The Ego and the Id: Concepts and developments.

In this note I have limited myself to describing some convergent and divergent developments arising from the innovative concepts present in The Ego and the Id. It could be argued that a part of the psychoanalytic movement wished to emphasize the function of the Ego (Anna Freud, Hartmann, Rapaport), while another part (Melanie Klein and her followers) delved into the dynamics of the Superego and the Id in primitive and pathological states of mind. I will examine three themes presents in The Ego and the Id: the assertion that a part of the Ego is unconscious; the idea that the death drive becomes part of the dynamics of melancholia and its Superego; the concept of fusion and defusion of the life and death instinct. Freud's writing represents a forge of new ideas that have made psychoanalysis ever more creative and capable of understanding the complexity and mysteriousness of the human mind.

Psychosis and analytic therapy: A complex relationship.

In this paper I try to summarise the contributions of some analysts who have been engaged in the therapy of psychotic patients. I have divided them into two categories: one following intuitive-non-systematic models, and the other theoretical-systematic models. My hypothesis is that the psychotic process is formed and nourished in childhood withdrawal, where the child constructs an alternative world that is dissociated from psychic reality. The patient no longer uses his mind as a thinking organ but as a tool to produce sensations that make psychic and emotional reality incomprehensible; this state of mind produces hallucinations and delusions. There is no doubt that psychoanalysis is faced with an important task as regards theoretical and clinical research in the field of psychosis. No therapeutic method possesses such a useful and effective observational tool as clinical psychoanalysis, which allows daily contact with the patient and continuous reflection on his transformations.

The perverse and the psychotic superego.

In this contribution I will sustain that, given its origin, meaning and function, the superego is readily susceptible to the pathological distortions observed in clinical psychoanalytic work. After all, while we as psychoanalysts are unacquainted with the "normal" superego, we are accustomed to seeing patients with either an abnormal sense of guilt or a seeming absence of guilt. However, a distinction must first be drawn between the primitive superego and its pathological counterpart. Whereas some clinical situations involve a superego whose primitive aspects feature prominently in the foreground, in other cases one encounters psychopathological structures that do not stem from the primitive superego, even if they share the latter's seductive, dominant or intimidatory aspects.

Essential elements of the work of a supervisor.

The supervisor's prime task is to consider from the very beginning the analytic ability of the analyst presenting the case; this can be assessed by observing how the colleague transcribes the clinical material and describes what is meaningful in the session. It is extremely important to understand whether the patient's suffering is neurotic, or whether he suffers from an initial psychotic disorder. In this latter case, the analyst will know that he cannot employ the same tools that he uses for the neurotic patient. It is fundamental to draw careful attention to the importance of the patient's personal history. In the process of reconstructing the past, the patient's difficulties are gradually understood by the analyst, the patient and the supervisor. Given that a memory may be distorted by present emotions and conflicts, the analyst must form meaningful hypotheses that, through reconstructing interaction with the original objects, help to comprehend the precarious equilibrium of the present. Over the course of supervision, I consistently emphasize the construction of the analytic relationship, which is based on the analyst's mind and of the patient's ability to communicate emotionally, so as to promote the analysand's mental growth.

Some Paths Towards Psychotic Alienation.

In this paper I use the term alienation to describe the mind's detachment from psychic reality and its withdrawal into an alien world that leads to progressive dehumanization. In spite of this phenomenon having a psychodynamic nosography and descriptive models that effectively reveal it in detail, mental alienation is still mysterious and unsettling, especially when it manifests all of a sudden in clinical work. Alienating withdrawal into sensory fantasizing, which causes increasing loss of contact with human reality, is often preceded by a long period of time spent in a dissociated world that has gradually replaced psychic reality. However, prior to the human world being completely replaced by the alien world, both worlds coexisted for a considerable length of time in the patient's mind. My hypothesis is that the dissociation from psychic reality that underlies the future state of psychotic alienation occurs in psychic withdrawal that begins in infancy. This mental state is particularly obvious in small children who constantly live in a fantasy world.

[Rosenfeld in Italy (1978 to 1985)]. / Rosenfeld in Italien (1978 bis 1985).

In this paper I try to throw some light on Rosenfeld's thought and his way of working when he came to Italy. I would like to show, in a sketchy way, the evolution of his thought and in particular the new way he looked at clinical practice at that time. My point is that the Rosenfeld we met in Italy was able to open new horizons in clinical practice, implicitly questioning some of his own or his circle's previous viewpoints.

Delusion and bi-ocular vision.

The delusional experience is the result of a grave disjunction in the psyche whose outcome is not readily predictable. Examination of the specific mode of disjunction may help us understand the nature and radical character of delusion. I will present the therapy of a psychotic patient who after many years of analysis and progresses in his life continues to show delusional episodes although limited and contained. In his case, the two visions, one delusional and the other real, remain distinct and differentiated from each other because they both possess the same perceptual character, that of reality. He has a bi-ocular vision of reality and not a binocular one because his vision lacks integration, as would necessarily be the case if the two visions could be compared with each other. The principle of non-contradiction ceases to apply in delusion. A corollary of the failure of the principle of non-contradiction is that, if a statement and its negation are both true, then any statement is true. Logicians call this consequence the principle of explosion. For this reason, the distinction between truth, reality, improbability, probability, possibility and impossibility is lost in the delusional system, thus triggering an omnipotent, explosive mechanism with a potentially infinite progression. The paper presents some thoughts for a possible analytic transformation of the delusional experience.

Hallucinations in the psychotic state: Psychoanalysis and the neurosciences compared.

In this contribution, which takes account of important findings in neuroscientific as well as psychoanalytic research, the authors explore the meaning of the deep-going distortions of psychic functioning occurring in hallucinatory phenomena. Neuroscientific studies have established that hallucinations distort the sense of reality owing to a complex alteration in the balance between top-down and bottom-up brain circuits. The present authors postulate that hallucinatory phenomena represent the outcome of a psychotic's distorted use of the mind over an extended period of time. In the hallucinatory state the psychotic part of the personality uses the mind to generate auto-induced sensations and to achieve a particular sort of regressive pleasure. In these cases, therefore, the mind is not used as an organ of knowledge or as an instrument for fostering relationships with others. The hallucinating psychotic decathects psychic (relational) reality and withdraws into a personal, bodily, and sensory space of his own. The opposing realities are not only external and internal but also psychic and sensory. Visual hallucinations could thus be said to originate from seeing with the 'eyes' of the mind, and auditory hallucinations from hearing with the mind's 'ears'. In these conditions, mental functioning is restricted, cutting out the more mature functions, which are thus no longer able to assign real meaning to the surrounding world and to the subject's psychic experience. The findings of the neurosciences facilitate understanding of how, in the psychotic hallucinatory process, the mind can modify the working of a somatic organ such as the brain.

The erotic transference: dream or delusion?

The erotic transference can be seen as the Janus face of clinical work in psychoanalysis: it may either arise out of the positive emotions necessary for the building of new shared realities, or be fueled by falsified and distorted constructions. In the former case, the erotic transference expresses the capacity to anticipate, or "dream," the emotional relationship with the object-which is why Freud valued its transformative aspect as one of the "forces impelling [the patient] to . . . make changes"-whereas in the latter it is equivalent to a flight from psychic reality and may be imperceptibly transformed into an actual delusion.

The paedophile and his inner world: theoretical and clinical considerations on the analysis of a patient.

The main feature of the treatment of the paedophile is the distance that separates the analyst from the patient. However hard the analyst tries to understand his patient, the paedophile's world appears to him, especially at the beginning of the treatment, incomprehensible, disheartening and distant. This paper describes the analytic therapy of a paedophile patient. The psychopathological organization that dominates his inner world originates from a delusional nucleus in which an object (a child or an adolescent) is idealized and worshipped in place of the parents. This object promises all manner of pleasure and happiness. The positive outcome of this patient leads one to believe that, if analytically treated, some paedophile patients are open to therapeutic transformation.

Psychotic withdrawal and the overthrow of psychic reality.

The author attempts to distinguish between the world of fantasy and the imagination (which fuels our capacity to 'dream') from a withdrawal into fantasy. In this withdrawal, the foundations of which are laid in childhood, a dissociation from psychic reality starts and from it the delusional world arises and constitutes the adult illness. During therapies of adult patients who have experienced a psychotic state, it is often possible to reconstruct the state of infantile withdrawal and understand how their dissociation from reality was ignored or unknowingly encouraged by their parents. Children destined to develop psychosis enter into the dissociated world not just as a defence against anguish or loneliness, but also for the pleasure of experiencing a delusional self-sufficiency and a gratifying omnipotence in which anything is possible. Mental workings that take place in the withdrawal do not follow the rules governing normal psychic functioning. Those fantasies cannot be either repressed or 'dreamed' in order to be transformed into thoughts. These psychopathological structures, which develop early and autonomously, have to be understood during analytical therapy in their origins and 'deconstructed' in order to help the patient to escape from their dominion. By means of clinical examples, the author tries to shed light on the possible ways of reaching patients in their psychotic shelters, thereby helping them to re-emerge into a psychic reality.

The psychodynamic of panic attacks: a useful integration of psychoanalysis and neuroscience.

This article tries to explain, in the light of some neuroscientific and psychoanalytical considerations, the repetitive pattern of panic attacks. Freud considered the panic attack as an 'actual neurosis' not involving any conflictual process. Recent neuroscientific findings indicate that psychosomatic reactions, set off by a danger situation, depend on the primitive circuit of fear (including the amygdala) characterised by its speed, but lack accurate responses and may also be activated by harmless stimuli perceived erroneously as dangerous. The traumatic terror is stored in implicit memory and may be set off by a conditioned stimulus linked to a previous danger situation. In the panic attack, the traumatic event is created by the imagination and this construction (a micro-delusion), built in loneliness and anxiety, has the same power as the real trauma. A mutual psychosomatic short-circuit between body and psyche, in which terror reinforces the somatic reactions and the psychic construction, is established. Therefore, it is important to highlight these constructions in order to analyse and transform them. In the second part of the article the author reviews the main psychoanalytical theories about panic attacks, stressing how, in his opinion, panic attack is a consequence of the breakdown of the defence organisation at various levels and may appear during periods of life crisis. Two patients suffering from a deficit of personal identity are presented. The various organisations and the different levels (biological, neuroscientific, associative, traumatic) of the panic attack determine different kinds of therapeutic approaches (pharmacological, cognitive and psychoanalytical). While the psychopharmacological treatment is aimed at reducing the neurovegetative reaction and the cognitive method is attempting to correct the associative and perceptive processes of fear signals, psychoanalytical therapy represents both a specific means to free patients from panic attacks as well as an indispensable route for their emotional growth.

Inconsciente y psicosis: consideraciones acerca de la teoría psicoanalítica de la psicosis / The unconscious and psychosis: some considerations on the psychoanalytic theory of psychosis

El autor afirma que las diferentes teorías y técnicas psicoanalíticas emplean modelos del inconciente distintos, cada una de ellos encamina a una realidad inconsciente diferente, que se puede describir en términos de funciones mentales específicas. Revisa, en particular, el inconsciente dinámico de Freud, basado en la represión; el inconsciente kleiniano que añade los conceptos de fantasía inconsciente y de escisión del objeto; el concepto bioniano de inconsciente, como una función mental de la que el sujeto no se da cuenta pero que puede formular pensamientos y metabolizar emociones; y el punto de vista neurocientífico que ve al inconsciente coincidiendo con el inconciente del que uno no se da cuenta y no coincidiendo con el inconsciente reprimido freudiano. De este modo, el autor hace una diferencia entre inconsciente dinámico y el emocional; y entre inconsciente y no darse cuenta . Apunta también el papel que juega la distorsión en las percepciones de las que el paciente no se da cuenta y que aparecen en las situaciones de impasse de la relación analítica. Le interesa ¹particularmente¹ mostrar que, mientras la neurosis implica un inconsciente dinámico, la psicosis altera el inconsciente emocional. Es decir, la entidad que subyace en el sentimiento de identidad y la conciencia sin darse cuenta de la existencia. En la psicosis, el inconsciente emocional está ciego, de tal modo que el paciente está consciente pero le falta la capacidad de darse cuenta. El inconsciente dinámico también queda afectado. Después de presentar dos historiales, el autor subraya la necesidad de investigar más en este campo, tanto desde el punto de vista clínico como teórico (AU)

Inconsciente y psicosis: consideraciones acerca de la teoría psicoanalítica de la psicosis / The unconscious and psychosis: some considerations on the psychoanalytic theory of psychosis

El autor afirma que las diferentes teorías y técnicas psicoanalíticas emplean modelos del inconciente distintos, cada una de ellos encamina a una realidad inconsciente diferente, que se puede describir en términos de funciones mentales específicas. Revisa, en particular, el inconsciente dinámico de Freud, basado en la represión; el inconsciente kleiniano que añade los conceptos de fantasía inconsciente y de escisión del objeto; el concepto bioniano de inconsciente, como una función mental de la que el sujeto no se da cuenta pero que puede formular pensamientos y metabolizar emociones; y el punto de vista neurocientífico que ve al inconsciente coincidiendo con el inconciente del que uno no se da cuenta y no coincidiendo con el inconsciente reprimido freudiano. De este modo, el autor hace una diferencia entre inconsciente dinámico y el emocional; y entre ´inconsciente´ y ´no darse cuenta´. Apunta también el papel que juega la distorsión en las percepciones de las que el paciente ´no se da cuenta´ y que aparecen en las situaciones de ´impasse´ de la relación analítica. Le interesa –particularmente– mostrar que, mientras la neurosis implica un inconsciente dinámico, la psicosis altera el inconsciente emocional. Es decir, la entidad que subyace en el sentimiento de identidad y la conciencia sin ´darse cuenta´ de la existencia. En la psicosis, el inconsciente emocional está ciego, de tal modo que el paciente está consciente pero le falta la capacidad de darse cuenta. El inconsciente dinámico también queda afectado. Después de presentar dos historiales, el autor subraya la necesidad de investigar más en este campo, tanto desde el punto de vista clínico como teórico

On the nature of intuitive and delusional thought: its implications in clinical work with psychotic patients.

The author tries to differentiate intuitive imagination from delusional imagination and hypothesises that psychosis alters the system of intuitive thinking, which consequently cannot develop in a dynamic and selective way. Scholars of different disciplines, far removed from psychoanalysis, such as Einstein, Hadamard or Poincaré, believe that intuitive thinking works in the unconscious by means of hidden processes, which permit a creative meeting of ideas. Thanks to Bion's work, psychoanalysts have begun to understand that waking thinking is unconsciously intertwined with dream-work. The delusional construction is similar to a dreamlike sensorial production but, unlike a real dream, it remains in the waking memory and creates characters which live independently of the 'dreamer's' awareness. It is a dream that never ends. On the contrary, the real dream disappears when it has brought its communicative task to an end. In the analysis of psychotic patients it is very important to analyse the delusional imagination which dominates the personality and continuously transforms the mental state, twisting emotional truth. The delusional imagination is so deeply rooted in the patient's mental functioning that, even after systematic analysis, the delusional world, which had seemed to disappear, re-emerges under new configurations. The psychotic core remains encapsulated; it produces unsteadiness and may induce further psychotic states in the patient. The author reports some analytic material of a patient, who, after a delusional episode treated with drugs, shows a vivid psychotic functioning. Some considerations are added on the nature of the psychotic state and on the therapeutic approach used to transform the delusional structure. This paper particularly deals with the difficulty in working through the psychotic episode and in 'deconstructing'the delusional experience because of the terror connected with it. In the reported case, the analytic work changed the delusional construction into a more benign one characterised by phobic qualities. The analysis of the psychotic transference allowed the focus to be on the hidden work which had been continuously influencing the transferential picture of the analyst and the patient's psychic reality.