I would like to survey some themes from Modern Psychoanalysis of the Schizophrenic Patient by Hyman Spotnitz. What is it about? Well, in the preface he explains that his intention in writing it was to provide an educational manual to students at “modern” psychoanalytic institutes. When I was a student at the New York Graduate School of Psychoanalysis (NYGSP) this text was sacred.
In this post I will describe what I understood to be some of the central points of what many refer to as The Red Book. These points are fundamental to modern psychoanalysis if for no other reason because they are integral to Spotnitz’s signature work and it was he who coined the phrase “modern psychoanalysis.” In other words Spotnitz literally wrote the book on modern analysis.
What’s the gist of Spotnitz’s texts? Narcissistic transference is a valid therapeutic mechanism. “Contact functioning” is regarded as the essential technique in establishing narcissistic transference. In school we were always told to “wait for the contact.” Sometimes it takes years of intensive analysis but the modern analyst, in treating narcissistic conditions, will refrain from enacting verbal interventions and from using emotional communication. You can imagine how prepared they are to intervene when the patient finally intimates that they are ready.
Narcissistic transference is the therapeutic counterpart to the puzzle as to what made narcissistic conditions historically untreatable. The etiological part of the puzzle is the explanation of the disturbance, or the period of sustained disturbance in the development of the condition. These disturbances were occasioned much earlier in development than those suffered by merely neurotic people. Spotnitz, like Melanie Klein, found that treatment of the more severely regressed patients required turning to the earliest of object relations, or in her case, to partial object relations.
Unlike Klein, Spotnitz does not principally employ “projective identification” and “introjective identification” to describe this crucial point of development. Instead he refers to introjection and projection as “egotization of the object” and “objectification of the ego.” His reasons for reconceptualizing these processes and the therapeutic repercussions of doing so are central to the philosophy and praxis of modern psychoanalysis.
Spotnitz and Klein—and even Freud occasionally—discuss the importance of hate and aggression in the earliest phase of object relating. In treatment the patient needs to return to an inadequate point in rearing in order to correct it. Disturbance during the earliest phases therefore requires not only narcissistic transference but to the degree that this phase involved inadequate aggressive object relating it requires “negative” narcissistic transference, another central mechanism.
Narcissistic and negative narcissistic transference are very difficult to work with. Thus, The Red Book explains how to manage and exploit narcissistic “countertransference” in light of early egotization and ojectification: “ego-syntonic” and “ego-dystonic”: “joining” and “mirroring.”
If I was to make one criticism it would be that The Red Book lacks thoroughly elucidated case histories. To compensate for this lack I will discuss two cases to color it. Both cases belong to professors at the Center for Modern Psychoanalytic Studies (CMPS), former colleagues of Spotnitz. Lynne Laub’s case history describes a schizophrenic patient she treated during her training field placement in a locked ward whom she refers to as “Sara.” Dolores Welber’s patient, referred to as “Mrs. M,” is not described as schizophrenic but nonetheless exhibits narcissistic character traits, flat affect and an inability to release aggression.
Using Freud’s “erotogenic” phases it would be most fitting to classify Sara as disturbed at the “oral” phase, the earliest of phases. She exhibits a most severe narcissism, often confusing her self with other people—“I’m Mrs. Laub. Is Mrs. Laub here?”—and lacks object permanency: hers vs. other people’s possessions giving her the impression that people are endlessly taking her things.
Mrs. M on the other hand exhibits an ability to relate to objects but only superficially—people on the sidewalk don’t seem real; they’re like cardboard. These clues suggest that her development was disturbed at an “anal” level come from her vocalized stinginess with all things and with herself: among her goals upon entering treatment she wants to acquire the ability to love and be loved and to treat the world and herself generously.
Both Laub and Welber are able to cultivate narcissistic transference in their patients and struggle to manage the countertransference occasioned when negative narcissistic transference reaches its climax in the treatment.
The turning point in the Mrs. M’s transference, when it became fruitfully negative, came about when Dr. Welber fell asleep during a session, an “induction” she interprets as having to do with the patient’s failing to receive attention or recognition from two narcissistic parents, one of whom was an alcoholic. Mrs. M becomes so enraged that she storms out and in group analysis says she is never going back.
In Dr. Laub’s case the negative transference, the danger of which cannot be overstated, caused the analyst to suffer a broken hip: she interprets this as an effort to break away from Sara. Sara, just before terminating her treatment, is severely beaten by other patients in her ward. The analyst hints that this might have been caused by the patient’s fear of progress in regard to self-improvement.
These two cases demonstrate many of the central lessons from Spotnitz’s guide and they offer complexities regarding the termination of treatment, the management and resolution of negative transference which can be now be discussed using those lessons.
Freud found schizophrenia and other narcissistic conditions incurable because he observed a total lack of transference capacity in patients of this sort. Spotnitz, among many other subsequent theorists, realized that these patients are not incapable of developing transference toward the analyst. They are merely incapable of developing object transference, which is fitting since they are or were disturbed as a pre-object level of development. Therefore, transference for these types of patients must be of a “preoedipal,” “primitive,” “preverbal” nature and will therefore consist of nonverbal communication.
In all of the narcissistic conditions ego boundaries were not fully developed in the first year of life. The inner, ego world never emerges from its blurred axis shared with the outer world. Therefore, the analyst often feels he is not in the room. Nevertheless, he is able to partake in in the patient’s selfsame relationship as an ego-syntonic, nearly inner object: “a two-way emotional transaction is revived and communicated as originating in one locale – the mind of the patient.”
Spotnitz understands schizophrenia as a defense employed during the earliest phase of life. Narcissism is not as originally thought the result of an abnormally high degree of self-love:
“Indulgence in self-love, to a pathological degree, then becomes comprehensible as an attempt to obtain erotic gratification in the presence of a hated object or situation.” (Hyman Spotnitz)
It is a primitive, inefficient defense but it deserves a great degree of delicate respect since it is has stabilized the patient and allowed him to survive.
Until the analyst is able to offer a stabler, safer pattern the defense cannot be tampered with. The narcissistic defense is not attacked: all effort is made to keep pressure off the patient: “Freedom from pressure to overcome it leads to a relative reduction in the need to activate it.” This is the essence of contact function.
As Sara’s case demonstrates, narcissistic transference usually becomes noticeable in schizophrenic patients when they progress from “word salad” to legible phrases if not sentences. Toward the end of her field placement Laub noticed: “this previously uncommunicative woman was now speaking to me in phrases I could understand…she seemed to be directing her message to me.”
As Michael Robbins points out in his essay “The Language of Schizophrenia and the World of Delusion” the schizophrenic patient uses “word salad” to speak a language to themselves alone. To the extent that object transference becomes possible so does legible speech: there is no reason to speak legibly if the patient is alone in the room.
When the patient’s speech becomes communication the analyst has entered the room. Laub writes of her initial impressions: “It was as if we did not speak the same language, as though I had taken a patient from a foreign land and had her lie on my couch and speak to me in a special kind of communication based on feeling and counter-feeling.”