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It is not often that one has the opportunity of analysing a patient who fights with a 'ghost' during the course of treatment and so I thought the case merited clinical discussion. I shall have little to say about the theoretical aspects of hallucinatory phenomena, but there are grounds for a discussion about various parameters that I used during the analysis which I think were necessary to sustain the analysis and bring it to a fairly successful conclusion.
Elizabeth Zetzel in her paper on 'The So-called Good Hysteric' (1968) which mainly concerns women patients, made a useful classification of hysterical patients into four grades according to their psychopathology and prospects of analysability. My patient would, I think, fall somewhere between her third and fourth grades and I shall briefly delineate what these grades represent. To quote:
Third, there are women with an underlying depressive character structure who frequently manifest hysterical symptomatology to a degree which disguises their deeper pathology. Fourth, there are women whose manifest hysterical symptomatology proves to be pseudo-oedipal and pseudo-genital. Such patients seldom meet the most important criteria for analysability.
She describes the fourth group as follows:
However, while their symptoms may present a façade which looks genital, they prove in treatment to be incapable of recognizing a genuine triangular situation. For them, as for Oedipus himself, the parent of the same sex has not remained a real object in any meaningful way. Such patients all too readily express intense sexualized transference phantasies. They tend, however, to regard such phantasies as potential areas of realistic gratification. They are genuinely incapable of the meaningful distinction between external and internal reality which is a pre-requisite for the establishment of a therapeutic alliance and the emergence of an analysable transference neurosis.
My patient was not quite as ill as this and was, perhaps also