DANGEROUS LIAISONS: PSYCHOSIS AND VIOLENCE – WORKING IN A PSYCHIATRIC INTENSIVE CARE UNIT

This paper describes work with psychotic and violent patients which led to thoughts about the use of projective identification in violent enactments to communicate at physical rather than emotional levels. The excessive reliance on projective identification in these patients seems to reflect early problems in containment and to be associated with underlying fears of annihilation expressed in a dynamic oscillation between a dread of separateness and a dread of closeness. A violent enactment may attempt to resolve overwhelming anxieties about separateness by an attempt at fusion, which then may stir anxieties about engulfment. Alternatively, overwhelming anxieties about closeness may lead to violent attempts at separateness which then stir fears of fragmentation.

Moments of therapeutic contact with these patients seem to be achieved from a painful recognition of separateness but which simultaneously allows real closeness. For therapist and patient such moments seem to reflect the capacity to tolerate a third perspective, very difficult for patients whose fathers were often absent or ineffective. The therapeutic working through to achieve an integrated and separate identity is especially difficult for these patients because of problems of mourning separateness and of unravelling complex webs of projective identification which attempt to bind a fragile identity together against fears of fragmentation and death.