Nuno Sousa Monteiro: Having worked so much on the understanding of psychosis, in which ways do you consider today the benefits of the application of the psychoanalytical process with severe psychotic patients?
Franco De Masi: Well…it is a good question… but, first of all, I think that we need to consider how psychoanalysis, in general, looks today at the psychotic illness. In my opinion, psychoanalytic thought has not been systematically applied to the psychotic illness… There has been very important work from great analysts, in the past, such as the work of Frieda Fromm-Reichmann;
Psychologist. Candidate member of the SPP. E-mail: nunosmonteiro@yahoo.co.uk
Titular Member with Didactic Functions (Full Psychoanalyst) of the Italian Society of Psychoanalysis. He was President of the Milan Psychoanalytic Center and Secretary of the Milan Training Institute. He is a Psychiatrist, having worked for twenty years in psychiatric hospitals. He lives and works in Milan, exclusively dedicated to Psychoanalysis. He has published several articles in the International Journal of Psychoanalysis and in the Rivista Italiana di Psicoanalisi. He is the author and editor of several books, translated into English, French, German, Spanish and Polish, including: The Sadomasochistic Perversion; Making Death Thinkable; Vulnerability to Psychosis; Working with Difficult Patients and A Psychoanalytic Approach to Treating Psychosis.
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Searles; Federn…and also Jacques Lacan, who had some interesting thoughts concerning psychosis, even though he did not develop them, but showed great intuition on the psychotic process… After that, of course, we had the kleinian group…not Melanie Klein herself. Albeit having profound intuitions, she did not focus her attention on the nature and developing of psychosis…but the likes of Hanna Segal; Rosenfeld; Meltzer, and specially Wilfred Bion… But, after the work of these great minds, there have been a progressive decrease… Nowadays, there are very few psychoanalytic contributions concerning psychosis…which, for me, is a very important state of mind…
NSM: And why do you think that has happened?
FDM: I think that these great works that I mentioned are not easily translated into the clinical work…and the analysts have been finding themselves in great difficulty in the course of the therapies with psychotic patients… So, the interest in this area has stopped, and this disinvestment happened in silence…there has not been an open scientific debate about it. I think that that is the main problem: the scientific enquiry on the nature of the psychotic illness has really stopped.
NSM: But not in your mind…
FDM: No… I have worked, during two or three decades, systematically, on the psychoanalytic therapy with psychotic patients. Thirty years ago, I formed a group of coleagues in Milano…and we carried on a continuous clinical reflection on the problems and difficulties found in treating such kind of patients. We examined many patients, and not only in analytic settings, but also in psychotherapeutic settings…
But, to me, what was really important was that the therapist or the psychoanalyst had to give the patient what was necessary, in order that the patient could understand his own ways of thinking.
NSM: Wouldn't you say that that also applies to the treatment of every patient in general?
FDM: Yes, but with psychotic patients it is really important to treat him for his condition, that is, to not treat him as a neurotic…and, working with that perspective in mind, we found that, even patients in psychotherapeutic treatment on a two-session a week program have improved, with very few relapses… So, I think that one has to treat this kind of patient along these lines, and enquire more and more about the psychotic state of mind.
NSM: In each session with such patients, I believe that there are some very concrete clinical problems, such as the way of communicating. Don't you agree that the way of listening, and also probably of speaking, is the first difficulty encountered by the psychoanalyst in such situations?
FDM: Yes, but I think that we have to understand, first of all, that the psychotic patient is not using his mind in a psychic way for understanding himself and other people… He is using his mind in a sensorial way. He is continuously producing images, sounds, narrations…because he is in a psychotic withdrawal… Regarding this matter, my main idea is that the psychotic patient, during his childhood, lived in a childhood withdrawal. This thought came from the work I did with another group, which had in treatment young children… very ill children… I discovered that some of them lived in an alternative world in which they were captured. And they used their mind to construct a sensorial world…in which they seemed not to suffer when they were alone. On the contrary, they often showed that they did not want to be with other children, ignoring their classmates. They really seemed captured in this dissociative world of a sensorial nature.
NSM: And that, as you were saying, can be very confusing…
FDM: Confusing and very dangerous… I think that a lot of psychotic transferences that these patients develop in analysis are originated by this kind of approach by the psychoanalyst. So, you are to listen…a lot…
NSM: In your work, how do you deal with these difficulties?
FDM: In my work, I try to get in touch with the healthy part of the patient's personality and try to help him to understand how he constructs his delusions. In my latest book on psychosis, I described my work with a patient which I had in analysis for sixteen years. I listened to him very carefully…and kept asking myself how he constructed his delusions. My system is to describe the patient's hallucinatory world. Not to interpret but to describe. And when I describe it, I am in contact with the sane part of his personality, with which I can form a therapeutic alliance. Then, that sane part of his personality can begin to see the psychotic part of his personality. And so, when this happens, the healthy part of the patient's personality can grow and contain the psychotic part of the personality. But it is a very difficult and long process…
However, the timing to begin the treatment is also very important. I prefer to treat psychotic patients after the first psychotic episode. Usually, the psychotic breaks will recur many times, but if you begin analysis after the first crisis, you will find that the patient's healthy part is more integrated, more alive.
NSM: And, as you had also wrote in your latest book, A Psychoanalytic Approach to Treating Psychosis, the prognosis is generally a lot better.
FDM: Yes, that's right.
NSM: In that book, stressing that you don't follow a kleinian perspective on the concept of phantasy concerning psychosis, you wrote: “Fantasy that leads to psychosis is founded not on representations of objects or on aspects of reality, but on sensory impressions proper; and what is produced via a sensory use of the mind is unfortunately not easily modifiable.” (p. 140) Could you comment on that?
FDM: I think that that concept still lacks some clarity in psychoanalytic thinking, because the kleinian concept ‘phantasy’ is the psychic equivalent to the impulses. But there are various kinds of fantasy, such as the creative fantasy in dream-like states. But the fantasy of the pscyhotic is sensorial. The kind of fantasy of the psychotic patient is a new reality; the psychosis is a new reality.
NSM: Would you say that, working with psychotic patients demands an extra strength from the analyst, which has to remain observing and listening, closer and closer to the psychotic part of the patient's personality, in order to describe to him that psychotic world in which he lives?
FDM: Yes, I agree…
NSM: …and preferably, resisting the urge to escape to a more confortable world by means of interpretation?
FDM: Yes, yes…but, you see, I am interested in investigating, not the known but the unknown parts, and the unkown functions, of the mind. Our mind is really very interesting, it is mysterious, and that is what interests me. As psychoanalysts, we know just a part of the mind functioning, but certainly not the total potentiality of our minds. And I think that psychosis is an expression of the potentiality of the mind. We use the intuition in order to try to know the unknown territories of the mind, and to me psychosis is one of those territories.
NSM: When you say that you are ‘interested’, I feel that you mean a lot more than that. Would you agree with the idea that you have a passion for psychosis?
FDM: Oh yes, for me it is a passion… Not in the beggining of my psychoanalytic work though, because I was very timid, and I would not take a psychotic patient for analysis. I worked for twenty years in a psychiatric hospital, and I followed a lot of psychotic patients there. When I left the hospital and my work as a psychiatrist, in order to become a psychoanalyst, I had this thought in my mind: I believed that, having had all that experience, I would be able to understand, as a psychoanalyst, more about psychosis. Really, as a psychiatrist, I have treated many psychotic patients, but without knowing and understanding why patients got better or suffered crisis. I used medication; psychotherapy; social psychotherapy…but I did not know how and why patients improved or aggravated their conditions.
NSM: But that understanding changed with psychoanalysis…
FDM: Well, yes, but not at first. When I begun my work as a psychoanalyst, I didn't accept psychotic patients for a long time…around fifteen years. And that was because I had to have a more and more skilled psychoanalytic attitude. For me it was not possible to translate my knowledge as a psychiatrist into a psychoanalytic setting. However, it was not possible to keep avoiding some psychotic patients asking to be treated analitically, and so it happened to me… I took into analysis a psychotic patient. I remember that he asked to start his analysis in July…in July… Well, we started the analysis in September.
NSM: And being your first psychotic patient in analysis, how did the work go?
FDM: Well, I followed this patient for seven years, on a four session-a-week in the couch model – and I wrote about this patient on the paper “Intimidation at the helm: superego and hallucinations in the analytic treatment of a psychosis”, that I published in the International Journal of Psychoanalysis .
But, after seven years of work, the patient had a terrible crisis during the holydays…for me it was a good shock, a very good shock.
NSM: How so, a ‘good shock’?
FDM: Yes, it was a good shock…we really have, as psychoanalysts to be able to tolerate frustrations…
It was very important for me, because I could think why this analysis was a failure. I realised that, during this analysis, I had worked with him as he was a neurotic patient: I waited for associations; gave interpretations of his dreams…but I recognise that I have avoided the psychotic part of his personality. I also did not discuss with him his psychotic break, because whenever I tried to discuss it with him he refused to do it. He was terribly afraid of what happened with him… After this analysis, I undertsood that he was afraid that if he would remember the psychotic episode, he would suffer another one. This patient showed me that he was unable to distinguish between a memory of a psychotic crisis and suffering a real psychotic crisis.
NSM: After that experience, how did you face the prospect of working with other psychotic patients in a psychoanalytical setting?
FDM: Well, after that experience I continued to work on the misteries of psychosis. When I published this case, I wrote about the reasons for this failure…
NSM: What is the origin of that shift?
FDM: Well, I think that some of the interpretations of Bion's ideas have contributed to this shift…and sometimes, it is as if the patient's development depends on the analyst's subjective response; on his fantasy, on his so-called rêverie. For example, Ogden's statement that we have to dream the dream not dreamt by the patient… Well, psychoanalytic clinical work is very hard, very difficult…it is not easy to dream the patient's undreamt dream.
NSM: When you started your training, was the psychoanalytical atmosphere different?
FDM: Yes… My experience as a young analyst started in a different environment, yes. I was trained during a period of great progress in psychoanalysis. The kleinian group, all of them, worked with very ill patients, which contributed greatly to the discovery of new and very important concepts, such as projective identification; communicative identification; adhesive identification; the psychotic part of the personality… many important concepts and ideas.
NSM:Which you think that does not happen today…
FDM: Well, it seems to me that most of today's contributions are more “elegant”, but not so deep. Today we are able to present very “elegant” contributions, very smart contributions…but without a cognitive and creative impact on the clinical work. There are many very ill patients, such as borderline; anorectics; psychotics; perverse…that escape from our vision.
NSM: And why do you think that that is happening?
FDM: It is mainly because, today, many analysts are not able to tolerate frustration. To tolerate frustration… I think that, as I have stated in my book Working With Difficult Patients, working with very difficult patients is not rewarding… Many psychoanalysts today prefer to work with psychiatrists; analysands in training, but not very ill patients. There are but a very few that still work with difficult patients, as we can also confirm by the papers generally produced these days. Psychoanalysis is escaping from the clinic. Today we have a lot of comments on movies; comments on novels…we turned psychoanalysis into a subject for conversation in piccolo salotto, parlor talk. Small talk, really…
NSM: I was also thinking of Bion's statement that: “(…) a lot of analysts seem to be bored with their subject; they have lost the capacity for wonder.”… don't you think that this is one of the reasons for what you were describing?
NSM: Considering that danger, and the necessity of exploring new ideas and approaches, with all your experience in the Milano Institute, what do you think that can be done to solve that problem?
FDM: Well…it is not easy to answer that question. I don't really know the training programme in other societies, I can only speak about my society. The Italian Psychoanalytical Society is well organized regarding the training. The training takes four years with the presence of the students, which have to take two cases, for two years, under the supervision of a training analyst. I think that this system is efficient, but, in my opinion, it is too similar to a high school type of education. There is little freedom, and autonomy, on the student's part. In the past, I have made some proposals to my colleagues with the intention of improving this system, but it was very difficult… One of the reasons was that, since the analysts do not get paid to teach at the institutes, sometimes there can be little motivation to spend a lot of time with this activity. So, each one, teaches two or three lessons and another colleague takes over. I proposed that the students should form research groups, with a tutor, functioning throughout the year. This would be a very different model, and I think a better one, than the old teaching model, where the teacher is above and the student bellow, like in high school.
NSM: And what do you think that change could accomplish?
FDM: I think that such a system would stimulate sudent's initiative and could allow the students to see how psychoanalytical ideas were born…how they evolved, and how they are present today. I wrote a book entitled Psychoanalytic Lesson, which is mainly derived from my lessons in psychopathology, in which I try to show some fundamental concepts, their place in the history of psychoanalysis and how they evolved. I think that this is an example of how to construct a new way of teaching, to offer the student a more open system, rewarding the autonomy of the students and not infantilizing them. This infantilization is still the current system, students cannot choose their way to grow and develop.
NSM: Why do you think that your proposed system is still not in use?
FDM: Well, we have to be carefull, because if you have a colleague that works with a group of students throughout a whole year, we will have envy, confrontations…this is a real problem. There are many, many conflicts which are not expressed, between training analysts.
NSM: How did your patients react to the fact that, during the confinement periods, they could not come to your consulting room?
FDM: Some of them felt deprived, deprived of the sensory experience of coming to the consulting room…their route through the streets to arrive, the shops nearby… These sensory experiences accompany each session. We can see that the transference is not only rooted in the analyst, but also affects the objects that accompany the analytic encounter.
NSM: When you resumed the sessions in your consulting room, how did the patients showed you that sense of deprivation?
FDM: Well, they were really happy to come for their sessions. It is true that, during the more dangerous periods of the pandemic, having sessions by telephone was safe, and gave us the possibility of continuing the treatments. But, as soon as it was possible, the patients decided to come because there is no doubt that the atmosphere of the consulting room is more communicative. And that allows for more intuition… and the hearing of the voices in the physical presence. I think that it is very important to differentiate a session without body from a session with body… If we think that when we were very little boys, that physical contact with our mothers was certainly very important. The vision, the noises, the hearing, it was all very important. And so, it is also very important in analysis…
NSM: You mentioned that in some cases of psychotherapy it is more acceptable to use a remote method… how do you differentiate psychotherpay from psychoanalysis. Is it the traditional and formal way that says that if the patient sees you at least 3 sessions a week on the couch, that is psychoanalysis?
FDM: Well, among the various positions on that matter, there is one perspective that says that the main difference is that in psychoanalysis we use the transference interpretation but not in psychotherapy… Personally, I don't agree with this idea…
Well, in any case, we are psychoanalysts…if it is a psychotherapy, it is a psychoanalytic psychotherapy. But what is most important is that we have to think what is better for the patient… For me, psychoanalysis is the most creative of all the therapies, it is really a continuous discovery of the potentialities of the mind. Ferenczi said that psychoanalysis is not a form of therapy, but a process of development…In this sense, psychoanalysis, in my opinion, differs from other forms of therapy, including psychoanalytic psychotherapy. With psychoanalytic psychotherapy, we still want to eliminate the symptoms, the discomforts, but with psychoanalysis we want to develop the patient's personality.
NSM: And what happens to such children? I mean, do you think that is any improvement possible?
FDM: Well when this process continues for years… And it is destined to continue, because it has a psychopathological structure, their minds continue to be devoid of intuitive functions. This
kind of mind does not work with the dynamic unconscious, symbolism, and repression, as typically happens with the neurotic mind…
But, returning to your question regarding communication, I think that, in order to communicate with psychotic patients, we have to…not to interpret but to listen…to listen…to listen to them and try to intuit how that mind works. And to try to locate when, in that patient's life, the psychotic process begun. We have to investigate in the patient's childhood, in his first and closest relations, so we can have a picture of his evolution.
NSM: You were saying that in such situations one should not interpret…
FDM: Yes. We are not to use the interpretative method… Well, we are trained, since the beggining of our analytic training, not to listen to our patients as in a communication between two people. We are trained to listen to our patients in order to interpret the hidden meaning of what the patient says… If we do the same with a psychotic patient, there will be a confusion, because his mind is devoid of intuitive and symbolic functions. So, he will not understand your interpretation as regarding the unconscious meaning of his mind. He will think that you are revealing to him a new reality…
That's why I think that the psychotic patient uses his mind as a sensorial organ, and not as an organ used to understand the psychic reality. So, this fantasy is a special fantasy…it is a concrete, realistic, substitute of the psychic reality. That is why we have to keep remembering, and being aware, of the special use of his mind by the psychotic patient.
NSM: I would say that even in a more passionate way after that first experience…
FDM: Yes, yes… I carried on working on the understanding of psychosis, also working in groups…both adult and children groups. This brought me more and more ideas on the psychotic process…
NSM: Wouldn't you say that writing about failure also requires that extra strenght that we were thinking about, not only with psychotic patients but with all patients in general, concerning the observation and listening, when we are able to refrain from interpreting, enduring the frustration of not knowing?
FDM: Yes… Yes, that is right. But, you see, for me what is most important is the interest on this fascinating subject that is psychoanalysis. We received a beautiful gift from Freud…and, yes, I am passionate. I am 81 years old now, and I am always interested…in new patients, supervisions… this work opens my mind… It is a marvellous gift…
NSM: With all these years of experience, what is your vision on the future of psychoanalysis?
FDM: …it's not a simple question… In my opinion, the future of psychoanalysis is uncertain… It is not clear. In my opinion, in the last decades, it seems that the development of psychoanalysts, both from a theoretical and a clinical perspective, has undergone a progressive slow down. There is not a good development of our discipline. In my opinion, one of the problems is that the attention of psychoanalysts has shifted from clinical investigation to the functioning of the analyst's mind in the session. The attention of the psychoanalysts has moved from the patient to themselves…
FDM: Yes, yes…that is true. I also think that it is necessary to extend our research to the least explored territories of the mind. Specially in the case of those mental conditions which show us processes of mental functioning that we do not know. Well, we know some very important mental processes. But there are other territories not yet well explored, that are new, in which the possibility for interpretation, and the symbolic function of the mind and the dreams…are different. They are not what Freud started to explore. For me it is necessary to develop a new metapsychology that goes beyond what was intuited by Freud, and that deals with the dynamic unconscious and repression. We have to broaden, to amplify, the field of what is already known, because we keep repeating continuously what we already know. For me, the main danger is that psychoanalysis may remain prisioner of itself.
I think that we have a difficult problem that concerns the new generations, which is this: are we able to transmit that the analysis is not a clinical application, it is a research; it is a science, to discover new territories.
NSM: Which we could say it is surprising…
FDM: No, no…I was the secretary of the Milanese Institute…it was not a good experience for me. All the proposals I have presented were not accepted… So, for me there is a problem in transmitting knowledge in the psychoanalytical community. When I was very young, in Milano there was not such a structured teaching as today, so we were really free. We organized clinical meetings and conferences, we invited Rosenfeld, Bion, Hanna Segal… We were free to learn and explore psychoanalytical thinking.
NSM: But not anymore…
FDM: No, no… Well, a structured system still has its advantages. In those days, we were alone for some time, and didn't have the organisation that there is today. However, we were able to communicate all the time between us, and not just in Milano. We had many students in Firenze, Rome… We were always in contact, organising work between us and inviting other people, because we were very anxious to know. At the same time, there was a great development of psychoanalytic thinking in England…
NSM: So, at that time, you didn't have a well organised structure and were more alone, but more passionate. How can we bring back some of that passion?
FDM: Well…I think that there are some young people that are very passionate about psychoanalysis…
NSM: In your perspective, there is hope after all…
FDM: I don't know…here, in Italy, we are not in a crisis. There are many people who come to our Society in order to become psychoanalysts…but I don't know if they are passionate. I think that most of them are not really passionate but want to be recognised as psychoanalysts and want to be included in a well organised Society like the Italian Psychoanalytical Society. So, I don't know… I don't know…
NSM: How was your clinical experience during the confinement periods originated by the COVID 19 pandemic?
FDM: We were well organised. We discussed, from the start, what we had to do to cope with the situation, and to continue our work. So, the Italian Society was really present in helping us all to deal with the situation. We had to close our consulting rooms, and had to think of possible ways of keeping our relationships with our patients. Me, like many other psychoanalysts have tried to adapt to the conditions imposed by the pandemic, and asked my patients to continue the treatments by Skype or by telephone. Almost everyone accepted… I didn't accept new patients, because in the beggining of the therapy is not advised to establish
a communication from a distance. So, for me, it was not difficult to continue a dialogue with my patients. Among the few that did not accept, and expressed discomfort continuing the therapy without being with me personally, was a psychotic patient who was convinced that his phone was being controlled by the persecutor. So, he refused to maintain the therapy under those conditons…
NSM: Have you already resumed the treatment with that patient, and with all the other patients, personally in your consulting room?
FDM: Yes, yes. After the confinements, I resumed all the treatments in person. In almost all cases I prefer to use the telephone and not a system with image, like Skype…
NSM: Why?
FDM: Because the telephone allows for greater concentration. When you use Skype, or other system with image, the attention and intimacy of the communication is disturbed by the vision of the facial expressions of the two people. Well, I use Skype mainly for supervisions, even now, but not for most cases of psychotherapy and not for psychoanalysis. In some cases of psychotherapy, when I know very well the patient, I think that it is acceptable.