Commentary on Paper by Paul Williams

Paul Williams has presented us with an excellent portrayal of the treatment of a severely disturbed female patient, in which, for long periods of time, he was confronted with the problems of an analysis of a state of mind in which the psychotic part of the personality is in the ascendancy over the nonpsychotic. The patient had created a dissociated, projected, delusional pseudo-object to govern her thoughts and actions as a protection against the panic of confusion, fragmentation, and annihilation. Here I comment on my experiences with similar patients who were not so much borderline as psychotic, in which the same types of problems apply but to a different degree.

For these patients, I have found it necessary to have them in four-or five-times-a-week analysis and to maintain a firm setting in order to hold and contain them. The maintenance of boundaries and limits represents a crucial aspect of treatment. The analysis, as Williams indicated, is particularly of the here-and-now of the transference and occasionally of the there-and-then when the relevant past is known. This is more easily said than done, because the hating of both external and internal reality together with the denial of its recognition makes secondary process or sane thought extremely difficult. In these patients, there are delusional objects that may be dissociated and projected and experienced as coming from external sources, as with the “Director,” or that may be internalized and experienced as different personalities. For example, a patient of mine knew he was God or Moses or even an ancient rock in the desert. As Williams has indicated, these delusional objects have to be addressed by the analyst as independent objects without attempting to integrate them into the nonpsychotic aspect of the personality as split-off parts and thereby creating anxiety or compliance. This means that the analyst must