without recognition
in early treatment phases of their object relations experiences with their
thing presentation qualities and without addressing ego problems of reality
testing, observing ego, and dissociations is experienced by the patient as
irrelevant, inaccurate, or reductionistic. This is because thing presentation
conviction quality is not attached to the abstract elements of the conflict. It
is not even attached to the affect elements. Elements of agency are not in
concept form and are not even fully in affect form, especially in the
preconscious of near psychotic condensations. If they are, then one is dealing
with much higher-level ego organizations, not near psychotic or borderline
as I and other hospital psychiatrists define it.
But agency conflict is at issue. Especially relevant are superego introjects
and condensations with attacks against real self-experience. Likewise, ego
ideal condensations with real self exist in hypomanic conditions. That these
condensations are also defenses against conflict between agencies is borne
out by the progressive psychoanalysis of these phenomena.
As these Object relations and thing presentation experiences become
conscious and decondense, the agency conflict elements are seen more
clearly. They are more linked to affect veracity and and are then more
describable in concepts and word presentations and can be analyzed with
classical technique.

Psychoanalytic Psychotherapy of Near Psychosis:

Behavioral/Borderline Type
The treatment of the behavioral borderline near psychotic is exactly the
same as the treatment of the pseudo-delusional type, but with one prior step
and one complication. The prior step is to convert behavior into a report of
the pseudo-delusional idea and attitude which is contained latently in the
premise for the action taken. The pseudo-delusional explanation, which is
preconscious, contains the reality condensations with fantasy that are latent
in the behavioral actions. The complication is that behavioral defense
structures may be based on splitting mechanisms which separate positively
valenced from negatively valenced self and Object relations. This separation
may not be limited to a focal area of pseudo-delusional content. These
defenses are across the board in those patients that I define as borderline.
These are very ill patients who do not function well in the world, who have
8. Psychotherapy of Near Psychosis 265

never functioned well, and who always end up for shorter or longer periods
of time in hospital because their behavior is so impulse-ridden.
Affect splitting is a defensive organization that maintains condensations
of reality with fantasy in multiple vertical dissociations of affect states that
defend against integrated reality and feelings about that reality. The
unintegrated affect state is then projected onto reality experience. This is the
mechanism of multiple projective identifications and involves the projection
of loving, positively valenced affect just as it does aggresSion. Aggression is
usually spoken about more in the technical literature because it is more
upsetting to the physician and is deemed etiologic by some (Klein, 1975;
Kernberg, 1975; Bion, 1984). Splitting defends against reality percept and
integration of percept. Without splitting, reality percept would confront the
affective day residue experience of the patient.
Splitting defenses may also be contributed to by an integrative defect in
the ego that is not based only on affect experience. These difficulties in
cognitive integration show up in the conceptual experience, mental status
examination, neuropsychological tests, and cognitive histories of such
patients. Sometimes these defenses exist as developmental delays due to the
intensity of affect in unstable affective illness. Thus, a concerted diagnostic
attempt must be made to diagnose the cause of the splitting and find
whether there are defects of autonomous cognitive functioning, as in covert
minimal brain damage, unstable affective illness, or mild SChizophrenic
fragmentation of cognition. Another common etiology for affect splitting is
extreme traumas of upbringing that have made integrative character
structure impossible due to intense traumatic affect states. Combinations of
these possibilities are not rare.
The technique for eliciting ideational content of behavioral material in
borderline patients is:

1. Observe behavior and understand that it is the enactment of fantasy

material. It is, therefore, a type of free association (Kernberg, 1975).
2. Some limit setting, particularly with more out-of-control patients and
those who are hospitalized, must be taken in order to provide motivation
and attention to the word processing channels (Kernberg, 1975;
Masterson, 1972).
3. The day residue instigating event must be observed and identified for the
patient. Observation of behavioral sequence and context, together with a
basic knowledge of human motivation, will enable hypotheses about the
instigating day residues if not observed. Separating these day residue
experiences from the ensuing emotional storms will clarify the
mechanisms and contents of symbolic transformations that are expressed
by behavior.
4. Careful observation of interactions in the transference will verify
hypothesized reality triggers and the mental capture mechanisms.
266 Psychosis and Near Psychosis

5. Loose associations and free associations are both used in the therapeutic
setting to uncover the fantasy underpinnings of behavior.

This method will quickly yield the elaborated fantasy which includes the
object relations and their condensations with reality that mediate disordered
behavior in the present. It is material that is the beginning of reconstructive
work with these patients.

Example:
A young suicidal borderline woman patient is voluntarily admitted to a
psychiatric unit. She arrives on the unit, and as soon as the locked door closes
she turns over a chair and yells, "You better let me out of here! I'm not crazy!
If you don't let me out of here I'll tear up the place! I'm not crazy!"
Psychiatric aide: "If you don't want us to think you are crazy, why are you
acting crazy?"
The patient calms down and is able to talk about her fears of being
mistreated on the unit. She then presents a list of demands if she is to stay. It
seems as though her fear of being mistreated is her fear of not getting her own
way.

The immediate day residue for the affect storm in this case was hospital
admission. Her behavior was an angry temper tantrum. The implied effect
on the real object seemed to be intimidation. The intervention was a
confrontation of the paradoxical dissociation of content between her words
and her behavior. Although her stated fear seemed to be domination and
control by real objects, her latent wish seemed to be to domineer and
control those Objects. The mechanism was projective identification acted out
in behavior onto objects in reality.
If this behavior is not confronted immediately, this patient will stay, but
with a whole list of demands, from passes to visitors to diet to television
shows. If she does not get her way, a suicide threat may ensue. This is one
reason hospital units have come to the idea that these patients should be
medicated and quickly diSCharged. This is too bad, since it overlooks an
opportune time to diagnose and interpret what goes on outside the hospital
anyway. (On hospital treatment see Kernberg, 1976b, chapter 6; and Marcus,
1981, 1987a, 1987b.)
Sometimes one gets past genetic day residue precipitants rather than
present ones. These past evokers are thematically related, superficially, to
present day residues and will give the therapist strong clues about what has
happened in the present. Particularly if it is transference material, the
therapist ought to have access to information about those events. The
therapeutic focus must be placed on the present and the full rush of affect
and elaborated fantasy material will ensue. This is because there is
displacement back and forth through time of affect and Object relations. One
can then go back to the past evocators and delineate the more unconscious
aspects of affect experience there that are truly encased, displaced and
8. Psychotherapy of Near Psychosis 267

triggering present day pathology. It is difficult to get at those deeper layers

of the past directly through the genetic material because of (1) the rigidity
with which thoSe layers are defended against, (2) the rigidity with which they
defend against complex affect in the present, (3) the conscious use of the
fact of the past to defend against full emotional significance of both the past
and present, and (4) the displacement of some of their complex affect to
present day evocators. Major aspects of validity and veracity are therefore in
the present. The use of the present to defend against the past is true for all
patients. The use of the past to defend against the present is true of sicker
patients. One ego reason for this phenomenon is that more complex layers
of psychological material, involving triangular situations and reality
complexities, require higher-level ego function to articulate and mediate.
These functions are damaged in very ill patients.

Splitting Mechanisms

The treatment recommendation for affect splitting mechanisms (Klein, 1975;

Kernberg, 1975) is not to permit the maintenance of what is essentially a
vertical dissociation. Efforts must be made to help the patient experience
objects and self as not separated by affect states and as continuous over
time. This is particularly true in the transference. Simply pointing to the
discrepancy from the vantage points of technical neutrality will often suffice.
The point is that technical neutrality has to concern itself with ego
dysfunction when that dysfunction is compelling. It does not violate technical
neutrality to focus on one agency or another. Analysts have considered
themselves technically neutral for years while focusing on repressed drive or
conscience material in the neurotic. Why not focus on the ego when
necessary? Crucial to the ego focus necessary for the treatment of splitting
is to describe both sides of that conflict and to engage the patient in a
discussion that might prove synthetic.
An example is the borderline patient who tells the therapist he is
wonderful in response to some administrative action concerning the patient
taken by the therapist in hospital. After the provoking day residue is pointed
out, the therapist may wish to point out that the patient said he was terrible
and thought he was mean only a moment before when she thought the
request would be refused. The patient will usually respond with a simple
denial. The therapist may wish to respond with a confrontation of that
denial. The patient may then respond with a recognition that indeed she did
say a moment before that she hated the therapist and did curse at him but
didn't mean it. The therapist may wish to point out that the patient said it
and appeared to mean it at the time. The patient may then respond that
although she did say it, and she did mean it, that was before and now is now.
The therapist may wish to point out that the therapist has been the same all
along. It was, in fact, the patient who felt differently about the therapist and
268 Psychosis and Near Psychosis

all because the patient was not getting what she wanted at the moment. This
is the repetitive experience of treating borderline, infantile patients.
The experience of yesterday as yesterday but today as today points to the
lack of integrated continuity over time that borderline patients experience
partly because of the extremes of their affect states. It is difficult for the
beginning therapist to realize that integrated states of positive and negative
valence are more painful to the patient than the rage attacks that they
experience. This is because the very angry patient who has been traumatized
in life by inconsistent Objects and/or inconsistent affective stability worries
that the experience of the integrated Object will only be more bad than good
(Kernberg, 1975; Klein, 1975) and this can cycle into a despair that is truly
dangerous in patients with associated affective illness and poor impulse
controls. It is the reason that the integrative interpretation of such patients
is sometimes a hospital procedure.

Hospitalization
Because of the dangerousness of impulsive behavior, the severity of vertical
dissociations, the difficulty diagnosing integrative defects and their causes,
the intensity of splitting defenses, and especially the dangers involved in
trying to heal those splits with the resulting temporary despair, many of the
sicker borderline patients are, in my opinion, best treated for periods of time
in hospital. On hospital treatment see Kernberg (1976b), chapter 9, and
Marcus (1981, 1987a). On outcome of hospital treatment see Marcus and
Bradley (1987) and the definitive study by Stone (1990). If a ward is stable,
organized, and psychologically sophisticated, hospitalization enables easy
observation of day residue organizers and their themes. These are helpful to
the therapist in organizing what seems to be emotional chaos into quite
psychologically understandable emotional events. It is helpful to remember
that just as inside of each delusion is a reality nidus, so inside each pseudo-
delusion is a reality nidus. Inside each near psychotic behavioral action is a
reality nidus. The closest analogy, again, in classical psychoanalysis is the
dream built around a reality day residue.
The handling of behavior is the most vexing aspect of treating borderline
patients (see Masterson, 1972). It is important to realize that some limit
setting must be done. In the hospital, the limit setting must be early,
consistent, and directed at all out-of-control behavior. In outpatient
treatment, the limit setting focuses particularly on the transference. Very
often, in healthier borderline outpatients engagement of the issue of
dissociation of behavior from other differently valenced and split-off affect
behaviors is enough to bring behavior in the transference under control. At
other times, the therapist must move out of technical neutrality and into the
ego function of behavioral control through the technical intervention of limit
setting.
8. Psychotherapy of Near Psychosis 269

It is important to realize that being silent or passive in the face of

extremely disordered behavior, especially in the transference, is not a
maintenance of technical neutrality (Zeligs, 1960; Calogeras, 1967). This is
because the condensation between reality and the fantasy in the ego
continues unabated in the face of silence on the part of the therapist. The
technical neutrality of treatment has been violated by the ego condensation
which does not allow any technically neutral space between the fantasy
object world and the reality object world at that point. Therefore, there can
be no midway between ego, superego, id, and reality because ego boundary
has failed in relationship to affect-reality relationships.
Limit setting, whether achieved by engagement of the conflict or by overt
limit-setting commands on the part of the ward staff or the therapist, should
be loose enough to let the patient get involved with the therapeutic
environment, but tight enough to contain dangerous behavior and to engage
word presentation channels. The milieu must be relaxed enough to let the
behavior, within limits, proceed along a path of unfolding of psychological
life, especially as the uncovering of the psychological life may only be
possible with some behavioral manifestations.
The difficulties of doing this are many. One must recognize the illness-
relevant behaviors. One must then hypothesize the near psychotic content.
One must also hypothesize the complex affect. The affect will be expressed
poorly in the impulse discharge of the behavioral action. This is not only
because behavior is ambiguous, but also because deeper layers of complex
integrated affect are prevented by the immediate behavioral discharge of one
side of the conflict. At first, the other side of the intense affect and the
complex integrations of affect will appear in the therapist's experience long
before they appear in the patient's experience. It permits the next step of
interpretation to take place in which a tactful way is found, in the patient's
own experience and language, to talk about what is essentially a
countertransference-based hypothesis (see Racker, 1968; Kernberg, 1976b,
chapter 6). One must be especially careful not to impose one's own
countertransference-based hypotheses on patients but, rather, to listen
carefully for associations and to observe behavior carefully and to invite
associations about that behavior so that countertransference hypotheses,
which have focused the therapist's inner attention, can be validated or
invalidated by the patients themselves.
One important warning. If analysis of content proceeds without analysis
of behavioral dysfunction and before repair of the ego boundary between
affect, fantasy, and action, then deeper layers of repressed material will
emerge and, if affectively charged, erupt immediately into behavior. The
patient and the therapist will be worse off!
It is important to focus immediately on behavior not only because that is
where the relevant dynamics are, but also because it is where the true
resistances to the treatment lie with their basic character defenses (cf. Reich,
1925; Sterba, 1953; Boesky, 1983). In the borderline there is no resistance
270 Psychosis and Near Psychosis

to transference, but there is great resistance to the treatment alliance. The

situation is different in the neurotic, where there is often a treatment
alliance but great resistance to the transference. It must be understood,
however, that for the borderline patient transference does not mean fantasy,
but behavior and attempted satisfaction in the real world, albeit with the
Object representation! There is an overwhelming of the distinction between
real object and object representation based on intense object represen-
tations. The same is true of self-representation, real self, and self in reality,
especially for depressed, borderline patients. Although the behavior is with
the real Object as manifested by the object in reality, or the real self as
manifested by the self in reality, the motivation for this behavior is a
condensation between reality and fantasy in the preconscious. This is why
one must move in quickly to identify content when affect erupts in the
transference and the transference threatens to become actualized. Identifying
the relevant day residue, the particular wish to change the day residue, and
the stubborn unyielding mediating defenses is helpful.
It is important to realize the extent of behavior and its approach to the
psychotic boundary. The best example of this is the anorexic who will starve
herself to death, all the time proclaiming she is too fat. Some of these
patients are actually psychotic, but often they are not. If they are not
psychotic, they do respond to engagement of the denial of factual reality.
Although with tears and anger, it will emerge that they consciously do know
they are too skinny. At that point, they say they feel too fat and they will go
with the feeling rather than their secondary process view. This is of great
help in advancing the analysis of their psychological state.
This example is true of all borderline behavior because:

1. The ego deficit is between mental experience and behavior.

2. The ego boundary problem between reality experience and emotional
experience permits condensations of reality and fantasy in the
preconscious.
3. Character defenses make the emotion more important that the fact.
4. Thing presentation quality of reality contaminates perception with affect
rather than linking affect with the conceptual mental life of ideas.

Because of all this, there is a push toward enactment; action process

becomes caught up with and part of affect-content. The therapist must
describe the elements of this enactment: the relationship of elements to each
other and to the attempt at integrating, but also defending against the
underlying conflicts. It is important to realize that the conflict takes two
different forms in this kind of behavioral pathology. The first is the
dissociation of parts of the conflict into different behaviors, or one side in
the behavior, and the other side in a partly repressed fantasy. The second
way the conflict is expressed is in the stereotyped repetition of the
behavioral paradigm which moves back and forth from the expression of the
8. Psychotherapy of Near Psychosis 271

intense negative side to the expression of the intense positive side. The
intense negative and positive aspects form the superficial level of a
conflicted story that never progresses. It is a "lock" that is expressed in
behavior just as in neurotic patients the "lock" is expressed in their symptom.
In psychotic patients the "lock" is the delusion. In all three levels of ego
organization, growth in real life is blocked at these specific points.
Borderline patients have an action style that is an extreme example of
milder forms of behavioral ego styles. A variety of patients have this
behavioral style, including some normal people who are not involved in
extremes of behavior or neurotic "locks" in their life. Some people need to
experience their behavior in order to experience their feelings and thoughts.
All people need to work out their psychology of motivation within the
reality of their lives. The question is not only the degree of integration or
of sublimation, but the degree of progress and growth. A better name for
this kind of healthy action might be acting through rather that acting out. A
focus on behavior with the goal of analyzing blocks to the progressive acting
through of conflicts into growth is a potential technique that can be very
helpful in that minority of borderline patients where the action style is fixed.
The last recommendation on technique that is usually made by
theoreticians in the field has to do with negative transference. The
recommendations fall into two groups. There are those who say deal
immediately with negative transference, even and especially if it is latent
(Kernberg, 1975). Others say to avoid the negative transference at all costs
(Adler, 1983). Again, the quarrel has to do with different groups of
borderline patients. If one takes neither approach but waits to see which
approach is forced by the patient's psychopathology, almost always in sicker,
hospitalized, borderline patients the negative transference is brought to bear
immediately in an open attack on the therapist, directly as a person,
indirectly as a physician, or more indirectly as a member of the hospital unit.
Alternatively, the patient may idealize the therapist or the treatment in
exaggerated descriptions and expectations. It is important to interpret these
idealizations. With interpretation, there is a flip into the oppositely valenced
aspect of the conflict. It is important to keep interpreting; otherwise you will
always be stuck in one half of the conflict and will have made no integrative
progress. Once you have gone back and forth a few times, the fact of the
oscillation can be described and the relationship of the two sides can be
analyzed with the patient. Therefore, even positive transference should be
analyzed early in the borderline patient when it is part of the dissociation of
conflict.
Because the therapist is often the focus of intense transference fantasy and
behavior, the treatment of these patients is very difficult. The reason is that
latent transference is in the preconscious, primary processed, and dissociated
from conscious secondary processes. The open affect-behavioral boundary
means that this material is a hair's breadth away from action. Interceptive
interpretations are therefore often required to prevent dangerous behavior.
272 Psychosis and Near Psychosis

One must translate with instant speed and timing the presentations of
behavior into words describing the patient's affect and integrative conflicts.

Rigid Character Neurosis with Near Psychotic States

When near psychosis is comorbid with rigid neurotic character disorders,
there is opportunity and leverage for change. This is because intercurrent
near psychotic illness causes a different degree of repression and integration
than is usual in the rigidly fIXed neurotic character. As a result, the
psychology of character may be clearer and experienced with greater veracity
by the patient. Therefore insight is potentially rapid. The understanding of
neurotic character can be used by the observing ego in understanding the
near delusion, but the near delusion can also be used by the observing ego
in understanding character conflicts! On the treatment of rigid character
disorders see Shapiro (1981); cf. Schafer (1991), and Winnicott (1991).
In analyzing the relationship between character and psychosis or near
psychosis, one observes the recapitulation of theme in the psychotic or near
psychotic material and also in reality, behavior, fantasy, the past and the
present, and character derivatives. Psychotic and near psychotic
decompensation provides an opportunity for character analysis. It is not an
opportunity to be sought, but it is an opportunity to be used if
decompensation occurs. In rigid character, the dynamic material and its
themes are more apparent during psychotic or near psychotic
decompensation. Character defenses are often increasingly plastic during
such times. Further, thing presentation quality is suddenly available as affect
veracity linked to the psychodynamics of character conflicts and themes. This
is because of the close proximity in the ego between the neurotic areas and
the more ill areas, because of the intensity of affect in acute
decompensations, and also because of the identity of theme.
It is important, however, to understand that in severely ill patients drive
material must not be interpreted before ego dysfunction is engaged and on
the way to being repaired. Behavior will grow increasingly disruptive and
near delusional material will spread if this rule is violated. But the potential,
if character analysis and analysis of psychotic and near psychotic material are
carried out in tandem, is for rapid and mutative change in both. Points of
character resistances at mediating defenses that maintain vertical
dissociations are particularly accessible points. These mediating defenses not
only protect the vertical dissociations and observing ego, but often protect
the delusion or pseudo-delusion from a reality engagement. Reality is the
most powerful antidote to fantasy. These character defenses manifest
themselves as resistance to treatment because the treatment will focus on the
real self and the real Object. We thus have a phenomena that overlaps the
defenses against reality, integration, and treatment and coincides with basic
8. Psychotherapy of Near Psychosis 273

organizing content, themes, and processes of character. The phenomenon is

expressed in numerous nodal points of condensation and overlap. It is at
these points that character treatment can be unlocked. It requires quick
identification of the nodal points and analytic unraveling of dynamic
psychological life. It requires experience, patience and time.
The benefit to be hoped for is twofold. First, analysis of character along
with psychosis and near psychosis can lead to a more rapid amelioration of
both than can supportive treatment alone, if attention is paid to integrating
vertical dissociations, liberating observing ego, and separating reality from
fantasy. The second great benefit is the hope that the reality triggers will be
incapacitated by unraveling the psychological resonance between character
and psychotic or near psychotic theme both in the present and in the genetic
past. The hope is that one will then have a patient less vulnerable to
recurrence. And lastly, it can unlock a rigid, stalemated, or neurotic
character organization with a resultant surge in growth and in life
gratification.
A simple way the character dynamics of repeated hospitalization express
themselves is in patients who continually stop prophylactic medication for
their psychotic or near psychotic illness. Many patients stop their medication
not because they are delusional about the medication, and not because of
side effects, which are numerous and often unpleasant, but because of
psychological reasons that express their most basic character defenses. This
is another way in which analysis of selected character defenses and of
character functioning more broadly can prevent recurrent hospitalizations.
A word, before closing this section, about rigid character problems in the
absence of psychosis or near psychosis. These patients often seem to be
purely neurotic, but because of the rigidity of their defenses they do not
change, with or without treatment. Some of them are so rigid that they do
not really form accessible transference that can be analyzed. It is important,
before giving up on such patients, to realize that the rigidity of their
defenses characterizes them in the very ill group.
A differential diagnosis must be done. Sometimes the greatest areas of
rigidity have the structure of near psychotic phenomena. In fact, some of
them are quickly discovered to be suffering from this organization. There
are, however, other points in the differential diagnosis of rigid character
structures. There is the rigidity of defense against psychosis, either as acute
decompensation or as in a chronic delusional introject. The other is rigidity
of defense against ego deficits. An example is the adult attention deficit
disorder patient with rigid obsessional defenses. A further example is rigid
defenses against intensity of affect. Examples are chronic, mild, hypomanic
patients and chronic depressives.
The point that I wish to stress, however, is that with rigid neurotic
characters with a failing psychoanalytic treatment, it is important to diagnose
the cause and look especially for covert ego problems. Do a careful
274 Psychosis and Near Psychosis

symptomatic review looking for formes frustes of known psychiatric illnesses.

A trial of medication may be indicated and most helpful.
The rigidity, however, may be a higher-level superego infused guilt over
change and progress at a purely neurotic level (see Coen, 1988). This guilt
must be engaged early and consistently if treatment is to move forward.
In all rigid characters who are locked out of life growth and treatment
possibilities, there are certain nodal points, external to their pSYCholOgy, that
provide opportunity for change. New socialization experiences, real-life,
present-day traumas, physical illnesses, life disappointments, and life
opportunities are all examples of stresses that challenge character
organization. At such times, therapy which has been previously unfruitful
can be very helpful and change a potential life crisis leading to worse and
more entrenched character pathology into a life crisis leading to character
change and positive ego growth.
A shift in psychoanalytic technique to take into account the ego problems
ofrigidity is also helpful. The techniques involve labeling, confrontation, and
manifest warmth and concern with interpretations about anxieties that this
then evokes. The technique of psychoanalyzing rigid character defenses is a
combination of patience, confrontation, elaboration of attitude and
exploration of dynamic affect expressed in attitude. At times, one can only
deal with the psychOdynamics in less rigidly fIxed derivatives. When to do
what varies with the patient and with time, that is, with the variations in the
rigidity. Careful observation is necessary to see which technique or sequence
of teChniques is most helpful. Interpretations that liberate affect may make
defenses more rigid, even though affect exploration is necessary to ease rigid
defenses. Therefore, in technique, how much and when is as important as
how to. Each patient has his or her own ego pattern of attitude defenses and
his or her own affect tolerance limits within those defenses. The rigidity of
the pattern, however, has one advantage: the pattern is rigidly fIxed and the
therapist can therefore come to know this pattern. One can fInd the
tolerable and useful sequence, type, and degree of intervention that usually
helps the patient. The key is a flexible trial-and-error attitude in the
therapist, so that the type and dose of intervention can be discovered.

Use of the Couch in Near Psychosis

The use of the couch in pseudO-delusional near psychotics does not depend
on the near psychotic condensation but on the intensity and rigidity of
character defenses and whether that intensity and rigidity is directed into the
transference or whether it needs to be. It also depends on whether the
dynamics are available in reports of interactions outside the transference. If
the transference is a necessary vehicle, and if the couch is helpful in bringing
the dynamic transference life to clarity, it should be used. Some near
8. Psychotherapy of Near Psychosis 275

psychotic patients find relief from transference intensity on the couch, where
without the observing gaze of the therapist, transference intensity actually
decreases. This is especially true where the transference affect is shame.
Other pseudo-delusional patients find their projective identifications
increase to unmanageable intensity on the couch. Often, the therapist can
see this in the first consultation and properly avoids a couch analysis (cf.
Greenspan and Cullander, 1973).
Some seem to need the couch and then cannot handle it. It is helpful if
the analyst is alert to the possibility of near psychotic transference intensities
and condensations projected onto the therapist so that immediate
interventions can be made (see Kernberg, 1976b; also Little, 1981). Alertness
to countertransference is crucial. Flexibility, tolerance, patience, tact,
sensitive empathy, insistence, and timing are all required. An ability to
articulate Object relations and affect-content scenarios at the affective level
of abstraction is also important. With these technical suggestions, many near
psychotic .patients do well in couch analysis. (See Fenichel, 1941; Reich,
1945; Giovacchini, 1975; Kernberg, 1991.)
The worst problem is with near psychotics who are the behavioral,
borderline type. Their affect-behavior condensations and lack of control
make a couch psychoanalysis often impossible or counterproductive. It
usually encourages too much passivity in the therapist and too much
intensity in the patient. Many of them have instant, intense transference and
constant free associations, so the couch is superfluous anyway. The treatment
can, however, proceed through early and early mid phases to a point in the
middle phase where the couch is helpful. On the other hand, patients often
do well at this point, coming to treatment three or four times a week in the
sitting up format, so that a therapist may properly hesitate to Change a
beneficial treatment situation. On psychoanalytic psychotherapy with such
patients see Langs (1973), Kernberg (1975), Kernberg et al. (1989), Searles
(1986), and Shapiro (1989).
In my opinion, these are the relevant issues in the sometimes heated
debate about psychotherapy versus psychoanalysis, sitting up or lying down.
It is at this level of conceptualization and at the specific ego function level
of specific patients that the discussion is most productively engaged.
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Author Index

Abend, S., 99, 251, 290 Cameron, J., 144,217,281

Aboitiz, E, 166, 184, 282 Campbell, R., 1, 9, 39, 179, 279, 284
Abraham, K., 151, 277 Cassirer, E., 34, 279
Adler, G., 251, 271, 277 Chekhov, A., 279
Albert, H., 150,217,224,294 Chiland, c., 217, 245, 279
Alexander, J., 179,277 Coen, S. J., 96, 184, 274, 279
Arieti, S., 16, 100, 144, 146, 150,201, Compton, A., 97, 179,280
217,224,277,294 Counts, R. M., 280
Arlow, 1., 18,49, 66, 143, 150,222,277 Cullander, C. H., 275, 283
Asaad, G., 131,277
Davis, J., 144,284
Banglow, P., 11, 277 Denckla, M., 166,280
Basch, M. E, 219, 278 Deutsch, E, 168, 280
Baudry, E, 179, 278 Diamond, L., 108, 280
Beitman, B. D., 191, 212, 278 DiMascio, A., 210, 295
Bellak, L., 9, 38, 86, 90, 117,249,278 Duane, D. D., 166, 280
Benton, A. L., 168, 278
Beres, D., 11,33, 143,278
Eissler, K. R., 80, 218, 280
Bernstein, S. B., 246, 278
Bion, VV. R., 150,265, 278
Blanck, G., 1,38,86,218,278 Fairbairn, R., 77, 143,280
Blanck, R., 1,38,86,278 Federn, P., 9, 12, 249, 280
Bleulcr, E., 77, 144, 206, 279 Fenichcl, 0., 181,275,280
Blum, H. P., 34, 279 Ferenczi, S., 34, 42, 280
Boesky, D., 270, 279 Fisher, c., 281
Boyer, L. B., 150, 217, 224, 279 Fleiss, R., 76,108,280
Bradley, S., 179, 184, 191,212,268,279, Forrest, P., 150, 217, 224, 294
288 Freeman, T., 144,166,217,219,281,296
Brenner,c., 18,26,40,41,66, 143,150, Frenkel-Brunswik, E., 180,263, 281
162,163,217,277,279 Freud, A., 40, 281
Freud, S., 16, 17, 18,20,21,27,38,39,
Calogeras, R. c., 269, 279 40, 41, 42, 43, 48, 49,50, 51, 53, 73,

297
298 Psychosis and Ncar Psychosis

76,80,84,99,100,105,107,108, Jamison, K. R., 151,282

116,124,140,141,142, 155, 156, Jaspers, K., 131, 284
162,169,179,185,243,281 Jones, E., 34, 42, 284
Friedman, L., 2, 281 Joseph, E., 33, 278
Fromm-Reichman, F., 150,217,218,224,
282 Kafka, E., 173,177,218,284
Frosch, J., 39, 51, 66, 73, 78, 83,113, 151, Kaplan, B., 34, 295
219,251,282 Karasu, T. B., 191, 212, 284
Karush, A., 11,285
Gabbard, G., 51,151,219,251,282 Kernberg, 0., 14,27,28,56,68,76,78,
Galaburda, A. M., 166, 184,282 82,86,99,105,112,113,114,116,
Gediman, H., 9, 38, 86, 117, 278 117,120,142,143,150,164,179,
Geschwind, N., 166, 184,282 181,251,256,257,265,266,267,
Giovacchini, P., 275, 282 269,271,275,285
Giovacchini, P. L., 150, 217, 224, 279 Khan, M. M. R., 247, 285
Glover, E., 38, 143,179,259,282 Klein, M., 27, 42, 76, 77, 99, 114, 116,
Goldsmith, L., 90, 278 150,151,162,265,267,268,285
Goodwin, F. K., 151,283 Klerman, G. L., 191,212,278,285
Gray, D. B., 166, 280 Knight, R. P., 77, 286
Greenacre, P., 151,217,283 Kohut, H., 58, 76, 251, 286
Greenson, R., 181,222,282 Kolb, L., 286
Greenspan, S. I., 3, 275, 283 Kraepelin, E., 3, 286
Grolnick, S., 116, 283 Kris, E., 80, 286
Grossman, w., 18, 283 Krystal, H., 136, 286
Gunderson, J., 78, 251, 283 Kubie, L. S., 73, 286
Kuhns, R., 34, 116,286
Harticollis, P., 283
Hartmann, E., 283 Lampl-de Groot, J., 180,286
Hartmann, H., 1,2,9,38,77,86,108, Langer, S., 34, 286
218,283 Langs,R., 222, 235, 275,286
Heider, F., 283 LaPlanche, J., 1,39,40,286
Heimarck, G ., 38 Le Doux, 1., 48, 115, 286
Hendrick, I., 179, 284 Lewin, B., 151,162,164,217,286
Hinsie, L., 1, 9, 284 Liebert, R., 179, 286
Hoch, S., 246, 284 Lion, J., 179, 286
Holder, A., 80, 291 Lipinsky, T., 184, 290
Holmes, 1.,166,291 Lishman, S., 166,287
Holt, R., 2, 284 Little, M., 226, 275, 287
Holtzman, P., 144, 284 Loeb, F. F., 198,287
Hurt, S., 144,284 Loeb, L. R., 198,287
Hurvich, M., 9, 38, 39, 86, 117,278,284 Loewald, H., 1, 34, 107, 287
Lowenstein, P., 218,287
Inhelder, B., 4, 34, 289 Lowenstein, R. M., 218, 287
Isaacs, K. S., 179, 277
Izaard, c., 39, 284 Mack, J., 287
MacKinnon, R., 117, 179, 182, 287
Jacobson, E., 27,56, 66, 77,108,117, Mahler, M., 164,287
143,151,155, 156, 162, 164,216, Marcus, E. R., 108, 179, 181, 184,209,
217,234,284 212,219,245,266,268,287,288
Author Index 299

Masterson, J., 181, 251, 265, 268, 288 Sadow, L., 11,277
Mateer, C, 18, 116, 289 Samberg, M., 168,291
Matte-Blanco, I., 34, 288 Samberg, R., 177,291
McElroy, S., 108, 288 Sandler, A-M., 28, 292
McGhie, A, 144,217,281 Sandler, 1., 28, 80, 99, 106, 122,291, r292
McNutt, E., 246, 288 Sarnoff, C, 34, 73, 235, 292
Meissner, W. w., 99, 288 Sarwer-Foner, G. J., 159, 185,212,219,
Meyers, B., 249, 278 292
Michels, R., 117, 179, 182, 287 Schafer, R., 1, 2, 16,28,42,90,99, 108,
Milrod, D., 162,217,288 272,292
Modell,A, 27,288 Schur, M., 21, 292
Morris, J., 246, 289 Scott, W. C, 151,293
Searles, H., 18, 86, 146, 150, 217, 224,
Namnum, A, 249, 289 226,275,292,293
Nersessian, E., 41, 289 Sechehaye, M. A, 240, 292
Nunberg, H., 38, 86, 289 Segal, H., 34, 293
Segel, N., 34, 293
Obeyeskere, G., 34, 289 Shahirn, S. A, 210, 295
Ogden, T., 99, 289 Shapiro, D., 15, 139, 179, 182, 184, '272,
Ojemann, G., 18, 116, 289 275,293
Ostow, M., 185,212,216,219,289 Shapiro, T., 293
Shaywitz, B. A, 166, 169,293
Pao, P. N., 50, 149,217,224,289 Shaywitz, 5. E., 166, 169,293
Piaget, 1., 3, 4,11,34,48,289,290 Sherman, G. E, 166, 184,282
Pine, E, 27, 290 Sims, A, 131,293
Plato, 38 Skodol, A, 131,293
Plutchik, R., 39, 290 Slap, J., 294
Pontalis, J., 1,39,40,286 Slap-Shelton, S., 294
Pope, H. G., Jr., 184, 290 Smith, G., 11, 295
Porder, M., 99, 251, 290 Spitzer, R., 131, 142,294
Steiner, J., 293
Racker, H., 256, 269, 290 Steiner, R., 99, 294
Rado, S., 162, 290 Sterba, R., 229, 270, 294
Rapaport, D., 2,290 Stern, D., 3,4,7,48,99, 145, 150,294
Rapin, I., 169,290 Stone, L., 162, 212, 267, 294
Redlich, E, 150, 290 Stone, M., 78, 86,150,194,217,224,
Reich, w., 68,105,116, 117, 142, 179, 268,294
181,270,275,291 Sullivan, H., 150, 224, 294
Reider, N., 222, 226, 291 Symons, N. J., 34, 294
Renick, 0., 218, 291 Szalita-Pemow, A B., 218, 294
Resnick, T., 169,291
Rizzuto, AM., 18,291 Tupper, D., 166, 184,294
Rosenblatt, B., 99, 292
Rosenfeld, H., 76, 234, 291 Vetter, H., 144,294
Rosen, G. D., 166, 184, 282 Voeller, K., 173, 184, 295
Rosen, v., 177, 218, 291
Rothstein, A, 166, 173, 184,218,291 Waelder, R., 41, 249, 294
Rudel, R., 166,291 Waldheim, R., 34, 294
Rudcl-Pandes, J., 166,291 Wallerstein, R., 233, 295
300 Psychosis and Near Psychosis

Walsh, K., 295 Williams, Jo, 131, 142,293

Wei!, A, 24, 295 Willick, Mo, 68, 97, 99, 150, 251, 290,
Weil, A Po, 3, 246, 295 295,296
Weinshel, Eo, 143,295 Winnicott, Do w., 16, 60, 72, 100, 116,
Weiss, Jo Mo, 295 201,272,296
Weissberg, So, 219, 296
Weissman, Mo Mo, 210, 295
Yahalom, I., 34, 296
Werner, Ho, 34, 295
Yorke, c., 219, 296
Wcstlundh, Bo, 11,295
Weston, Do, 296
White, Ro, 3, 296 Zcligs, W. A, 269, 296
Subject Index

Abstraction, 4 and psychoanalysis of near

Acting through and acting out, 271 psychosis, 264
Action(s),105-106 Agency contents, 21
pathological, 105 Aggression, thymoleptics and, 204
psychoanalytic theory of, 104-113 Analysis of psychotic structure, 236--240
symbolic, motivation for, 107-109 Antidepressants, 198-204
Active questioning, 120 Antipsychotic drugs, 185-197
Affect-affect boundary, see Affect Associations, 125
boundaries Attention deficit disorders, 166
Mfect boundaries Autonomous apparatuses
in character disorder, 180-181 defined, 8-15
defined,l1-13 in near psychosis, 79-95
in manic-depressive illness, 155-156 primary, 2-3
in mental status examination, 127 in psychosis, 46--47
in near psychosis, 81-82 Autonomous ego characteristics of
in organic mental syndromes, 171 dyslexias, 178
in psychoanalytic psychotherapy and manic-depressive illness, 151-158
psychoanalysis of near psychosis, schizophrenia, 145-148
257 Autonomous ego function in near
in psychosis, 47 psychosis, 87-88
in schizophrenia, 147 Autonomous ego function in psychosis,
"Affect leak," 153 46,47
Mfect modulating capacity, 82
Mfect-percept boundary Behavior, mental experience and, 85-86
in mental status examination, l3ehavioraltype ncar psychosis, 212
126--127 l30rderline states, 77; see also Near
neuroleptics and, 187 psychosis
thymoleptics and, 200 130undaries
Mfect-percepts, 18 between levels of consciousness, 80
Mfect splitting mechanisms, 267-268 between levels of awareness, 124-126
Mfects,5 in character disorder, 180-181
Agencies in psychoanalytic psychotherapy defined,8-13

301
302 Psychosis and Near Psychosis

in manic-depressive illness, 151-156 Day residues

medication effects for ncar psychosis in character disorder, 182
and, 205-207 defenses in, 196--197
in mental status examination, 122-128 defined, 16--17
in near psychosis, 79--82 in manic-depressive illness, 158-160
object relations and, 29, 31-32 in mental status examination, 135-136
in object relations experiences, 123-124 in ncar psychosis, 91-92
in organic mental syndromes, 166-172 neuroleptics and, 188
between psychic agencies, 22 in organic mental syndromes, 174-175
in psychoanalytic psychotherapy and in psychoanalytic psychotherapy and
psychoanalysis of psychosis, 224-226 psychoanalysis of near psychosis, 262
in psychosis, 46-47 in psychoanalytic psychotherapy and
in schizophrenia, 145-147 psychoanalysis of psychosis, 241-243
in psychotic structure, 53-55
Categories, 4 in schizophrenia, 148
Character, psychosis and, 69-70 thymoleptics and, 201
Character disorders, 179-184 Defense content, thymoleptic effects on,
rigid neurotic, 272-274 203-204
Compromise formation, 26-27,41 Defenses
Compulsions, 132-133 in character disorder, 184
Compulsive phenomena, hierarchy of, 132 in day residue, 196--197
Concept boundaries, 11 defined, 22-26
Concept-percept boundary layering, 193-194
in mental status examination, 126-127 in manic-depressive illness, 164-165
neuro\cptics and, 186-187 mediating, 67
thymoleptics and, 200 medication effects for near psychosis
Conceptualization, 11 and, 208-209
Concrete ncar reality, 101 in mental status examination, 138-140
Condensation, 9-11, 31, 41 in near psychosis, 95-97
defined,6-7 neuroleptics and, 191-197
of fantasy with reality, 49-51 object relations and, 196
Conflict, primary process and, 26-27 observing ego and, 195-196, 203
Confrontation, 120 in organic mental syndromes, 177, 178
Conscious-preconscious-unconscious in psychoanalytic psychotherapy and
boundaries, 12-13 psychoanalysis of near psychosis,
in manic-depressive illness, 153-154 255-256
in organic mental syndromes, 170 in psychosis, 65-67
in schizophrenia, 146 reality experience, 192-193
Conscious thinking, 12 reality experience and, 202-203
Conscious-unconscious boundary reality testing and, 195
in ncar psychosis, 80 rigidity of, 253
in psychosis, 46 in schizophrenia, 150
Couch, use of thymoleptics and, 202-204
in psychoanalysis of ncar psychosis, vertical, 194-195
274-275 vertical dissociations and, 203
in psychoanalysis of psychosis, Defensive motivations, 107
246-249 Delusional structure, 58-60
Creativity, symbolic alterations of reality Delusionosis, neuro\cptics and, 190
in, 103 Dc1usions, 13, 17, 129, 130
Subject Index 303

classification of psychotic structures "Flashback" experiences, 95

such as, 60-64 Fragmentation, 144
Denial, 140 Free association, 125,237
in near psychosis, 100 Fusion, 9-10, 31
Depression, 151-165
Descriptions, interpretive, 120-121 Hallucinations, 13, 129, 130
Displacement, 7 classification of psychotic structures
Dissociations, vertical, see Vertical such as, 60-64
dissociations differential diagnosis of, 13, 129
Domains, 5 medication and, 189
Dreams, 6, 16, 17,49,50,53,54 Hallucinosis, 14, 129, 130
Dyslexias, 170 neuroleptics and, 189-190
autonomous ego characteristics of, 178 in organic mental syndromes, 167
boundaries, 168 Hospitalization, 268-272
day residue, 174
defenses, 177 Id,21
integrating capacity, 172 Identification, projective, 98-100,
object relations, 176 139-140
observing ego, 172 Illness, definitions of levels of, 67-69
reality testing, 172 Illusions, 129, 130
symbols, 176 Imagination experiences, 95
thing presentation, 175 In-out boundary
in character disorder, 180
Echolalia, 151
defined,9-11
Ego, 1,21
in manic-depressive illness, 151-153
observing, see Observing ego
in near psychosis, 79-80
term, 1-2
neuroleptics and, 186
Ego apparatuses, 1
in organic mental syndromes, 166-168
Ego functions, 1-43
in psychoanalytic psychotherapy and
affected by psychosis, 75
psychoanalysis of near psychosis,
aspects of, 78
254-255
examination of, 121
in psychosis, 35
symbols and, 36
in schizophrenia, 145-146
Ego organization, mixtures of, 63
thymoIcptics and, 199
Eidetic expcriences, 95
Inside-outside boundary, see In-out
Emotional experience
boundary
defined, 5-7
Integrating capacity
in near psychosis, 84-85
in character disorder, 182
regulation of relationship of reality
defined, 15
experience to, 15-33
in manic-depressive illness, 157
relationship to reality experience, 7-8
medication effects for near psychosis
validity and veracity experiences, 72
and,210
Experience(s)
in mental status examination, 137-138
emotional, see Emotional experience
in near psychosis, 86
reality, see Reality experience
neuroleptics and, 190-191
seemingly near psychosis without ncar
in organic mental syndromes, 172-173
psychotic structure, 95
in psychoanalytic psychotherapy and
Fantasy, condensation of, with reality, psychoanalysis of near psychosis,
49-51 259-260
304 Psychosis and Near Psychosis

in psychoanalytic psychotherapy and Mnemic symbol, 42

psychoanalysis of psychosis, 230-231 Modulating capacity
in schizophrenia, 147-148 medication effects for near psychosis
Interpretation, timing, and sequencing of, and,210
243-244 in mental status examination, 136-137
Interpretive descriptions, 120-121 neuroleptics and, 191
in psychoanalytic psychotherapy and
Junction point in mental status psychoanalysis of psychosis, 231-232
examination, 135 Mood stabilization, medication effects for
near psychosis and, 210
Layering, defensive, 193-194 Motivations, defensive, 107
Levels of illness, dcrinitions of, 67-69 Multiple function, principle of, 41
Lithium, 198-204
Logical principles, 4 Near psychosis, 77-116
Loose associations, 125 autonomous apparatuses in, 79-95
autonomous ego function in, 87-88
Mania, 151-165 behavioral type, 212
Manic-depressive illness, 151-165 boundaries in, 79-82
boundaries in, 151-156 categories of, 251
day residue in, 158-160 day residues in, 91-92
defenses in, 164-165 defenses in, 95-97
integrative capacity, 157 defined,78
object relations in, 162-164 medication and, 205-212
observing ego, 156 object relations in, 89-91
reality testing, 156 preconscious and, 80-81
relation of reality experience to pseudo-delusional type, 78, 211-212
emotional experience, 157-158 psychoanalytic psychotherapy and
symbols, 162 psychoanalysis of, see
thing presentations, 160-161 Psychoanalytic psychotherapy and
Mastery motives, 108 psychoanalysis of near psychosis
Medication, 185-216 reality experience and emotional
near psychosis and, 205-212 experience and their relationship in,
psychosis and, 185-197 84-85
Memory defect, 170 reality testing in, 82-83
Mental boundary, 8-9 rigid neurotic character disorders and,
Mental experience, behavior and, 85-86 272-274
Mental representation, 18 symbolic alterations of reality in,
Mental status examination, 117-142 100-104
boundaries in, 122-128 thing presentation in, 92-94
day residues in, 135 thing presentation quality in, 94-95
defenses in, 138-140 Near psychotic compulsion, 132
of ego functions, 121 Near psychotic obsession, 33
general principles of, 117-119 Near psychotic organization, 32
integrative capacity in, 137, 138 Near psychotic patients, 14, 254
of object relations, 122, Near psychotic structure, 109-110
observing ego in, 134-135 Neuroleptics, 185-197
reality testing in, 127-131 boundaries, 186
technique of, 119-121 defenses, 191
Merger, 31 integrating capacity, 190
Subject Index 305

near psychosis, 205 in organic mental syndromes, 172

percepts, 186 in psychoanalytic psychotherapy and
reality testing, 187 psychoanalysis of near psychosis, 259
symbol,189 in psychoanalytic psychotherapy and
thing presentation, 189 psychoanalysis of psychosis, 228-230
Neurosis, symptom, 179 in psychosis, 55
Neurotic character disorders, rigid, in schizophrenia, 147
272-274 Obsessions, 133
Neurotic compulsion, 132 Obsessive phenomena, hierarchy of, 133
Neurotic defenses, 23 Organic brain syndromes, 166
Neurotic obsession, 133 Organic mental syndromes, 166-178
Neurotic organization, 32 boundaries in, 166-172
Neutrality, technical, 232, 237,242 day residue, 174-175
Nodal point, 135 integrative capacity, 172
observing ego, 172
Object(s) reality testing, 172
real, 29, 123 relationship between reality experience
in reality, 29 and emotional experience, 173-174
Object presentation, 18 symbols, 176
Object relations thing presentations, 175-176
boundaries and, 29, 31-32 Overvalued ideas, 129, 131
in character disorder, 183
defenses and, 196 Pathological action, 105
defined, 27-28, 30-31 Percept-affect-concept boundaries
in manic-depressive illness, 162-164 in character disorder, 180
medication effects for ncar psychosis in manic-depression, 152-153
and,211 in near psychosis, 180
in mental status examination, 122-123 in organic mental syndromes, 168-170
in ncar psychosis, 89-91 in psychosis, 48
neuroleptics and, 188 Percept boundaries, 11
in organic mental syndromes, 176-177 Pictorial symbolic thinking, 20-21
in psychoanalytic psychotherapy and Plastic representation, 42
psychoanalysis of psychosis, 232-234 Preconscious, ncar psychosis and, 80-81
in psychosis, 55-57 Preconscious thinking, 12
in schizophrenia, 149-150 Primary autonomous apparatuses, 2-3
thymo\cptics and, 201 Primary process, 4, 5
Object relations experiences, boundaries conflict and, 26-27
in, 123-124 defined, 6-7, 71
Object representation, 29 Primary process-secondary process
Observation, 119 boundary
Observing ego defined, 13
in character disorder, 181 in manic-depressive illness, 154-155
defenses and, 195-196,203 in ncar psychosis, 81
defined,I4-15 in organic mental syndromes, 170-171
in manic-depressive illness, 156-157 in psychosis, 46-47
medication effects for ncar psychosis in schizophrenia, 146
and, 207 thymolcptics and, 199
in mental status examination, 134-135 Primary process thinking, 126
in near psychosis, 83-84 "Primitive material," 68
306 Psychosis and Ncar Psychosis

Primitive phenomena, 97 summary of, 220--222

Projective identification, 98-100, symbolic transformations of reality in,
139-140 240--241
Pseudo-delusional type, ncar psychosis, theory of treatment, 218-224
78,211-212 thing presentation in, 234-235
Pseudo-delusions, 14, 129, 130--131 thing presentation quality in, 235-236
Pseudo-hallucinations, 14, 130 use of couch in, 246-249
Psychiatric illnesses, 143-184 Psychoanalytic symbols, comparison of
character disorder, 179-184 signals to, 35
manic-depressive illness, 151-165 Psychoanalytic theory of action, 104-113
organic mental syndromes, 166--178 Psychodynamics, 118
schizophrenia, 144-150 Psychological stress, 3
Psychic agencies, boundaries bctwecn, 22 Psychoneurosis, symbolic alterations of
Psychoanal ysis, 117 reality in, 103
of near psychosis, see Psychoanalytic Psychopathology, 60, 118
psychotherapy and psychoanalysis of Psychosis, 45-76
ncar psychosis autonomous apparatuses in, 46-47
psychoanalytic psychotherapy versus, character and, 69-70
246 defensive structures in, 65-67
of psychosis, see Psychoanalytic ego functions affected by, 75
psychotherapy and psychoanalysis of medication and, 185-197
psychosis near, see Near psychosis
Psychoanalytic psychotherapy, object relations in, 55-57
psychoanalysis versus, 246 psychoanalytic psychotherapy and
Psychoanalytic psychotherapy and psychoanalysis of, see
psychoanalysis of near psychosis, Psychoanalytic psychotherapy and
251-275 psychoanalysis of psychosis
affect boundaries in, 257 reality testing in, 51-53
behaviorallborderline type, 264-272 symbolic alterations of reality in, 102
day residue in, 262 Psychotic compulsion, 132
defenses in, 255-256 Psychotic defenses, 23
in-out boundaries in, 254-255 Psychotic ego phenomena, 63
integrative capacity in, 259-260 Psychotic experience, validity and
observing ego in, 259 veracit y experiences, 72
reality testing in, 257-259 Psychotic obsession, 133
relationship ofreality experience Psychotic organization, 32
to emotional experience, 260--261 Psychotic patients, 13-14
thing presentation quality in, 262-263 Psychotic structure, see also Psychosis
use of couch in, 274-275 analysis of, 236-240
Psychoanalytic psychotherapy and characterization of, 73-74
psychoanalysis of psychosis, day residue in, 53-55
217-249 defined,45
boundaries in, 224-226 relationship of reality experience to
day residues in, 241-243 emotional experience in, 47-60
integrating capacity in, 230--231 structure of symbolic representation
modulating capacity in, 231-232 and symbolic alterations of reality in,
object relations in, 232-234 70-75
observing ego in, 228-230 Psychotic symbol, defined, 71
reality testing in, 226-228 Psychotic transference, 247
Subject Index 307

Questioning, active, 120 Repression boundary, 9

Rhythmicity, thymoleptics and, 204
Real object(s), 29, 123 Rigid neurotic character disorders,
Real object introject ions from object 272-274
representation, 113 Rigidity of defense, 253
Real object projections, 112
Real self introjections, 111-112 Schizophrenia, 77, 144-150
Real self projections, 110-111 boundaries in, 145-147
Reality, 3 day residue, 148
condensation of fantasy with, 49-51 defenses, 150
object in, 29 integrating capacity, 147
symbolic alterations of, see Symbolic object relations, 149
alterations of reality observing ego, 147
Reality experience reality testing, 147
defenses and, 202-203 relationship of reality experience to
defined, 3--4, 5 emotional experience, 148
in manic-depressive illness, 157 symbols, 149
in near psychosis, 84-85 thing presentation, 148-149
in organic brain syndromes, 174 Schizophrenic disintegration
regulation of relationship of emotional phenomenon, 144
experience to, 15-33 Secondary process, 4
relationship to emotional experience, "Self," 29
7-8 Self-esteem, technique and, 244-245
in schizophrenia, 148 Sequencing and timing of interpretation,
validity and veracity experiences, 72 243-244
Reality experience defenses, 192-193 Signals, 42
Reality testing comparison to psychoanalytic symbols,
in character disorder, 181 35
defenses and, 195 Splitting concept, 116
defined, 13-14 Splitting mechanisms, 267-268
losses of, 129 Splitting phenomena, 97
in manic-depressive illness, 156 Stress, psychological, 3
medication effects for ncar psychosis Superego, 21
and,207 Symbolic action, motivation for, 107-109
in mental status examination, 127-131 Symbolic alterations of reality, 70-75
in near psychosis, 82-83 in character disorder, 183
neuroleptics and, 187 in creativity, 103
in organic mental syndromes, 172 in manic-depressive illness, 162
in psychoanalytic psychotherapy and medication effects for ncar psychosis
psychoanalysis of ncar psychosis, and,208
257-259 in ncar psychosis, 100-104, 102
in psychoanalytic psychotherapy and neurolcptics and, 189
psychoanalysis of psychosis, 226-228 in organic mental syndromes, 176
in psychosis, 51-53 in psychoanalytic psychotherapy and
in schizophrenia, 147 psychoanalysis of psychosis, 240-241
thymolcptics and, 200 in psychoneurosis, 103
Regression with treatment, 245-246 in psychosis, 102
Representability,39 in schizophrenia, 149
Repression barrier, 165 thymolcptics and, 201
308 Psychosis and Ncar Psychosis

Symbolic processes, definitions of, 71 in psychoanalytic psychotherapy and

Symbolic representation, 33-35 psychoanalysis of near psychosis,
structure of, 70-75 262-263
Symbolic thinking, pictorial, 20--21 in psychosis, 58-60
Symbolism, 33 in schizophrenia, 149
Symbols, 6, 42 Thymoleptics, 198-204
defined, 71 aggression and, 204
ego functions and, 36 autonomous ego and, 199
psychoanalytic, comparison of signals defense content and, 203-204
to, 35 defenses in psychosis and, 202-204
Symptom neurosis, 179 ncar psychosis and, 205
object relations and, 201
Technical neutrality, 237 rhythmicity and, 204
Technique, self-esteem and, 244-245 thing presentation and, 201
Thing presentation Timing and sequencing of interpretation,
in character disorder, 182-183 243-244
defined, 18-19,71 Transcategorization, 26--27
in manic-depressive illness, 160-161 Transference, psychotic, 247
medication effects for ncar psychosis Trauma experiences, 95
and, 208 Treatment, regression with, 245-246
in mental status examination, 140-141
in ncar psychosis, 92-94
Uncanny experiences, 95
neurolcptics and, 189
Unconscious-conscious boundary
in organic mental syndromes, 175-176
neuroleptics and, 188
in psychoanalytic psychotherapy and
thymoleptics and, 200
psychoanalysis of psychosis, 234-235
Unconscious thinking, 12
in psychosis, 58--60
in schizophrenia, 148-149
thymolcptics and, 201-202 Vertical defenses, 194--195
validity and veracity experiences, 72 Vertical dissociations, 57-58
Thing presentation quality defenses and, 203
in character disorder, 182-183 in ncar psychosis, 88
defined, 19-21 in psychoanalytic psychotherapy and
in manic-depressive illness, 160-161 psychoanalysis of near psychosis,
medication effects for near psychosis 261-262
and, 209 in psychosis, 57
in mental status examination, 141-142
in ncar psychosis, 94-95 Word presentation, 18