Inside Out - an observation of psychotic states of mind in both analyst and patient

Inside Out - an observation of psychotic states of mind in both analyst and patient.

IPSO Writing Award 2013, First Place. Reprinted with permission IPSO Journal


During my psychoanalytic training, I did an observation of psychotic patients in a psychiatric unit in a teaching hospital. This experience had a profound impact on my development as a psychoanalyst. This paper explains and discusses why this is so.


As part of my psychoanalytic training, I did an observation of psychotic processes over six months in a locked psychiatric unit in a large teaching hospital.

There were four general aims to the psychotic observation. The first was to provide an experience of psychoanalytic observation as a method of investigation, along the lines of the infant observation. The second was to identify psychotic states in clinical work by observing people who were experiencing psychosis. The third was to deepen understanding of counter-transference through the subjective effect on the observer of the severely mentally ill person. The fourth aim was to enhance the candidates understanding of the frame in which the observation occurs.

This paper is a discussion of how these observations affected me and my clinical work, the frame that I worked in, and the value of observation as a method of investigation.

The experience of the psychotic observations were formative to my development as a psychoanalyst. I came to realise that psychotic processes were an important part of every day psychoanalytic work. This realization began to emerge as I observed my own reactions as I arrived at the psychiatric unit each week. One observation begins: I arrive at the unit. The keys, the white doors, the feeling of complete disorientation already and I wasnt yet inside. As I walked into the unit, and stepped from the outside world into the unit, I felt myself recoil. I wanted to flee. The feeling of agony and despair seemed to ooze through the floor and walls.

By contrast, the staff did not appear to share my struggle. They seemed to do everything possible to avoid real emotional contact with the patients anguish. They were focused and goal oriented. In fact, I came to notice over time that it was actually the patients who seemed to be able to bear each others pain. I observed the patients reaching out to each others terrible states of despair and I witnessed the transformative effect of one human being understanding another. I realized that the patients were familiar with the terror and torment of psychosis and that this enabled them to tolerate each others suffering. I realized that the capacity to be able to bear the pain was an important first step in engaging with psychotic states of mind.

Through these observations, I saw first hand the impact of the capacity to take in unbearable states of mind. The observations involved experiencing and writing about frightening and painful experiences. As my capacity to tolerate these experiences grew, so did my engagement and understanding of psychotic processes. I became aware that psychotic processes exist in ourselves and in our patients and that just as it is important for us to understand infantile processes so that we recognize them in ourselves and our consulting rooms, it is also important that we understand and recognize psychotic processes.

During my training, I did an observation of psychotic patients. I did the observations in a psychiatric unit in a teaching hospital. This experience had a profound impact on my development as a psychoanalyst. This observation facilitated a much greater capacity in me to face and bear the pain.

There were four general aims to the psychotic observation. The first was to provide an experience of psychoanalytic observation as a method of investigation, along the lines of the infant observation. The second was to identify psychotic states in clinical work by observing people who were experiencing psychosis. The third was to deepen understanding of counter-transference through the subjective effect on the observer of the severely mentally ill person. The fourth aim was to enhance the candidates understanding of the frame in which the observation occurs. This paper is a discussion of how these observations affected me and my clinical work, the frame that I worked in, and the value of observation as a method of investigation.

A significant difference between the infant observation and the psychotic observations was that the psychotic observations were not of one person. They were made inside a hospital ward and although the same people were often part of the observation, the observation was much more about observing psychotic processes, their impact on the people around them and on myself as the observer.

Each week I attended the unit at the same time. I met with my supervisor and then entered the ward and sat in the same place. I sat in a communal kitchen area where patients and staff gather. It was an acute locked ward. After each observation, I met with my supervisor and discussed the experience. I then wrote up the observation.

During the observation, I placed emphasis on developing the capacity for receptivity to its fullest. I believed that developing such an attitude/capacity would greatly facilitate the overall aims of the project. Didier Houzel, (1999), suggests that one of the values of Esther Bicks method is that of focusing the observers efforts on all aspects of their mental receptivity. He distinguishes three areas:

  1.             receptivity at the perceptual level which involves trying to objectively observe the conduct and behaviour of the child and those around (eg. gestures, sounds, expressions) and to become aware of everything that can be either seen or heard;
  1.             emotional and emphatic receptivity in which the observer allows him or herself to experience whatever the infant or those around him may be experiencing; and
  1.             unconscious receptivity, which manifests itself in counter-transference through feelings, representations, ideas, even physical manifestations.  This requires tolerating the experience of a situation that may at times be extremely painful without having any understanding of it. 

I think one of the most significant discoveries I made came out of focusing on the three areas distinguished by Houzel. I became aware of the importance of this type of mental receptivity in terms of what it communicated to me about the patient. I learnt that a great deal of analytic work is about observing that words and actions are often responses to unbearable states of mind that have not been contained. I realised, for example, that a patient who has not learnt to bear painful feelings but has instead somatised since childhood will not communicate their experiences in a way that is easily accessible to their analyst.

I discovered that psychotic processes were an important part of every day psychoanalytic work with patients with non-diagnosable psychotic illness. I became aware that these processes exist in ourselves and in our patients. That just as it is important for us to understand infantile processes so that we recognize them in ourselves and our consulting rooms, it is also important that we understand and recognize psychotic processes. I began to think that developing a clearer understanding of psychotic processes may in fact create a greater capacity in the analyst to take in unbearable states of mind, which are projected, and to hold on to them for some time.

Rosenfeld (1987) discussed this interaction:

The psychotic patient who projects impulses and parts of himself into the analyst is expelling them. But in doing so he makes it possible for the analyst to feel and understand his experiences and to contain them. In that way the unbearable experiences can lose their frightening and unbearable quality and become meaningful.

In a psychoanalytic training, candidates are taught a great deal about psychoanalytic concepts such as transference, denial and splitting. I think the power of these concepts and how they are communicated in the analytic relationship became much clearer to me as I sat, watched and recorded my observations and experiences on the unit. They came to life for me in a way that had an enormous impact on my work, and my capacity to understand and work with these concepts.

My supervisor beckons me to sit down on my usual chair. It feels isolated and alone. As I sit down the noise of the television pierces my consciousness. No, I think_. Not here, youve made a mistake. Im next to the television. Come back; dont leave me here next to this noise._ I watch despairingly as my supervisor disappears into the labyrinth of rooms and corridors.

**Ill move. He didnt realise the TV was on next to me. It isnt that I cant stay here, it is just not a good place to observe, I tell myself. I should move. No, he put you here for a reason. Stay in the frame, stay in the chair and observe, I counsel myself. I feel the agitation in me growing. I have decided that I must stay where I am. It begins to feel impossible. Turn down the television, I shout inside myself. Who would leave a television on so loud? No-one is watching. I am beginning to feel angry and stuck. I want to observe and it feels like I cant. I try really hard to focus. **

**A nurse is sitting with a young woman and talking to her. There is a man sitting outside in the courtyard adjacent to me. He is alone. I cant hear what the nurse and the girl are saying, the television is too loud. I try harder to focus, I can feel my mind strain as I desperately try and shut down the distraction of the television. _ I cant stand it. I shall have to move. Use the experience, I tell myself furiously. This is something of the experience of this Unit and people in it_. I try and think about this. I dont care, I have to move. I cant hear, I cant think. This is ridiculous. I cant stand it. I close my eyes for a moment. I cant do this observation. I hate this place. Why has my supervisor put me here? I cant observe anything. I am trapped in my own internal rage about being stuck in a place where I cant hear because there is a constant distraction. **

I am reminded of an adolescent patient. During one of his sessions there was a tradesman standing on a patio outside my room speaking on a mobile phone. The noise of his chatter was distracting and made it very hard for me to give my full attention to the boy. After a while I decided to comment on the intrusion. That mans voice in the background is very distracting, it is very intrusive, I commented. Welcome to my world, came his reply. That is what it is like for me all the time, every moment of every day.

The memory settles something inside me**.**

After the experience in the training of the infant observation and the psychotic observation, I was becoming increasingly aware of what I was learning by putting myself into situations in which I tried to notice and examine everything around me. Ella Sharpe said,

We do so much listening to words we need to look, feel & observe.

I had become increasingly interested in the idea that we learn through what we see and observe and not just from what we hear, that patients will show us rather than tell us.

I bought Didi-Hurbermans (2004) book, which documents Charcots photographic experiment at the Salpetriere. The more I looked at the photographs, the more I became aware of Charcots fascination with observation. Freud described Charcot as having the nature of an artist - a visuel, a man who sees. Here is what Freud told us about Charcots working method.

He used to look again and again at the things he did not understand, to deepen his impression of them, til suddenly an understanding of them dawned on him.

The patients in this next observation are in terrible states of despair. I think that the pain and helplessness that are evoked in me serve as important communications about the patients unbearable state. I have often heard people talk about primitive material. In this observation, something primitive is communicated; it is no longer a theoretical concept to me but a lived experience. It is powerfully communicated to me and it is not the words that stay with me.

During the observation, I begin to fragment and there is no space for any reflection so that some sense can be made from the turbulence I am experiencing. I think it reflects the fragmentation of the patients at that moment and the inability of anyone to receive what is happening. In the inner world, especially in the Bion-Bick model, the experience of the mothers reverie pulls together the potentially fragmenting infant. I think the next vignette contains a vivid example of the absence of reverie.

I notice a man outside in the courtyard again. He looks like a fisherman with his deeply lined and sun tanned body. He has a woollen hat pulled over his head. His shoes have no laces. The absent laces tell so much of his story. He rubs his face with his strong thick hands. Dont cry, I plead. He isnt but his suffering is so visible. I cant watch him. It hurts. He turns and his blue eyes cut through me. His look fills me with shame, as if I have intruded into his suffering. I retreat from his gaze and he turns back to the courtyard and drops his head back into his hands.

**The girl remains limp and pale on the couch, her legs crossed staring at the floor. The nurse continues to talk to her. His voice adding to the overwhelming cacophony of noise. I hear snippets of what he is saying, Youve done so well todayYou should feel pleased with yourselfYou got up, you got dressed on time, you ate breakfast on time.. At first she appears not to be taking anything in but once or twice I notice the muscles around her mouth tighten and it feels as if she wants to smile but cant. Every so often she asks about her mother and the nurse tirelessly reassures her that her mother will be there soon. **

**Another young woman wanders into the room. She sits down at the table. She has the same drab clothing. Grey pyjamas and slippers. She is pale and her hair limp and greasy. She looks tired. She gets up to move and looks as if she might fall asleep as she walks. A nurse speaks to her and I see her struggle to respond. She stands up straighter. She is trying hard. She reminds me of a school girl who has been called to the Headmistresss office. When they have finished speaking she turns away from the nurse and walks to the couch adjacent to me. She doesnt appear to see me. Her body slumps exhausted after the effort she has just made. Her legs shake uncontrollably and she sits, like the man outside, with her head in her hands. I think she is crying but there are no tears. An unbearable sadness has pervaded my whole being. I think I am going to cry. Tears form behind my eyes. Stop, the voice inside me commands. I cant get rid of this feeling of despair, which is seeping in through my pores. The fisherman moves inside and sits with his back against the wall. He stares at nothing. Nothing, nothing, nothing. **

_What is happening?_** My body silently heaves with tears of sadness. _What am I doing here? Where am I? _I feel so disoriented. The nurse has left my limp comrade and she remains motionless on the couch. The four of us, each against a different wall. Only the television blaring. I have to get up. I want to move, I cant sit here any longer. They are all so motionless and despairing. I begin to make patterns with the formations of where we four sit. I feel like my mind is splintering. Nothing is happening and my mind is disintegrating. The patterns help.**

When I had previously worked in a locked psychiatric unit, I learnt little about the emotional phenomena I am discussing today. In fact, I suspect my own fear and difficulties around what was being communicated distanced me from being able to receive much of the pain and suffering of psychosis. My observation on this unit was that the staff were doing everything that they could to get away from the pain and terrible states of despair and agony that abound in such a place. No one wanted to feel what was actually being experienced and communicated.

It made me wonder about the ways analysts may find to avoid these painful states in their patients. Perhaps our thinking may act as a similar shield. That in focusing on what to say or what is happening and how to form an interpretation, we also avoid receiving what is being communicated to us.

In the following observation, I think about how Bion described beta elements as things which travel, like missiles, through space, looking for somewhere to land. They are not thoughts but parts of the personality, which have been disowned with the aim of not facing painful reality, or transforming or modifying frustration.

This observation helped me to think about Bions concept of containment what it looks like, what it feels like. I learnt about how emotions without a container are homeless and potentially attacking, or invading. In this instance, we see the failure of the container contained - there is no containing object. The psychotic processes of splitting and projective identification are evident everywhere in this observation and my own thoughts and confusions clearly reflect this.

**A woman strides about the room. She looks angry. Fuck, fuck fuck is all I can hear. She moves over and pulls up a chair opposite me. I feel her eyes on me. Im too scared to make eye contact. I look straight ahead. Who are you? I tell her my name. Huh, she snorts and looks away. I want a fucking cigarette. Why the fuck cant I have a cigarette? No-one answers. She gets up and continues to mutter to herself as she makes a cup of tea Fuck, fuck, fuck. I want a lawyer. I want to get out of this fucking place. I want a cigarette. She grabs her tea and marches up to one of the nurses. I want a cigarette. Not now Elaine. I want a lawyer. Do you have a lawyer? Yes. Well why dont you ring them. Dont laugh at me Sarah, she shouts at one of nurses who are sitting quietly filling out forms. Sarah looks up and answers honestly, I was not laughing at you. **

**The room slowly empties of people. Two nurses remain, as do the two patients, Catriona and Elaine. Catriona is slumped in a chair and Elaine is frantically pacing. Elaine stops to make a cup of tea. As she does, she swears about the nurse who gave her a haloperidol. They shouldnt give me haloperidol, it makes me so aggressive. That is why I am so aggressive. I told that stupid nurse not to give me a haloperidol. A nurse on the other side of the room begins to tell her that she didnt give her a haloperidol. Another nurse beckons her to be quiet, to let it go. **

The nurses sit on the couch and talk to themselves. Catriona appears to have drifted into her own private world. As she talks to herself she pulls faces. I try and imagine what she is talking about. I want a cigarette, asserts Elaine again. No one responds. She moves to the door close to me and begins to rub her wrists against the edges of the door. She is trying to hurt herself. The edges are too blunt and quickly she moves to the next edge. It is a sudden desperate attack. I look around hoping that someone will notice but they are all absorbed in their own conversations. She finds a part of a door that looks sharper. I feel myself breathing harder and faster. What will I do? I cant watch her hurt herself; I must stop her or find someone to stop her. Where is everyone? STOP!! Stop now!!! She continues to violently rub. A terrible frantic sadness grabs my chest and I cant move. After a moment she gives up. She stops as suddenly as she started. She moves away and on to another task. I feel as if I have just witnessed something terrible. My hands hold on to the sides of the chairs as if I might fall. I am struggling to balance. I am the only witness. The rest of the room is as it was before.

**Elaine shouts, I want a cigarette. I have watched her agitation growing throughout the observation. She feels like a pressure cooker about to blow. One of the nurses on the phone covers her ears. Elaine screams, I want a fucking cigarette. Why cant I have a cigarette? Shh Shhh, pleads a patient quietly. **

**Why cant I have a cigaretteI want a cigarette, she wails. She seems so distressed, so frustrated. It is as if everything will be fine if she can just have a cigarette. She begins to wail more loudly. The sound is filling the room. Everyone is quiet. She begins to bang on the window of the nurses station, she is screaming now. I want a fucking cigarette. Give me a cigarette. No one seems to know what to do. She is like a baby left crying, unattended. Her crying escalates to an unbearable fervor. A nurse gets up and begins to rub her back and tells her it will be okay. There, there, she says gently. I feel moved by her tenderness. There, there Elaine, dont cry. You can have a cigarette soon. Elaine quietens and falls back into a chair. Her sobs carry the sound of her anguish. **

The following observation illustrates something very important I learnt about listening and emotional attunement and the transformative effect of being understood. This observation stayed with me. There are two patients Jane and Anne. Anne is profoundly unwell and Jane is about to be discharged. Jane listens to Anne in a way that I believe begins to bring about some change in Anne. Unlike the staff member, Jane does not intrude into Annes experience. She stays with Annes unbearable and unimaginable terror. She does not challenge Annes thinking or try and change it. Jane in no way tries to dispel Annes beliefs and seems able to engage with her fear. I am also aware that something of my own terror was transformed by Janes attunement. It is not the interpretation or the words of understanding. It is the actual experience of another human being fully receiving and understanding that seems to provide the transformation - reverie. Jane does not attempt to provide understanding but she does understand. I think observations like these had a profound effect on the way that I now work and really developed my capacity to be with what is really happening in the moment. A real understanding of reverie was emerging for me.

**A nurse approaches the woman who is now cowering in a corner with her face hidden behind crossed arms. Anne, what is the matter?? Why dont you come and sit over here?_._ Anne does not reply but seems to try to bury herself more deeply into the wall. She looks like a woman about to be attacked. What is the matter?_ _Repeats the nurse slightly more firmly, Anne what is the matter, are you alright? Silence. Aliens. Anne mumbles not moving. There are no aliens here, replies the nurse. Would I be here if there were aliens here? No. There are no aliens here. Look up and you will see. Anne does not move, only tiny whimpers betray her existence. The nurse crouches down and tries again to encourage Anne to look around. She takes Annes arm and gently guides her to the table next to me. Anne sits down and drops her head beneath her arms. I feel immediately uncomfortable, a bit frightened. Anne seems so completely inaccessible. Now come on Anne, persists the nurse. There are no aliens come with me and we can check your room and you will see that there are no aliens. There are no aliens in this room; there are no aliens anywhere. There are NO aliens. I am momentarily reminded of putting my own children to bed when they were little and frightened of the dark and what might come with it - monsters, witches. Anne groans. A deep rumbling groan. My fear intensifies and I want to move away. The nurse leaves telling Anne that she will come back and check on her in a little while. Anne appears not to hear. She doesnt move, she just groans. It is a terrible groan, like a physical pain. Jane who has continued to talk to me whilst the nurse has been attending to Anne now turns to Anne and says, You are not feeling good Anne, hey? There are aliens here?, she asks. A silence hangs in the air for a moment. Aliens trying to get me, mumbles Anne from her buried arms. That is terrible, replies Jane. Where are they?. There is no reply. Jane turns back to me and talks more about the book she is making and how meaningful it is to her now that she is well. Anne begins to groan. I feel so uncomfortable. I am so outside anything that feels familiar. I want to get up and run away. Jane moves closer to Anne. It is really frightening hey?, shes says tenderly. Where are they? Why are they after you?. She continues appearing both genuinely concerned and engaged with Annes aliens. She speaks with her with no doubt about the aliens existence. She recognizes they are terrifying Anne. I realize Jane knows the fear and is not frightened of it herself. I notice Anne move a little. As Jane continues to talk with her about her terror Anne lifts her head very slightly and looks out from her crossed arms. Do you want me to go look for them?, Jane says. They are after me mumbles Anne. Bastards, replies Jane. You will be okay. I am here with you. Ill protect you. Anne sits up slightly and looks around. Jane rests her hand on Annes back and continues to talk to me. After a while Anne gets up and walks slowly down the corridor. Her arms no longer cover her face. Ill be here if you need me, calls Jane. It is an extraordinary and moving interaction. I no longer feel frightened of Anne. As she walks slowly away down the corridor I feel overwhelmed with sadness, I want to follow her and stay with her until her terror abates. **

Perhaps the most valuable aspect of the psychotic observations was that they were lived experiences. I will use the concept of transference to illustrate what I mean. The transference, in this next observation, became a lived experience, which brought the meaning of the construct to life in a very powerful way. Here is a brief extract from an observation to illustrate the lived experience I am talking about.

Have you been here before? Are you a doctor?

No, I reply but I have visited before.

Me too and she laughs wildly.

Im much better now. Are you Italian? she asks me.


You look like an angel

**An angel? I reply. **

A beautiful angel. You look like a beautiful angel. She pauses before continuing

** You look Italian, in the best way. Like a painting. You look like an angel in a painting. Yeah she leans back looking at me and raises her arms and hands as if she is holding a big sun or beach ball with my face in the frame. Yeah. An angel in a painting. **

**We sit quietly for a moment. A woman walking past pauses and comments enthusiastically, **

You two look so alike. Your hair. You must be relatives. The pleasure that I had drawn from some narcissistic fantasy of a beautiful Botticelli Italian angel was shattered. I wanted to protest. _No I dont look at all like her. _

The red headed woman seemed excited.

Do we? Do we? Do you think? No, shes beautiful.

**The woman, perhaps detecting my own panic continued, It is the hair, you have the same hair. Again I scream inside, how can you say that? her hair is bright red look, we are completely different. I looked at the red heads wild red hair and saw a likeness. **

I have been to this unit many times and each time I have sat quietly and still in a chair. I have observed rather than participated. Understandably, people have been curious about who I am. More surprising to me are the roles or positions that have been given to me. So far I have been assigned the role of a patient, a patient being admitted, a visitor, the doctors daughter, a new doctor and a medical student. And now the list has grown to include an Italian and an angel. I feel I am understanding something fundamental about the transference for the very first time.

Likewise it has also been interesting to experience having no role. To be no one. I am not someones mother or wife. Im not a clinical psychologist or a candidate. Im not a patient or a relative. Im not a doctor or medical student. Im not the doctors daughter, an angel or an Italian. In my consulting room, I realize that I draw on the frame or my role as an analyst to help me manage any role being projected onto me. Although I try and allow the transference to unfold, I take refuge in a place that exists somewhere in my mind. I retreat to a role I know. Here in this unit, there is nothing to draw on; I am stripped of anything familiar. It feels more honest, empty of any clutter. I want to hold onto to this place when I go back to my consulting room.

I found that being on the receiving end of psychotic processes in the context of this unit, heightened my own awareness of the pressure that they create to act or speak or do anything to diffuse the situation. I became increasingly aware in my own practice of the destructive impact of psychotic processes on the analytic work. I realized that such processes were resistant and anti thought and often accounted for an impasse in the work.

Perhaps most importantly I think that the psychotic observation developed my capacity for reverie. The observation involved experiencing and writing about almost unbearable experiences. During the psychotic observation I was able to see and experience these states of mind and was exposed to the battle involved in staying with them. Reverie can only come about by tolerating these unbearable feelings long enough to start thinking about them.

In the training, we learn a great deal about the importance of the frame in psychoanalysis. I think these observations taught me about the frame both internally and externally. James Telfer, (2007)_, _points out that the frame is not just a set of ground rules and boundaries. It is, in fact, a dynamic process, a container but also a living form that requires constant maintenance. As the frame represents reality for the patient, it will be constantly attacked by psychotic processes. He goes further to discuss how the work of keeping the frame is antipsychosis work because it creates conditions for thinking and can be used to measure how a patients mind works. Non-psychotic parts operate the frame. Esther Bick created the concept of the frame for a non-directive observer whose only role is to observe. In the unit, I found the pressures on the frame at times unbearable. I began to realize how the frame was both an internal mental state and an external reality. I began to see the pressures extended by the psychotic parts of the personality to break the frame. I learnt how this pressure affected psychotic parts of myself, how important my own counter-transference and own subjectivity was, and I learnt a great deal about developing an internal frame which provided me with a place to think.

I find myself becoming increasingly curious about observation as treatment. I have come to place a much greater emphasis on observation in my own clinical work. I think the integration of the observational skills I have developed into my clinical work has facilitated a deep and rich learning in me. It has helped me to recognise the deeper inner moment-to-moment communications that are occurring between myself and my patients and within myself and to bear them.