Working With Preoedipal States of Mind

Some Reflections on the Problem of Narcissism in Psychoanalytic Practice

by Chris Fry

“That, we repeat, is the sine qua non for resolving the pattern: the bringing to consciousness of the original experience and the discharge of aggressive impulses in new feelings, thoughts and language.”
– Spotnitz

I would like to talk with you about the serious issue of making therapeutic contact with patients who are suffering from the more primitive disturbances that psychoanalysis has come to classify as preoedipal states of mind.  Here we are concerned with problems that have developed in early life while the child was in the process of constructing a mind with which they could safely contain and elaborate the deepest and widest experiences of being alive.  This is something that all of us have had to wrestle with and it is clear that there are remnants of preoedipal experience in all of us – and indeed it is difficult to imagine a good life without access to these deep, and at times, intense experiences of being alive.  Most of us can get in touch with them and elaborate them in our intimate lives and our creativity.   But it is also clear that some people are confined to a form of relating that was established at this early time in life and that this is getting in the way of them developing a more coherent sense of self and of making and sustaining satisfying relationships with other people.  Franco De Masi writes:

Once mother-child communication breaks down, those destined to become psychotic enter the dissociated world of psychic withdrawal not only as a defence against anxiety of the void, but also for the pleasure of experiencing an illusory self-sufficiency, an omnipotence that makes anything possible. The destruction of meaning that takes place in withdrawal increasingly distances the child from the possibility of learning from emotional experience, which is facilitated by the maternal presence, and generates a dependence on an omnipotent system based on false constructions.

What is happening inside the mind of someone who is confined to these ways of being?  What is our best guess about how these states of mind have developed and lastly and of course in some ways most importantly what can be done about this?  How is it possible to reach people who are struggling in such terrible pain?

I have the strong impression that Kurt Lewin’s words are vital for us as we proceed in this endeavour – there is nothing as practical as a good theory.  Good psychoanalytic psychotherapy rests on a foundation of theory – and the best theory of course has been created by therapists wrestling their experiences with patients into some sort of shape.  If we are to have any hope of reaching difficult states of mind then we must have grappled with and internalised psychoanalytic theory.  We are once again thinking about the theory of narcissism.

I am going to make the assumption that most of us are well acquainted with the beginnings of psychoanalysis.  By this I mean Freud’s discovery of the dynamic unconscious, the power of dreams, infantile sexuality and the elaboration of the libido theory.  In other words I am going to take it for granted that people have a good understanding of the neurotic states of mind that Freud was grappling with when he developed the psychoanalytic method.  Central to his method as it developed were the concepts of resistance and transference.  Classical psychoanalytic practice rested on the idea that every human being was troubled by a conflict between a desire for pleasure and the reality that other people had to be negotiated to secure that pleasure.  Neurotic disorders are essentially problems with conflict – desires and wishes that people are terrified of owning and therefore have banished to another part of their mind.  This part of the mind Freud described as the dynamic unconscious and saw it as the task of psychoanalysis to put people back in contact with their denied desires and wishes – to make conscious that which was unconscious.  By undoing repression Freud hoped that people would have more choices about their lives.  With the concept of transference Freud opened up access to the deep ways that people are related and connected to each other and allowed the psychoanalyst to make contact with disturbed relational patterns in the here-and-now of the analytic situation.  Transference became central to psychoanalytic technique.  The task of the psychoanalytic situation was to create conditions for transference to grow and develop until the clinician could use this developing relationship to show the patient how their suffering was alive in the present tense – to give them clear evidence of their self-defeating relational patterns which hopefully would offer them the possibility of entering into a more satisfying relationship with self and others.

And then there was trouble.  Psychoanalysts discovered that there were people that did not get better.  That there were people that were not helped by the insight orientated interpretations given to them.  People who balked at a dependent relationship with the analyst and did not seem to be developing the positive transference deemed necessary for successful treatment.  It was the experiences of analysts with these patients – some described by Freud as schizophrenic, others as hypochondriacal – that led to the theorising of narcissism.  I would like to quote from Joseph Sandler, “Schizophrenics display two fundamental characteristics: megalomania and a corresponding withdrawal of interest from the outside world.   The schizophrenic’s withdrawal is different both in kind and in degree from that of the neurotic.  In analysis, the neurotic is shown to maintain an erotic relationship to a fantasised object if not a real one; the schizophrenic, by contrast, withdraws interest from the external world without investing in fantasy objects”.

You can see the problem.  Psychoanalysis worked by engaging the patient in a repetition of early life experiences and slowly exposing the patient to the conflicted nature of their relationships with loved people.  The narcissistic patient confounded this.  It was as if these patients had become so caught up in themselves – what Freud at that time would have described as having an excess of ego-libido – that their ability to connect with the analyst was highly problematic.  It is well known that Freud expressed derision about these sorts of patients and deemed them unreachable by the psychoanalytic method.  But maybe his derision was the door to discovering something?  Because the history of psychoanalysis from this time onward becomes a struggle with aggression.  It is aggression that moves to centre stage in psychoanalytic thinking from this time onward.  At the peak of his theorising Freud transforms his ideas of early conflict between sex and hunger into a grander scheme of life versus death – and by this we have understood that there is conflict in us all between something that binds things together (Eros) and that which can tear things apart (Thanatos).

Aggression must be grappled with.  The more disturbed a patient is the more important it is to get to grip with the problems of aggression.  Freud had described the oedipal patient as struggling with sexual desire in the context of three people – the two parents and the child.  It is a struggle mainly centred on managing conflict and competition.  In the preoedipal realm the problems are more serious – they are about survival.  They are about establishing a mind in which later on there can be conflict.  The problems are centred around security and integrity or fragmentation and chaos.  And at the earliest time they are about two people – a child and their primary care-giver; usually their mother.

The narcissistic patient seems to be suffering from something that has gone badly wrong at this early stage of life.   When Karl Abraham was grappling with the idea of psychosis he talked about psychotic patients suffering because of the ‘destruction’ of the capacity for sexual transference and the problem of never having “a proper capacity for transferring their libido to the outside world”.  Melanie Klein noted this problem with aggression when she wrote, “the patient split off those parts of himself, i.e. of his ego, which he felt to be dangerous and hostile toward the analyst.  He turned his destructive impulses from his object toward his ego, with the result that parts of his ego temporarily went out of existence…if he could build up again the good breast inside himself, he would strengthen and integrate his ego, would be less afraid of his destructive impulses; in fact he could preserve himself and the analyst”

I would like to put forward two more ways of thinking about this from the conceptualisations of two other great psychoanalysts of primitive states of mind – Wilfred Bion and Harold Searles.  Bion’s theory of ‘containment’ – developed out of his own problems treating psychotic patients – allows us to think about the how the psychotic mind comes into being.  He talks about an infant being full of unmanageable, chaotic, unthinkable experiences.  If the infant can induce in the mother these powerful experiences and if she can manage to feel, experience and contain them then this aids the infant to develop and grow their own inside place, their own place of safety, their own mind.  This living-breathing internal mother installed inside is the blue-print from which a mind can be grown.

But when the care-giver is consistently unable to bear the infants projections; unable to think about their distress then Michael Eigen’s words are important, “But what if the baby is thrown back on itself, meets a wall or more anxiety or hostility?  What if, to use Bion’s locution, the object is intolerant of projective identification?  What if the caregiver cannot let the baby’s feelings affect her or reacts destructively?  What if the worst a baby can feel cannot get into another person for modification or psychic reworking?  What if the other person refuses the input, evacuates it, cannot bear it, or does not have equipment to process it?  What if the baby’s feelings have nowhere to go or very hurtful places to go?

When the baby cannot get into the mother’s mind they are left with nowhere to go but into their own mind and interestingly not alone – but rather with a torturing sense of nothing.  A present absence.  A deep wound.  A black hole which threatens to engulf them.  To suck them into darkness.  The patients who we are trying to think about have developed a way of dealing with this – developed powerful barriers to protect themselves from a terrible sense of emptiness.  This is at the heart of narcissistic disturbance.  Barriers, fortresses, bulwarks against unspeakable pain.   When Harold Searles describes the psychotic condition he puts forward the idea the psychotic patient has not entered into a symbiotic relationship with the care-giver and this is what leaves them feeling outside of life.  The symbiotic relationship is that important part of infancy where we are merged with our mother, mixed up in a deep relatedness that allows us to develop what Winnicott calls ‘going-on-being’.  It is where we build a sense of what it is to be alive, a core of self-esteem that allows us to emerge robust into the world of complex relationships.  If you cannot get ‘in’ you are lost outside and all energy is moved to survival.

I hope this has conveyed something of the terrible predicament that patients suffering from preoedipal disturbance are in.  And reminded us again about how difficult it can be think about reaching these states of mind therapeutically.  We must now consider the instruments that Modern Psychoanalysis offers to us as ways of reaching these primitive states of mind.

Spotnitz’s work is pragmatic.  He notes the ‘barriers’ that have been put in place by patients who are suffering from narcissistic disturbance and feels that something else other than interpretation is needed to reach people.  As the disturbance is situated in early life he sets out to develop new ways of reaching these states of mind.  Perhaps the most important of these is emotional communication.  Offering emotional communication is not offering detailed understanding about the patient’s conflict but rather offering interventions that allow more and more talk from the patient.  Modern psychoanalysis has the idea that the analyst must position themselves so as to encourage the growth of connection.  A developing narcissistic transference is the result of carefully constructed emotional communication – that is the analyst presents themselves as close to the patient’s experience as possible.  It is an attempt to open up a door to human relatedness again.  In being like the patient, in not being too different the analyst slowly unlocks the patient’s resistance to contact and allows feelings which have to date been secluded in narcissistic enclaves to become attached to another human being.  At times the modern literature is more blunt – it talks about the patient being caught up with unexpressed aggression which they have not been able to express toward their objects and the analyst allows this rage to be directed toward them thereby opening the path to relatedness.  But it is important to note that modern psychoanalytic work is not just about expressing rage – the purpose of this expression is the opening up of pathways toward connection, toward relationship with the other.

Contact functioning is another important concept when approaching the preoedipal patient.  The analyst tries to match as much as possible what the patient desires – to not go beyond what is being asked for.  Interpretation at inappropriate times could be considered as overfeeding and the analyst learns to respond with an appropriate dose of intervention.   All of this was considered in even earlier times by Michael Balint when he spoke about the analyst being an ‘unobtrusive object’.  I hope you can see that the interventions are aimed at encouraging a re-entry into object-relations.

All of this of course must be considered through the lens of countertransference.  It is clear to us all that as psychoanalysis moves toward considering more severe disturbance that countertransference becomes more central to treatment.  It is the instrument that allows us to consider how we can use all of the modern psychoanalytic instruments – contact functioning, joining, reflection, bridging, insulation.  The more disturbed the patient the more the self of the analyst is called upon.  This always reminds me of a line of monologue that opened the Terrance Malik Movie – The thin red line – “there is no place we can hide except in each other”.  Rather than countertransference being an obstacle – it is now considered the royal road to the unconscious.  And modern psychoanalysis helps us with its consideration of objective countertransference – the idea that a large part of what is happens with disturbed patients is the patient ‘inducing’ their split-off feelings in the analyst.  The analyst working through the patient’s feelings in their own mind, studying their own reactions in detail is the technique which requires the most work and will allow the other techniques to be effective mutative contacts rather than dead-on-arrival intellectualisations.

It is important to remember that we all have pockets of preoedipal disturbance and that at some stage in every therapy these will become obstacles that need to be resolved.  However, this it is a different story altogether when patients are struggling predominantly with the problems detailed above and a brief excursion into the theory is important as theory is a way of telling a good story about the complexity of these patients.

Lastly it is important because narcissistic problems are problems with tolerating difference.  The purpose of our theoretical construction today is to offer us a different place to stand in relation to the patient.  The unobtrusive stance offered to the patient or the group, the provision of symbiotic relatedness in the service of the patient’s development comes from the analyst’s ability to be different.  We do not meet narcissism with narcissism.  We must always have one foot in our theory, in our thinking about our patients so that a door is opened toward something new.  Something more satisfying.  Something more alive.

Response to “Working With Preoedipal States of Mind”

by Dr. Jane Snyder

Chris Fry’s paper on working with narcissism is an impressive overview of modern psychoanalysis and other theories dealing with the preoedipal patient and very early mental states, as well as modern psychoanalytic techniques for getting beyond the “stone wall of narcissism,” so designated by Freud.  Fry surveys relevant theory on the development of mind and what can go wrong if the early environment does not provide “good enough” mothering or a receptive mothering presence which, as he says, can facilitate a symbiotic relationship between mother and child, enabling the child to use the (m)other to contain and process early chaotic impulses and experience. Such failures lead to the development of “barriers” to the outside surrounding an inner emptiness, a “black hole.”  He then reviews modern psychoanalytic techniques for reaching and developing relationships with narcissistic patients, respecting their need for a nonintrusive presence very similar to themselves, allowing the possibility of a symbiotic relationship to develop and maturation to proceed to full object relations.  He leads off the section on technique with appropriately noting the emphasis on emotional communication rather than interpretation in working with narcissistic states.

In response to this excellent paper, I had a few amplifying thoughts and commentary.  Fry does a great job of pulling together various theories on the early development of mind and mental processing and says very forcefully at one point, “aggression must be grappled with” – something Freud recognized later in his theorizing.  Modern psychoanalytic theory does prioritize the role of aggression in understanding narcissistic pathology.  Spotnitz describes the “narcissistic defense,” which functions at the root of schizophrenia and other narcissistic disorders.  This is a turning of aggression against one’s own mental functioning, leading to fragmentation, delusion, severe self attack, or paranoia.  This turning of aggression against the mind occurs while the mind is still developing in order to protect early object impressions from obliteration.  It may develop due to caretaking failures in accepting and containing the infant’s distress and rage or even  overstimulating and heightening tension states, e.g., through abusive behavior.  Sometimes tension states are exacerbated by inborn temperamental or somatic agitation and inability to be soothed.  As Fry notes, a goal of treatment for the preoedipal patient is the careful reversal of the narcissistic defense, which will entail the direction of rage towards the analyst.  Only after this has been achieved can libidinal feelings be freed to be experienced. (They are no longer tied up in directing the aggression against one’s own mind.)  Thus we often find that it is only after a patient has told us everything they can’t stand about us, all of their complaints and frustration, only then can they begin to experience more loving or libidinal feelings.

As Fry implies, modern psychoanalysis works in a maturational frame; the goal in early treatment is to facilitate the development of the narcissistic transference, a transference in which the analyst is experienced as nonexistent, as part of the self or a twin image.  The analyst works, through the contact function (observing the patient’s contact or lack of contacting the analyst) to keep tension states in the sessions manageable, not to overstimulate or understimulate the patient—to provide the proper doses of “feeding.”  If no contact is made, the analyst may ask a few object oriented questions, a useful technique with narcissistic patients. The analyst asks nonintrusive, non-ego related questions to help the patient say more, addressing topics the patient brings up, or focusing on the analyst. For example, a patient may be asked to expand on what they are saying through questions, or asked if the temperature in the room is comfortable, or if the analyst should say something or ask a question. In asking such questions, the analyst makes their presence known, models contact, and takes pressure off of the ego.  If contact is made through questions, the analyst uses reflecting and joining techniques to insulate the patient’s ego and provide a mirroring presence.  Providing a comfortable, nonintrusive environment allows gradual evolution of a transference in which the analyst is perceived as like the self. Early self states are repeated and can be worked through as the analyst, like the self, may be seen as inadequate, frustrating, hostile, and no good. Through working through the negative narcissistic transference, the patient gets to more libidinal feelings.

The importance of using one’s own countertransference feelings as important information about the emotional state of the patient is something that Fry points out as a critical part of work with the preoedipal patient.  The analyst will feel the patient’s unexperienced feeings, or split off feelings as Fry suggests, but also will feel the patient’s experienced emotional state—anxiety, paranoia, depression, or emptiness.  Figuring out whose feelings are whose is an important part of the treatment and critical to making interventions.  Using emotional communications, interventions are made in the here and now of the transference, rather than reflections on the transference or what is going on (interpretation or explanation).  For example, an impulsive, exhibitionistic patient who could not stop himself from engaging in dangerous behaviors and asked to be locked up in the office at night was told, “You may need to live with me.” The communication led to months of discussion as to the pros and cons of living with the analyst, the effect on the therapy, the wish for and abandoning of control, and many other relevant topics and feelings hitherto not expressed.

As Fry so well describes, to help someone emerge from narcissism into a relationship, it is essential to go wherever they take us emotionally and help them say as much as possible.  Modern psychoanalytic technique is a useful set of tools for the gradual dissolving of the wall.

Chris Fry is a graduate of the Center for Group Studies in NYC.  He is a psychoanalytic psychotherapist and certified group psychotherapist (CGP).  He is based in Belfast, Northern Ireland and works both in the NHS and private practice.   This paper was presented as part of the Center for Group Studies international training program in Russia in September of 2016.

Jane Snyder, Ph.D., is a licensed psychologist and certified psychoanalyst and IS the president of the Boston Graduate School of Psychoanalysis. She is a faculty member and training analyst and conducts a private practice in Brookline, Massachusetts. She has written and presented many papers on a variety of topics related to psychoanalytic treatment, and research.