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Int J Psychoanal (2014) doi: 10.1111/1745-8315.

12267

A development of Freudian metapsychology for


schizophrenia

Juan Francisco Artaloytia1


Full IPA Member, APM, Spain – jfartaloytia@yahoo.es

(Accepted for publication 1 May 2014)

The author states that psychoanalysis has much to contribute to schizophrenia.


Beginning with a development of Freudian metapsychology, he addresses the
in-depth psychopathological study of a session (the first on the couch) with a
schizophrenic patient who hears voices and feels that he is being watched.
Since the symptoms appear at the level of the heard word and the visual image
– key to Freudian metapsychology – he delineates a circuit for the word and
one for the image, describing a blockage in both and the consequences of these.
Furthermore, with regard to the patient’s progress, he demonstrates first a
quantitative improvement in symptoms, and later qualitative changes in his
functioning. He shows how, over a time, functioning is improved in a once-a-
week on-the-couch setting after two years of face-to-face treatment.

Keywords: schizophrenia, psychoanalysis, Freudian metapsychology, auditory


hallucinations, word-presentations, thing-presentations

In Freudian metapsychology, there are two aspects with a key function: the
heard word and the visual image. And it is no coincidence that it is within
the sphere of these two elements where schizophrenia’s most striking symp-
toms occur: patients hear voices that speak to them and they feel as though
they are being watched.
In the following paper, I shall begin by revisiting the metapsychological
framework emerging from the study of the aphasias (Freud, 1891) which,
although progressively becoming complexified, persists nonetheless through-
out the Freudian oeuvre. My point of focus will be the examination of the
two key elements mentioned above. Keeping this metapsychological skele-
ton as a foundation, I shall build on it by adding a series of elements as set
out by post-Freudian authors which are noteworthy in this connection,
attempting to integrate them despite the fact that they are rooted in differ-
ent theoretical approaches. Later on, I shall address the clinical aspect: in
the first section I shall set out the complete raw material of one analytic ses-
sion – the first on the couch after almost two years of face-to-face work.
Here the patient’s auditory hallucinations appear firsthand, and there is an
abundance of material that, albeit confused and disorganized, has signifi-
cant affective impact. In the second clinical section, and from a more ‘sec-
ondarized’ discourse, I shall provide a brief overview of what took place
over eight years of treatment, the patient’s sexual life serving as a focus in
our study of his progress. After this I shall proceed to the discussion of
1
Translated by Caroline Williamson.

Copyright © 2014 Institute of Psychoanalysis


2 J. F. Artaloytia

both clinical sections and in conclusion will establish the principal conclu-
sions of this study.

Freud’s metaphysychological schema of the aphasias


The patient I shall present hears voices and feels that people are watching
him and thinking ill of him. He hears voices; that is to say, auditory halluci-
natory activity is occurring in the afferent pole of his mental apparatus.
Consequently there is a hallucinatory reactivation of the mnemic image of
the heard word. Fortuitously enough, the heard word is the cornerstone of
the word-presentation. And in Freudian thought, as we shall develop later,
the rearrangement of previous registrations around the word-presentation is
key to repression, the formation of the post-oedipal superego and the orga-
nization of a neurotic mental apparatus.
He is being watched, that is to say, within the visual drive-circuit of watch-
ing–being watched–watching oneself, a particular fixation occurs upon being
watched. Also fortuitously, the visual image is the cornerstone of the thing-
presentation which, as we shall see, is in turn fundamental to the ability to
establish a unified and differentiated image of one’s own self and of the other.
What we find, then, is that the patient’s symptoms appear precisely at
two key points of the formation of the mental apparatus according to
Freudian metapsychology. Let us explore this in a little more depth.
Freud introduces the distinction between signs (indications) of perception,
thing-presentations and word-presentations in his text on the aphasias
(Freud, 1891). Shortly afterwards, in his Letter 52 (Freud, 1896a) these
three elements form the essence of his proposal for an outline of the mental
apparatus. In Chapter 7 of his book on dreams, Freud (1900) gives particu-
lar prominence to how the connection with the word affords us an insight
into the psychical apparatus. In his work on the unconscious (Freud, 1915),
in Chapter 7, he emphasizes the centrality of the connection between word-
and thing-presentation to an understanding of the essence of repression.
Strachey’s (1957) sensational Appendix C to the aforementioned work may
truly be regarded as a bridge between Freud’s 1915 reflections and his study
of the aphasias. Further on, and in the second great text of the turn of the
1920s, The Ego and the Id (Freud, 1923), in his second chapter he insists
upon the importance of the connection with the mnemic residue of a word
that has been heard to the process of becoming conscious. And in his fifth
chapter, he attributes the origin of the superego in part from things heard.
In fact, within the schema of the psychical apparatus presented in this work,
the ‘cap of hearing’ plays a germane role.
My view is that Freud’s schema of the aphasias integrates fully into his
structural model, or model of the second topic, which has been progressively
expanded upon and made more complex. From here on I shall continue to
develop it, seeking to maintain its fundamental Freudian metapsychological
coherence, while providing the enrichment of many subsequent authors.
Let us traverse the schematics of Letter 52 from right to left, from the
most developed to the most primitive, taking fully into account that each
step to the right entails a rearrangement of the previous one.

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18 J. F. Artaloytia

Let us begin by remembering that something is occurring in the transfer-


ence–countertransference field (Baranger and Baranger, 1969) which is initi-
ated by the erotic transference drive movement. Soon enough the patient
associates with the crime in which a person was stabbed by a group of
assailants. We may determine a triangular structure: the victim, the aggres-
sors and the patient who observes, excluded, through the eyes of the press.
We see that this is directly connected with the “THEY’RE TAKING ME,
THEY’RE STABBING ME” in his hallucinatory activity. We might sup-
pose that the patient identifies with the stabbed victim; but, curiously
enough, also with the aggressors, as it is clearly he who is thinking about
the matter while defecating. On top of the triangular level, a rather more
dual level – that of victim/persecutor in which the patient may occupy both
positions alternately – may be superimposed. Or even a unitary magma level
where the three elements merge and blend into one.
But the “THEY’RE SHITTING ON ME”, followed by the explanation
“[. . .] chucking the shit, the piss, the blood from the coke all over him. . .” pre-
sents us with yet another level. We are reminded that the patient defecates
and masturbates in the same place. As such there may be some relationship
between the faeces and the semen penetrating the toilet bowl, and conse-
quently a close link between sadistic–anal aggression and coital penetration.
Thus he may have some difficulty in differentiating between a coital rela-
tionship and a sadistic–anal aggressive act. The father also defecates in the
same place and, in addition, at certain times penetrates the mother. The fact
that blood emerges from the nose (an appendage that bleeds along the mid-
line) cannot but allude to castration or to menstruation. Therefore there
may be a fusing and a combining, just as we have described for the syncy-
tial identitary magma, of a primary or primitive scene (the father penetrat-
ing the toilet bowl with his faeces but particularly the mother with his
semen) with a castration scene (they are cutting the patient, blood is coming
out of his appendage) and with a seduction scene (the patient penetrates or
is penetrated sexually). Of course, all these levels would be unfolding simul-
taneously in the transference–countertransference field. Lying down on the
couch awakens an erotic transference movement and the analyst may be
called on to play all of the roles we have referred to above.
Additionally, references to various bodily activities from poorly-differenti-
ated erogenous zones are breaking through, which appear on a first plane
without it being clear to whom they relate. It is not clear who is defecating
nor upon whom (as when mouth and nipple are merged) nor if he is defe-
cating, or stabbing, or penetrating himself. This is reminiscent of Tausk’s
case, as discussed by Freud (1915), of the female patient whose eyes were
twisted [verdrehen] with those of her lover; the eyes taking prominence with-
out us knowing if those eyes which are twisted are his or hers, or otherwise
hers through the influence of his. Freud discusses the hypochondriac trait
of the utterance. When in metapsychology I say that the signs of perception
may break through into the clinical symptomatology, I am referring to this
part of the material. They appear on a first plane with all of their confusio-
nality, without it being clear to which thing-presentation or word they
belong.
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4 J. F. Artaloytia

psychoanalysis’ forefronting of the retroactive [N€ achtraglichkeit] reorganiz-


ing value of the word. However, his choice of the term ‘signifier’ (taken
from linguistics), relegating the Freudian mnemic image of the word that
has been heard, or ‘sound-image’ of the spoken word (taken from neuro-
physiopathology), moves increasingly away from the Freudian corporal
schema. Green (1973) reproaches Lacan for this distancing from Freudian
corporality, referring to the way he deals with affect. Laplanche (1987),
who has regard for the Lacanian signifier, also insists upon the reorganizing
power of the word in the Freudian sense of N€ achtraglichkeit. Roussillon
(1999, 2001) refers to this reorganization by the word as ‘secondary symbol-
ization’.

Thing-presentation
That said, the mnemic word–sound–image will rearrange nothing if it does
not have a firm handhold to fasten itself to. And as Freud has already sta-
ted (Strachey, 1957), the connection is established with the visual image,
which stands for the thing-presentation as the word–sound–image to the
word-presentation.
In my view, the visual image may be regarded as a kind of container able
to comprise a whole series of signs (indications) of perception as contents.
And here we find ourselves in the realm of Narcissus (Freud, 1914) and of
the mirror (Lacan, 1954b; Winnicott, 1967). And in the gaze of the mother
as mirror, which in the interplay of the drives – between looking, being
looked at and looking at oneself – permits at once the organization of a
thing-presentation of one’s own self and of the primary object, at first clo-
sely interrelated and intertwined. The Botellas (2001) attach great signifi-
cance to what they term ‘secondary autoeroticism’ and to the transition
from looking to being looked at and to looking at oneself. By secondary
autoeroticism, they refer to the capacity that may be gained by the infant,
through sucking its thumb, to join together in one unifying movement a
whole range of diffuse perceptions and sensations experienced in the
encounter with the primary object during breastfeeding. And they relate this
to the capacity to reproduce, in the sensory-motor sphere, what the baby
feels while the primary object is looking at him. In the autoerotic reproduc-
tion of this situation, one would move towards being able to look at oneself
(the ‘double-return’ of Green’s thought [Green, 1983, 2002], from the pas-
sive being looked at to the active looking, and thus reflexively, from looking
at the object to looking at oneself) as one had felt looked at. The connec-
tion with the Bionian model (Bion, 1962a) of the container/contained is also
evident. Roussillon (1999, 2001) refers to this as primary symbolization.
Just as the introduction of the sound–image of the word affords a rear-
rangement of that which went before – that which remains to the left in the
schematics of Letter 52 – under the oedipal symbolic order with all of its
consequences, the introduction of the visual image also implies a certain
rearrangement of what went before. In my view, what is imposed is the ten-
dency to establish the unicity of each thing-presentation. Certain thing-
presentations may be confused with others, but they will forever tend more

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A development of Freudian metapsychology for schizophrenia 5

to present a boundary that seeks to differentiate a within from a without of


each thing-presentation.
The dream as it is experienced, and not as it is related in words, would
come to illustrate the mode of expression of the thing-presentations, in a
‘thinking in images’ (Freud, 1923) older in ontogeny and phylogeny than
thinking in words. This I consider along the same lines as Bion’s (1957) ide-
ograms, Aulagnier’s (1975) pictograms, the Botellas’ (2001) work on the
double and figurability in the session and Sapisochin’s (2013) enactment
during the session. These are fleeting representations in images which often
escape conscious memory immediately if they fail to be adequately bound
by the word, like the dream experienced in images that we do not manage
to translate into words. These are images which have their origin in the
face-to-face exchange and in the visual drive-circuit with the primary objects
and which help us in part to understand, as we shall see, psychotic symp-
tomatology during the real or imagined contact with the gaze of the other.

Signs (indications) of perception


It seems as though with every step to the left in the schematics of Letter 52,
the deeper we get into speculative and slippery terrain. It is conceivable
that, in order to have at our disposal a fair number of mnemic traces of
varying features as signs of perception which would become integrated into
a thing-presentation, these traces would have to have been fixed within a
determinate range of psychic excitation.
An excess of traumatic excitation might arguably lead to no memory-
trace remaining (Freud, 1895a) or to these being registered in a less accessi-
ble way. A failure of excitation would perhaps lead to an inadequate fixing
of mnemic traces. At all events, both extremes would lead us to signs of
perception off the track of what may subsequently be included within the
thing-presentations and reorganized by the word-presentations. They are
thus off the track of repression and the return of the repressed. Sara Botel-
la’s (2010) concept of the ‘memory of the Id’, as discussed by Green (2012)
is very interesting in this regard. In a re-reading of Chapter 7 of The Inter-
pretation of Dreams, Botella underscores that Freud speaks of a first system
of memory, the Mnem. system, contiguous to the Pcpt. system, which
receives perceptual stimuli but retains no trace of them (and thus has no
capacity for subsequent transformations); as well as a second system of
memory-traces (signs or indications of perception in the terminology of our
current work) which may be incorporated into more evolved forms of repre-
sentation. To this first system Botella gives the name ‘memory of the Id’.
In reference to the quantitative dimension, to the amount of excitation and
to the necessity for this amount to be introduced within a manageable range,
it is impossible to conceive of the infant in isolation, rather the binomial pri-
mary baby-object and its surroundings, in relation to which Bion’s (1962a)
contributions on reverie and Winnicott’s (1960) on holding are fundamental.
We shall see throughout the present work how the signs of perception to
which I am referring, those which did not achieve integration into the path
of the thing- and word-presentations, may make their appearance in

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6 J. F. Artaloytia

psychosis. Perhaps they may also at times be recovered through new visual
images, as mentioned in the previous section, by means of figurability in the
dream-work or in the double work during the session (Botella and Botella,
2001), or in the enactments in the transference–countertransference scene
(Sapisochin, 2013). Bion’s transformation of beta-elements into alpha-ele-
ments (Bion, 1962b) is also related to the subject matter.

First session on the couch after two years of face-to-face work


During the session, the auditory hallucinations are presented firsthand,
which the patient comments on and attempts to incorporate into his dis-
course with all the organization of which he is capable. I shall present the
session ‘as-is’, the raw material, with the reader knowing nothing more
about the patient at this point. This approach was inspired by the method-
ology of Donnet and Green (1973), who take the notes from a single session
as their point of departure for the study of the case of Z, from which they
elaborate the concept of ‘white psychosis’. The material I am presenting is
psychotic and difficult to understand from the vertex of secondarized
thought. I suggest to the reader that he or she read and re-read the material
before proceeding, pausing afterwards to try to apprehend as much as pos-
sible.
The patient’s account is written in italics preceded by a hyphen; the con-
tent of the voices is placed in capital letters and my interventions are writ-
ten in regular type, with my notes to the reader between brackets:

-I have been fine since the last session during which, after finally laying down
on the couch, the voices showed up here. Today I went to renew my special
vehicles licence, and I’m not sure whether they’ll let me keep it going. . . the
normal class one is fine, but not the other one. The voices are coming back.
-THEY’RE TAKING ME.
-Who are they referring to?
-I don’t know, to me, to him. . . like they take you and they kill you.
-Perhaps it has something to do with what we touched on before, that if the
voices turn up here and we are able to understand them better, maybe they
can then disappear.
-THEY ARE BEING CURED. He’s saying, as if he’d heard what you said.
THEY’RE DROWNING. This is one of the usual remarks. THEY’RE
SWIMMING. CARLOS [patient’s first name] THEY’RE STABBING
YOU. They’re stabbing you again.
-We’ve spoken before about the verb ‘stab’ and the word ‘slit’2 . What do
you make of it?

2
Translator’s note: the Spanish verb rajar can also mean to slice, cut, slash or knife. It connotes slitting
open. The noun raja similarly can mean cut, gash, slit or slice. In its slang form, it can also mean “arse
crack”.

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A development of Freudian metapsychology for schizophrenia 7

-That they’re sticking a dagger, a knife, in you. You know it’s something
they often say. WE HAVE YOU. [Here I feel something that surprises me,
a certain sexual excitation] They are still playing around inside of me.
CONDOMS, ANA USES. You know that Ana is the girl from the tae-
kwondo.
-Why are they talking about Ana now?
-Just that he’s heard it, it sticks with him and he brings it up. WE ARE
BEING CURED. As if someone were saying to him that we are being cured.
The same explanation as before.
-It seems as though they do not let you think in peace.
-They intrude upon my thinking. Sometimes they make me go blank. . . I think
something and then suddenly it goes out of my head. IT HURTS HIM
THERE. Before the session they had said that there was no need to talk
here. YOU ARE BEING CURED CARLOS CARLITOS [diminutive
form of Carlos] ADELA, WHAT’S UP? As if they were saying hello to her.
[Adela is the only girlfriend he had, when he was no more than 16 years
old.]
-What does this have to do with Adela, why are they talking about her
now?
-They almost always talk like that; I can’t make head or tail of it.3
THEY’RE TAKING.
-Again the ‘they’re taking me’ from before?
-THIS ONE, KILL HIM. THEY’RE SHITTING ON ME. THEY’RE
TAKING ME. Shall I explain the “they’re shitting on me”? For them, when
they killed that guy [in the days prior to the session a young man had been
stabbed in a nearby area, apparently for a settling of scores]. . . coke, blood,
nose. . . on top of killing him, they think about him when they shit, as if they
were shitting on top of him. Chucking the shit, the piss, the blood from the
coke on top of him. JUST KILL ME. This guy keeps going on about it. Like
when I’m in the gym I look and it seems as though they’re looking at me on
all sides and saying to me, one, and another, and another. . . it’s too much,
Fran. - THEY’RE HUNTING ME. Maybe they’ll kill him. ANA FOR
HIM, HUH? ‘Him’ refers to me, as if he’s making Ana be [the one] for me.
PERFECT YOU UNDERSTAND. He’s answered us just then. WHEN
DO TAKE ACTION?
-What do you think the voice is referring to?
-I don’t know, maybe to killing me.
-If Ana is the one for you, will they kill you?

3
Translator’s note: the Spanish phrase used by the patient is “sin pies ni cabeza”, literally, “without feet
or head”.

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8 J. F. Artaloytia

-Well, they haven’t been able to for ten years now. . . so they want to take
action to kill me. CARLOS IS GREAT, I KNOW. Like he helps people
who say it to him and he repeats it. There are other voices that say it to him.
-Great?
-It’s that there are other voices who think a lot of me, they care about me,
they know what I’m going through. It’s what gives me the strength to go on
fighting sometimes. CARLOS IS THE KING. He is thinking that it’s the
king.
-Over these last two years you hadn’t told me this about the king.
-Well yes, sometimes they talk about that. TO THIS ONE KISSES THEY
GIVE. DAGGER HUH? KILL HIM. . . Like they’re picking up a dagger
and killing me.
-In spite of that, you seem calm to me.
-Yes, if not I would have called you after the other session, don’t worry Fran,
I’m fine. HERE YOU LEAVE HIM. Maybe saying something like I
[should] stay here. . . I heard the voice and it said that to me. Apart from
this voice, there are other good and bad ones.
-You are becoming able to talk to me in more detail about what the voices
are telling you.
-And I am getting calmer. HOW GOOD CARLOS IS, HE IS THE ONE
FOR ANA. Here’s this one again like a parrot. . .. in delirium tremens. . .
[laughs] How come he’s so crazy, this voice? WHAT A PRICKLY ONE
HE IS, THIS ONE OF ANA’S. I don’t know what he means. Meaningless
words, I can’t make head or tail of it. THEY’RE KILLING ME. . . again
he’s said I don’t know what to him. . . and MAN! This guy was dying, like
this game, and he doesn’t believe it yet. [He suddenly starts to hiccup]. I
HAVE SEMEN OF YOURS, ANTONIO IS KEEPING IT. [Antonio is
Adela’s uncle, the only girlfriend mentioned before.] The one who is doing
all of this. . . the main voice, the one who made up. . .. the game of talking to
me. There is more than one voice caught up in this game. They call it a
game. . . but there’s nothing good or clean about it. TELL HIM MAN, I
don’t know what he’s referring to, THIS ONE WAS THE KING.
-How do you feel now that we are coming to the end of the session?
-Fine, happy because I am telling you about it. I am calm. . . I’m used to what
the voices say to me by now, Fran. The worst of it was when I was first
admitted. Now I don’t get shaken up by it. I feel more at ease because I’m
telling you to try to understand it. It’s like you’re more freed up.

Secondarized clinical history of the patient


In contrast to the previous section, here I shall present the patient’s clinical
history and the synoptic account of eight years of treatment with him in a

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A development of Freudian metapsychology for schizophrenia 9

secondarized way. I shall focus on genital sexuality, since it is an area in


which the qualitative changes brought about by the treatment may be
observed.
I first see the patient when he is 28 years old. It has been eight years since
his psychotic activity first manifested. At the time of the first outbreak and
hospitalization he was consuming cannabis and alcohol on a daily basis and
stimulants in particular at weekends. He had a first admission, followed
shortly by a second. He prepared himself mentally for having to give up
substances and did so, demonstrating significant willpower. However, his
hallucinatory and delusional activity did not disappear once he had given
up the drugs, despite following the prescribed pharmacological guidelines in
a timely manner. After trying various medications in a variety of prepara-
tions, the most effective was found to be clozapine, which he had been
taking in doses of 700 mg/d when he first came to my consulting room.
However, in the first interview, in which his psychotic anxiety is very pres-
ent, he reports having suffered for years from hearing “voices” that speak
to him almost continually and being frequently tormented by “looks” when
he comes across other people. He comes to my consulting room as an
acquaintance from the same modest Madrid neighbourhood where he lives
had told him that her voices went away (hers was a case of hysterical psy-
chosis) following treatment with me. The diagnosis he brings from his psy-
chiatrist is that of treatment-resistant paranoid schizophrenia, which I
share. I manage his expectations by explaining the differences between his
case and that of his acquaintance. I tell him, however, that feeling listened
to may help him to get better, and I propose that we begin face-to-face psy-
chotherapy at a frequency of once a week, and he accepts. I coordinate with
his psychiatrist, who continues to manage his medication.
Carlos is the youngest of four siblings, with a gap of over five years between
him and his older brother (“I was an accident, Fran”). He lives in a small flat
in a very modest neighbourhood. His father worked in industry and is retired;
his mother has always been a stay-at-home parent. At first he does not bring
up many memories from childhood. He recounts that he was a playful and
mischievous child, who liked to play out on the street all day long. He soon
gave up his studies. Through the influence of other youths in the neighbour-
hood, he soon began to dabble in various forms of drug use. At 16 years of
age he had his first and only girlfriend (Adela), with whom he maintained a
very turbulent relationship, with countless disagreements and arguments. On
one occasion, some of the girl’s uncles came to beat him up for having had a
fight with their niece. The relationship ended soon after.
The patient did his military service, where he obtained a number of driv-
ing licences, starting to work in an area related to vehicles, a job he had to
leave owing to the onset of schizophrenia. Since that time, he has become
increasingly more reclusive, limiting his activities to those related to sports –
martial arts and gym – walking his dog and spending time with his family,
especially his parents, as his brothers and sisters have for some time been
leading increasingly independent lives.
Within his poorly-structured delusional attempt at systematization, he
believes that the voices belong to the relatives of the only girlfriend he ever
Copyright © 2014 Institute of Psychoanalysis Int J Psychoanal (2014)
10 J. F. Artaloytia

had, Adela. He thinks that they are watching him and pursuing him, that they
do not want him to have any other romantic relationships; that they are going
to steal his semen from him and kill him. A component of filiation vaguely
appears, with the patient feeling that he comes from parents from another gal-
axy, although this does not quite mesh coherently with the above.
When we begin treatment, the patient displays from the outset some
transferential idealization, which I register but do not interpret. With regard
to his delusional interpretations, I suggest to him that we consider them as
attempts to understand what is happening to him, which I will respect, but
which we will weigh up, at the same time as I offer alternative explanations,
and that between the two of us we will try to better understand what is
happening to him. During the first months of treatment, his manifest psy-
chotic anxiety diminishes significantly, seemingly contained by the setting.
The patient decides to give up smoking tobacco, which he does without
pharmacological help, and his psychiatrist is able to reduce the clozapine to
600 mg/d. We are realizing that “the voices” do not show up in just any sit-
uation, rather they have a preference for certain ones. Thus, they do it, for
example, when he notices, or fantasizes about, women he may find sexually
attractive. If at night, in bed, he tries to come up with a fantasy so as to
become sexually aroused and to masturbate, the voices become very active
and prevent him from doing so. In fact, in order to masturbate, he devises
the following strategy: he goes to the only bathroom in the house with a
pornographic magazine and closes the latch, having previously chosen an
image to immediately arouse him sexually, and he masturbates hurriedly. In
his words: “That’s the only way I manage to trick the voices, and I feel
more fantastic than God4 “. The only bathroom in the house also holds
some significance as a result of a certain joke he keeps up with his father
about the smell that each of them leaves after defecating.
At more or less the year-and-a half mark of treatment, his clinical symp-
toms having greatly improved (quantitative decrease in intensity and fre-
quency, without qualitative changes), the sessions are beginning to feel very
long to me. I have the impression that the patient no longer has anything
else to tell me, nor do I have anything more to contribute. The hands of
the clock creep forward very slowly; I become very sleepy despite not feel-
ing so in previous or subsequent sessions. I endeavour to self-analyse; I
mention the case to several colleagues. . . but I am unable to resolve the sit-
uation. I increasingly think of Freud (1913) when he talks about not being
able to put up with being stared at by other people all day long, and finally
I propose a change of setting (two years after the beginning of treatment),
on the couch at a frequency of three sessions a week. There is a problem in
that the patient has only limited financial resources, which means in effect
charging for three sessions what he had been paying for one. In addition, at
precisely the moment when the matter had just been raised, his name is
4
Translator’s note: Here the choice of phrase used in the Spanish original: “me quedo m as a gusto que
Dios” is significant. The idiom “como Dios” in Spanish is used to indicate something superb or outstand-
ing – roughly equivalent to “pleased as punch” in the context above, for example. However, in the Span-
ish phrase used by the patient, it is important to note that contained within this “como Dios” is, once
again, an indirect allusion to the figure of the Father (God the father).

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A development of Freudian metapsychology for schizophrenia 11

drawn to be assigned protected housing which is under construction –


clearly excellent news for him, but it will take a large chunk out of his lim-
ited resources. And with that, he even requests a reduction in the amount
he had been paying me. After having read authors such as Ogden (1997),
who had even the once-a-week patients lie down on the couch, I decide to
give it a try, and to my surprise I realize that we return to much better
functioning. The session I have reproduced above is the first on the couch.
During the session prior to that, he had only lain down for the last few
minutes when we saw that the voices turned up firsthand, for which reason
I took the decision to note down the material shorthand. Furthermore, a
countertransference reaction occurred within me, in the form of a certain
sexual excitation, leading me to think that, amidst so much disturbing mate-
rial, the most explicitly sexual had slipped by unnoticed.
After this, we continue to work once-a-week and on the couch. My feel-
ing is that this is bringing about great change and that the material is gain-
ing in depth. Thus for example, the idea I had of his parents was that of a
modest, amiable, well-matched couple who are very involved in the care of
their sick son. However, other content was now able to emerge. The patient
remembers how at one time, during his childhood, his father lost his temper
with him, throwing him against a window pane, which he broke with his
head. Or how, on another occasion, his father dragged his teenage sister
out of a bar by her hair. He also remembers how his mother would place
him in her bed to watch television until late, as his father would stay in
front of the television in the living room, watching other programmes. That
is to say, in addition to their more benign aspects, certain sadistic compo-
nents of the father and seductive components of the mother are beginning
to emerge. At one time, shortly before a holiday separation, and after my
reflecting that I am getting to know him in greater depth, but questioning
the extent to which he is becoming able to know himself better, I am taken
aback to hear him say that I do not know the extent to which I am helping
him. Almost at the door, and, tearfully, he turns around, hugs me before I
can stop him and tells me: “You have no idea how much you are helping
me” – a moment so emotional that neither can I contain my tears.
Some time later, around five or six years after starting treatment, he finds a
job, which leads to some improvement in his financial circumstances and
enables us to move to two sessions a week. Only then does he tell me that he
has been going to a brothel more or less monthly since he began treatment
with me. He recounts that he was unable to do so before starting with me,
since the voices would become very agitated. And during these years he has
felt comfortable enough with the prostitutes to be able to achieve sexual
enjoyment from the experience. However, in recent months he has been con-
cerned as he is no longer able to reach orgasm. We begin to work on this, and
gradually we see that in fact what he wants is a real girlfriend, who can under-
stand his issue with the voices and with whom he can have a relationship that
is more than purely sexual. A few months later he meets a woman ten years
his junior and they begin a relationship. After a month or so, they commence
a sexual relationship and his anorgasmia disappears. For several months he
experiences the relationship very intensely and joyfully. On one occasion,
Copyright © 2014 Institute of Psychoanalysis Int J Psychoanal (2014)
12 J. F. Artaloytia

again tearfully, he turns over on the couch to look at me and tells me that he
never thought he would be able to have a girlfriend. Some ten months before
writing this, she announced to him that she did not want to be in such a com-
mitted relationship, that she is still young and she wants more out of life. She
suggests to the patient that they be friends who go to bed from time to time.
He says no to this as he wants a true girlfriend.
To date, we are continuing our work. The voices and the looks show up
very little and do not cause him a great deal of anxiety. His psychiatrist has
been able to reduce his medication to 350 mg/d of clozapine. His discourse
during the sessions tends to focus primarily upon current concrete events.
He dreams little and finds it difficult to make associations, but I continue
to feel that his work with me is mentally enriching to him. Just how much
we will be able to achieve, I cannot say.

Psychopathological study of the session


Everything that I shall develop below forms part of my reflections over
the course of years in relation to that particular session, rather than what
I worked on at the time with the patient. As with Donnet and Green’s
(1973) Case Z, the material from a single session may nevertheless serve
in our attempt to get to know a patient’s mental functioning in greater
depth.
Owing to considerations of space, I shall limit myself to examining four
significant fragments from the session:

First fragment

-I have been fine since the last session. . . the driving licence. . . I’m not sure
whether they’ll let me keep it going. . . THEY’RE TAKING ME. . . like they
take you and they kill you.

The sequence appears to suggest a conflict between two opposing poles.


The patient starts by saying that he feels fine after having lain down on the
couch at the end of the last session and yet he immediately associates this
with having his driving licence withdrawn. We may outline both poles: a
drive-related pole (he felt fine) and a censor pole (they are going to with-
draw his licence). However, at the hand of this second pole, a hostile audi-
tory hallucination appears: “THEY’RE TAKING ME”.
With all the material from the session and by connecting it up with previ-
ous and subsequent material, I can confirm that the drive movement is
related to an erotic transference component.
According to the Freudian model of the 1890s (Freud, 1894, 1895b,
1896b, 1896c), in what we nowadays know as schizophrenia, the hallucina-
tory activity related to defence is primarily auditory and hostile in nature.
In the language of the ‘second topic’, or structurally-speaking, we would
say that this type of hallucination is ‘super-egoic’ albeit involving a failed
superego. The self-reproach on her sexual activity, which Frau P (Freud,

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A development of Freudian metapsychology for schizophrenia 13

1896b) stored up within herself, had to be heard from the outside. Here we
are far from the model for ‘Meynert’s Amentia’ in which there is a break
with reality and the imposition of ‘friendly’ rather than ‘hostile’ hallucina-
tory activity, which we would say originates in the id rather than in the
superego. The woman who hallucinates the longed-for arrival of her
beloved (Freud, 1894) could be a paradigm for this other model. From the
vertex of this other model we may understand other types of voices, which
are much less present in this case, but nonetheless also appear during the
session, as “CARLOS IS THE KING”, which clearly represent the drive-
related rather than the censor part.
The patient lies down on the couch. As in the Freudian model of the
dream, sensory deprivation occurs and, when the erotic drive movement
breaks through, it demands a representation of the analyst with an erotic
component. I consider that we are coming into contact with something that
has been unable to be symbolized. It is precisely at this point when the
hostile auditory hallucinations break through. Here we might suppose that
“the voices” are reproaching, censoring and threatening the patient from the
external world as a result of his erotic transference movement. They bear
testimony to a faulty post-oedipal superego, at least in this area. Instead of
a post-oedipal superego that has organized a repressed unconscious, we find
ourselves up against the hostile auditory hallucinations.
Let us return to the metapsychology. The word that has been heard is
received passively at the afferent sentient pole and the child must take it on,
make it his own. The superego in part comes out of that which has been
heard. At a certain point, the child begins to actively emit at the efferent
motor pole (he says to himself inwardly, “reel”, “mama”). This circuit of
the word is fundamental to the introduction of the oedipal order and to the
restructuration of previous registrations along primarily neurotic lines. Nev-
ertheless, in one area at least, he lacks the symbolization required by a
developed post-oedipal superego. Something has not sufficiently transited
towards the efferent motor pole and appears to be blocked. Beyond the
blockage in the circuit of the word we encounter a faulty area of the super-
ego, with the absence of certain elements in his mental apparatus. Thus, for
example, he was not able to differentiate between forbidden and permitted
women for his sexual advances. During his adolescence he would fantasize
about having sexual relations with his sister for “practice”.5 On the near
side of the blockage, we encounter a hallucinatory insistence of the censor-
ing word, which acquires a hostile and threatening quality: “THEY’RE
TAKING ME”. And this does not appear at just any moment. It appears
when the (re)presentation of an erotic component in the relationship with
his analyst is required, which is missing. And it appears in the place of the
post-oedipal superego.
Albeit without taking up Freudian terminology sensu stricto, there are
various authors who appear to have developed parts of his thought from

5
In the “secondarized” clinical material we may note that any sexual approach to a woman is experi-
enced as an incestuous advance upon the mother, triggering an extreme hallucinatory defence, with the
hostile voice breaking through at the very place where a post-oedipal superego is missing.

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14 J. F. Artaloytia

the starting point of these formulations. Thus Klein (1932) speaks in terms
of schizophrenics projecting their superego. Lacan (1956), in his concep-
tion of ‘foreclosure’, considers that that which has not been integrated
internally returns from the external world. And Bion (1957) holds that
where, in the neurotic personality, the unconscious emerges, in the psy-
chotic part we find instead the world populated by strange objects, or
‘dream furniture’.

Second fragment
Like when I’m in the gym I look and it seems as though they’re looking at me on all
sides and saying to me, one, and another, and another. . . it’s too much, Fran.
THEY’RE HUNTING ME. Maybe they’ll kill him.

Although this fragment of the session comes chronologically after the


third and fourth fragments, I shall address this one first for the sake of
expositional clarity. This is a relatively frequent situation with schizophrenic
patients. Faced with the real or imagined gaze of others, he feels as though
they are reading his thoughts and that through gestures or lip movements
they are transmitting contents to him, such as that heard in the voices
(other patients I work with hear voices at moments such as these). In the
metapsychology, we saw that the visual drive-circuit is crucial to the consti-
tution of the thing-presentation of oneself: one is first looked at (especially
by the primary object) and then goes on to look at oneself according to
how one has been looked at.
As in the circuit of the word, a certain blockage occurs in the afferent
pole. Beyond the blockage we come up against difficulties in representing
oneself in a unitary, personal and differentiated way from others. (In fact,
one’s own thoughts are readable to the other, there is no personal boundary
to keep them intact; similarly, the thoughts of others are also accessible to
oneself. If we imagine a membrane surrounding each person to preserve
their unicity, it is as though there had been a fusion of these membranes,
from the head of the patient to the head of whoever is watching him, as
when two intracellular vesicles are fused. Thus the thoughts belonging to
the patient are now indistinguishable from the thoughts belonging to those
who are watching.) On the near side of the blockage, we encounter an im-
positional symptomatic insistence on the reception at the afferent pole.
“THEY’RE WATCHING ME”.
At times the sensation of being watched occurs without any perceptual
basis. For example, people feel as though they are being watched, they are
convinced of it, and they attribute this to hidden cameras that are recording
or photographing them. The presence of faces and eyes or cameras is not
hallucinated visually; the conviction as to their existence is rather a delu-
sional interpretation that comes afterwards. The hallucinatory component
resides in the sensation of being watched, often experienced with a persecu-
tory or menacing undertone. On other occasions there really are (for exam-
ple, in the gym, as in the sequence described above, or typically on public
transport) people who may be looking. Overlaying this ‘normal’ perceptual

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A development of Freudian metapsychology for schizophrenia 15

foundation, delusional illusions such as lip movements or gestures may


appear. In any case, the hallucinatory component would also reside in the
sensation of being watched with a persecutory or harmful undertone, but is
more difficult to discern here since it is superimposed over a ‘normal per-
ceptual’ component.
In both the visual and the word circuits, a certain blockage has taken
place. On the near side of the blockage, we encounter a hallucinatory or
perceptual insistence at the afferent pole: “THEY’RE TALKING TO ME,
THEY’RE WATCHING ME”. These are symptomatic manifestations
which should not appear in a well-constituted mental apparatus. This is
why they are noticeable and easily recognizable. Reynolds (1858) and Jack-
son (1889) (an author who exerted such a decisive influence upon the
Freudian metapsychology [Artaloytia, 2005]), at the dawn of neurology,
termed these types of manifestation ‘positive symptoms’. From there, this
terminology is taken up by contemporary psychiatry (Strauss et al., 1974)
Beyond the blockage, we come up against what is missing, with what has
been unable to be constituted – far more difficult to perceive and to theo-
rize given that we must in fact imagine what should be there in order to go
on to define it negatively as missing. Along the terminological lines men-
tioned above, we may refer to these as ‘negative symptoms’. In the circuit
of the word, there is an absence of a well-constituted post-oedipal superego,
and in the circuit of the image, a representational unit comparable to the
ego. The missing aspects only become evident when the patient is faced with
elements that he has been unable to symbolize, as we may see in the study
of the session.
The concept of ‘identitary syncytial magma’6 , which I shall expand
upon later, is particularly difficult to define and to recognize because is it
primarily a consequence of what is missing in the visual and word circuits.
It is pure negativity, in terms of the visual, because the imperative of
unicity of the thing-presentations has been lost. Conveyed in an intuitive
way, in Klein’s (1932) combined parental figure, father and mother,
having lost their unicity, merge and blend into one, like two intracellular
vesicles that are fused together. This may not be apprehended by seconda-
rized thought. It is pure negativity also in terms of the circuit of the
word, as we have just seen in the previous section, as the lack of impor-
tant components of a post-oedipal superego, and more generally as the
consequences of the lack of rearrangement of previous registrations
around the word and reorganization around the introduction of the oedi-
pal symbolic order.

Third fragment
This relates to three hallucinatory expressions appearing at different times
during the session, which I have collected together because of the close
connection they show in content:

6
I would like to thank Rafael Cruz Roche who, during our discussion of the case, suggested the image
of the syncytium.

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16 J. F. Artaloytia

-THEY ARE BEING CURED [. . .] WE ARE BEING CURED [. . .] YOU


ARE BEING CURED.

Strikingly, the language “of the voices” passes from THEY ARE BEING
CURED to WE ARE BEING CURED to arrive at YOU ARE BEING
CURED. There is a major lack of syntactical organization. It is difficult to
understand who is speaking, to whom they are referring or whom they are
addressing. Freud (1915) describes the ‘stilted’ or ‘precious’ speech with syn-
tactical disorders observable in schizophrenics, although he does not expand
much further upon this. To my knowledge, it is a loose thread of Freudian
thought yet to be pulled at by other psychoanalytic authors.
If we imagine the scene we see that in “THEY ARE BEING CURED”
apparently someone (the main voice according to the patient) is addressing
the patient in the second person to refer to a third group of persons. That
is to say, we may sketch out a triangular structure. However, in “WE ARE
BEING CURED”, the three elements merge into a collective unit. And fur-
ther on, in “YOU ARE BEING CURED” the subject addresses the patient
in the second person, that is to say, we may trace out a dual structure.
From a triangular structure, a collective unit is then formed, which finally
becomes a pair. While reflecting upon this question, the image of synctytial
magma comes to mind, transiting between triangular, unitary and dual
forms.
I recall that Freud (1914) uses the metaphor of the amoeba, with the
emission of the pseudopodia which it puts out, and may also reincorporate,
to account for the dynamism and the movements of object and narcissistic
libido. The amoeba is a unicellular organism, with a single nucleus (provid-
ing a “genetic identity”) and is bounded by a cytoplasmic membrane that
separates and distinguishes it from the external environment. What I find
problematic in this metaphor is that the unicity of the amoeba is guaranteed
from the outset, and at no point is it called into question. In Freudian
thought, the ego does not possess a priori unity, since Freud considers that
“we are bound to suppose that a unity comparable to the ego cannot exist
in the individual from the start” (Freud, 1914, pp. 76–7); it is something
that has to be developed by means of a new psychic action. And I consider
this psychic action to be the rearrangement of previous registrations around
the visual image, thus imposing the imperative of unicity. Only from this
point is the metaphor of the amoeba of service to us.
In contrast to an amoeba, a syncytium, in biological terms (I am thinking
namely of the placental trophoblast in mammals), is a structure in which
various nuclei coexist within a single cytoplasmic membrane; thus the unici-
ty of each cell is impossible to establish. During implantation into the endo-
metrium, the syncytial magma will incorporate certain elements and discard
others; it is striking in its mobility, dynamism and apparent lack of fixed
structure.
Let us imagine a triangle that holds an amoeba on each vertex. Let us
say that first we have fixed the unicity of each amoeba (this would be done

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A development of Freudian metapsychology for schizophrenia 17

by being translated into thing-presentations around the visual image). And


that afterwards, through the word, we have named the amoebas ‘mama’,
‘papa’ and ‘baby’ (this would be done around the symbolic organization by
the word in the word-presentation). If we reinforce the line traced between
the ‘mama’ and ‘papa’ amoebas, the baby is excluded from a primitive
scene. If we reinforce the line traced between the ‘mama’ and ‘baby’ vertices
we may come up against a seduction scene with the mother where the
excluded father may become a castration threat. In other words, we come
across a framework in which the primal or originary fantasies, which help
to structure a mental apparatus along neurotic lines, may unfold in an
assortment of ways. What will happen if the amoebas of the vertices are
not subject to unicity and have not been fixed by the word? The three verti-
ces may become fused and blended into a single unit or separated into a
pair, as we saw when we examined the syntactic disarray of the language of
“the voices”, behaving more like syncytial magma than amoebas. What then
would happen to the primal fantasies and the possibility of structuring a
psyche according to oedipal triangularity?
From here I shall go on to define the concept of syncytial identitary
magma, in which representational forms are rapidly introduced precisely at
the point where the establishing of unicity by the visual image and the sym-
bolic fixing by the word has failed. These forms transit unstably from cer-
tain modes to others, and may account for part of the incomprehensibility
of schizophrenic patients’ material from a secondarized perspective. As I
have sought to explain why I use the term ‘syncytial magma’, I should also
give my reasons for the adjective ‘identitary’. And it is that ego-unity, a suf-
ficiently unified representational basis (in my opinion unified around the
visual image) is fundamental to the establishment of identity. Should this
unicity fail, identity becomes flimsy and unsound, shifting, fluctuating
according to the situation. Speaking of negative symptoms, we referred to
the difficulties in defining them. In a somewhat summary way, we might
say that syncytial identitary magma appears precisely in those situations
where it becomes apparent that, owing to the failure of the word, a post-
oedipal superego is missing, and, owing to the failure of the image, an ade-
quately unified self is missing.
Let us see how we may make use of the above in the following point.

Fourth fragment

-THIS ONE, KILL HIM. THEY’RE SHITTING ON ME. THEY’RE


TAKING ME. Shall I explain the “they’re shitting on me”? For them, when
they killed that guy [in the days prior to the session a young man had been
stabbed in a nearby area, apparently for a settling of scores]. . . coke,
blood, nose. . . on top of killing him, they think about him when they shit, as
if they were shitting on top of him. Chucking the shit, the piss, the blood
from the coke on top of him. JUST KILL ME. This guy keeps going on
about it.

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18 J. F. Artaloytia

Let us begin by remembering that something is occurring in the transfer-


ence–countertransference field (Baranger and Baranger, 1969) which is initi-
ated by the erotic transference drive movement. Soon enough the patient
associates with the crime in which a person was stabbed by a group of
assailants. We may determine a triangular structure: the victim, the aggres-
sors and the patient who observes, excluded, through the eyes of the press.
We see that this is directly connected with the “THEY’RE TAKING ME,
THEY’RE STABBING ME” in his hallucinatory activity. We might sup-
pose that the patient identifies with the stabbed victim; but, curiously
enough, also with the aggressors, as it is clearly he who is thinking about
the matter while defecating. On top of the triangular level, a rather more
dual level – that of victim/persecutor in which the patient may occupy both
positions alternately – may be superimposed. Or even a unitary magma level
where the three elements merge and blend into one.
But the “THEY’RE SHITTING ON ME”, followed by the explanation
“[. . .] chucking the shit, the piss, the blood from the coke all over him. . .” pre-
sents us with yet another level. We are reminded that the patient defecates
and masturbates in the same place. As such there may be some relationship
between the faeces and the semen penetrating the toilet bowl, and conse-
quently a close link between sadistic–anal aggression and coital penetration.
Thus he may have some difficulty in differentiating between a coital rela-
tionship and a sadistic–anal aggressive act. The father also defecates in the
same place and, in addition, at certain times penetrates the mother. The fact
that blood emerges from the nose (an appendage that bleeds along the mid-
line) cannot but allude to castration or to menstruation. Therefore there
may be a fusing and a combining, just as we have described for the syncy-
tial identitary magma, of a primary or primitive scene (the father penetrat-
ing the toilet bowl with his faeces but particularly the mother with his
semen) with a castration scene (they are cutting the patient, blood is coming
out of his appendage) and with a seduction scene (the patient penetrates or
is penetrated sexually). Of course, all these levels would be unfolding simul-
taneously in the transference–countertransference field. Lying down on the
couch awakens an erotic transference movement and the analyst may be
called on to play all of the roles we have referred to above.
Additionally, references to various bodily activities from poorly-differenti-
ated erogenous zones are breaking through, which appear on a first plane
without it being clear to whom they relate. It is not clear who is defecating
nor upon whom (as when mouth and nipple are merged) nor if he is defe-
cating, or stabbing, or penetrating himself. This is reminiscent of Tausk’s
case, as discussed by Freud (1915), of the female patient whose eyes were
twisted [verdrehen] with those of her lover; the eyes taking prominence with-
out us knowing if those eyes which are twisted are his or hers, or otherwise
hers through the influence of his. Freud discusses the hypochondriac trait
of the utterance. When in metapsychology I say that the signs of perception
may break through into the clinical symptomatology, I am referring to this
part of the material. They appear on a first plane with all of their confusio-
nality, without it being clear to which thing-presentation or word they
belong.
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A development of Freudian metapsychology for schizophrenia 19

It would be interesting to reflect upon whether the auditory hallucina-


tions we have referred to in our study of the first fragment do or do not
return as signs of perception. There is no doubt that, in the ontogeny of the
process, the heard word was first only one sign of perception more among
others (those of odours, tastes, tone of voices, visual images. . .). Only at a
later time, via the circuit of the word that we have described, is the word-
presentation constituted with all of its consequences. Indeed, the hallucina-
tory voice, which “speaks from outside”, more closely resembles the voice
of the parents or carers who spoke from the outside when the heard word
was still merely a sign of perception. However, with recourse to the meta-
phor of a mechanical motor apparatus, in which various pieces have to
engage for the apparatus to move (so that the circuit of the word functions
appropriately), what we encounter is that a loose piece (the heard word),
which was inadequately integrated, appears at the point where it should not
(the hostile auditory hallucination, or ‘positive symptom’) and yet does not
however provide what it should for the apparatus to move (the lack of a
post-oedipal superego, or ‘negative symptom’). In fact, these do not appear
at just any moment, but precisely when what is called for is a post-oedipal
superego functioning, which is missing. Consequently, its presentation is
much more complex than merely a regression to the ontogenic time in
which the word was just one sign of perception more.
That which appears as signs of perception and the rapid transitions of
what we have called syncytial identitary magma produce a type of elusive,
unstable and changeable material which is very difficult to apprehend,
understand and remember as it cannot easily be fixed by the word, and
which produces a significant affective impact upon patient and analyst. The
material would have been impossible to study if notes more-or-less in short-
hand had not been taken, and if there had been insufficient time and dis-
tance (away from the transference–countertransference storm) to attempt to
understand it in greater depth.

Discussion of the clinical facts presented in the patient’s


secondarized clinical history
Quantitative improvement of the symptoms in the first year and a
half of treatment
We may state as an objective fact that, after a year and a half with his psycho-
analyst in a face-to-face psychotherapeutic setting at a frequency of one ses-
sion per week, there was a manifest improvement in the patient’s clinical
symptoms which had been so disturbing to him (voices, looks and essentially
psychotic anxiety) and which had not responded to other therapeutic attempts.
Phenomenologically-speaking, his psychotic anxiety appears to have all but
disappeared. The voices and looks have reduced in frequency and in intensity
of disturbance generated by them. We could speak in terms of a ‘quantitative’
decrease in symptoms which was unable to be achieved by clozapine.
In my opinion, something is occurring which we could almost grasp from
the vertex of a quantitative economic model. In the patient there is some

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20 J. F. Artaloytia

overflowing. And he encounters a psychoanalyst able to act as a container


(Bion, 1970; Lombardi, 2003). I think that this is sufficient to produce a
temporary quantitative improvement in his symptoms. Perhaps we do not
need to understand very much at the beginning, nor be too precipitous in
the interventions we may feel pushed to make by patients who are spilling
over to such a degree. Perhaps it is enough to convey to the patient that
one can take in his psychotic anxiety and most disturbing contents, and that
one can survive (Winnicott, 1969) and continue thinking, giving things time,
escaping the immediacy demanded of us and introducing the perspective of
temporality. I am completely in agreement with authors such as Rosenfeld
(1987) and Searles (1965) who, after years of experience with psychotic
patients, advise not to rush to interpret negative transference, and to come
to tolerate certain degrees of idealization or symbiosis, for example. Even if
one does not understand at first, to attach importance to the patient’s con-
tents and to convey to him that these may have a meaning which will need
to be thought through with respect and patience are particularly vital for
this kind of patient.

Psychotic whiting-out, exhaustion of material and capacity for


thinking at the one-and-a-half year mark
After a year and a half of treatment, something begins to happen. It seems
as though the material has been exhausted. The sessions begin to feel extre-
mely drawn out, I am overcome by somnolence and I feel as though there
is no longer anything to be done for the patient. Reactions like these are
described by authors such as Bion (1954, 1959), Donnet and Green (1973),
Racamier (1980) and Rosenfeld (1987). In my view these are attacks on
thinking and linking; the imposition of a psychotic whiting-out which also
affects the analyst’s mental functioning. Although we have not discussed
this in the psychopathological study of the session, it is clearly manifest in
the material:

They intrude upon my thinking. Sometimes they make me go blank. . . I think some-
thing and then suddenly it goes out of my head. IT HURTS HIM THERE. Before
the session they had said that there was no need to talk here.

It is as if the patient (with a basic level of education and no training in


psychoanalysis or psychology) had studied these authors, such is the clarity
with which he describes it.
Donnet and Green (1973) define ‘white psychosis’ on the basis of a single
interview with Z. The patient is the son of an incestuous relationship
between his mother and his mother’s son-in-law (he is the son of “that
(id)”). He displays a marked difficulty in his capacity for thinking. The
authors describe a collapse, or rather a non-constitution, of his thinking
apparatus (a concept taken from Bion), which they term the ‘navel of the
psychosis’. Although they do not appear as typical psychotic symptoms,
they define his inability for thinking, referring to it as psychotic whiting-out
and considering it a psychotic nucleus or a basic condition or potentiality,

Int J Psychoanal (2014) Copyright © 2014 Institute of Psychoanalysis


A development of Freudian metapsychology for schizophrenia 21

upon which a typical psychosis may appear. Later, Green (1983) would
develop their formulations on negative narcissism. He understands the
death drive as the tendency towards a zero degree of excitation, describing
it in terms of the ‘disobjectalizing function’, according to which all invest-
ment, or cathexis, is withdrawn from the object. But investment may also
be withdrawn from the self-presentation. In a subsequent recapitulation
(Green, 2002) he describes how one may even come to disinvest thinking or
indeed the entire process of investment. In light of all this we might define
as psychotic whiting-out the process of disinvesting anything which comes
close to the unthinkable.
Why the appearance of sexual excitation in the countertransference? I
believe that until then I had been unable to fully understand the entire sex-
ual aspect of the material. So much death, stabbing, blood, urine, faeces. . .
I had grasped these primarily in their most aggressive dimension, rooted in
a more secondarized thinking. While one theoretically knows about the
implication of sexuality in all of this, only by feeling it in my own body was
I able to grasp its crucial significance to a more in-depth understanding of
the material. Only a posteriori did I realize that the psychotic whiting-out or
attacks on thinking pointed precisely to the fact that the entire sexual com-
plexion of the material was unthinkable.

Improved functioning in a weekly on-the-couch setting as opposed


to a face-to-face setting
At the time of the change of setting, I thought that we were going to work
on the basis of three sessions per week, having to reduce each session to
one third of the fee. However, a change in the patient’s financial situation
puts an end to this option. As an analyst, at that moment, I feel as though
I am bungling the work, unable, as I was, to find any worthwhile solution.
But seeing what is happening, realizing that the voices are appearing first-
hand and unmediated, without any increase in psychotic anxiety or aggrava-
tion of the clinical symptoms, I am prepared to wait and see what happens.
Gradually the realization dawns on me that what is occurring is a complete
re-launching of the process, and that our functioning has improved in com-
parison to the previous setting. This fact is objective and verifiable in the
concrete experience with this patient, as shown by my impression of his par-
ents before and after the change in setting, the material is gaining in depth,
becoming less one-dimensional or superficial.
The loss of visual contact of the analyst demands of the patient a greater
level of representational activity (as in the contrast, mentioned earlier, in his
masturbatory activity between the face-to-face with the magazine image and
the breaking through of the hallucinations if he attempted to elaborate a
fantasy without a visual perceptive aid). This conceivably motivates the
breaking through of the hallucinatory activity and the unfolding of all the
material – all this on a very regressive level save that here it occurs within a
containing setting, without any overflowing occurring. And I think that this
is important for me too. In the face-to-face setting, it was as if the patient’s
gaze had brought about the collapse of my capacity for thinking; as if I had

Copyright © 2014 Institute of Psychoanalysis Int J Psychoanal (2014)


22 J. F. Artaloytia

been more vulnerable to the patient’s attack on thinking or psychotic whit-


ing-out. With the patient on the couch, it is as though a space had opened
up where the countertransference reaction might break through, and I am
able to restore my capacity for thinking (like a virtual space that has first
collapsed only then to be reformed).

Change to two sessions, emergence of the sexual theme,


anorgasmia and the partner
The patient’s progressive clinical improvement enables him to find part-time
employment, improving his financial situation and allowing us to increase
to two sessions a week.
Shortly afterwards, the patient begins to talk about his experience in
brothels. He had not done so before, and seems to do so in order to be able
to talk to me about his anorgasmia, which has appeared over the last few
months and is of great concern to him.
We may describe three stages. First, before beginning treatment with me,
during which time he only very occasionally goes to the brothel, as the
voices go through the roof and do not allow it. That is to say, there is a
conflict that he feels with the external world: on the one side, his sexual
drive activity and, on the other, the censorship or criticism that comes from
the external world by way of auditory hallucinations. Second, the period
during which, after having started treatment with me, he is able to go to
the brothel quite regularly without the hallucinations preventing it. We may
consider that the setting contains part of his psychotic contents and contrib-
utes to a symptomatic improvement, enabling him to do something he was
not able to do before. The conflict seems to have abated. We can only
assume, however, that the patient brings his sexuality to the relationship
with the prostitutes as a form of acting out (Baranger and Baranger, 1969)
or lateral transference (Denis, 2011). We have furthermore seen that at least
until the two-year mark of therapy I myself, as an analyst, find it difficult
to think more explicitly about sexual content in the transference–counter-
transference axis. Third, the appearance of the anorgasmia: we have been
working together for over six years, and suddenly something appears which
is suggestive of a qualitative change in relation to previous material. The
conflict of his sexual drive activity no longer resides with the voices, with
the external world, rather with something inside himself which is preventing
him from reaching orgasm. The beginnings of neurotization appear (like a
green shoot in the desert); for the first time the conflict is intrapsychic,
between a drive pole and an internal superego pole (as rudimentary as it
may be).
It is possible that the relationship with me has also been gaining in depth,
quality and warmth. The session with the hug and the tears at the door
bears testimony to this. The affective component is so intense at that
moment that one would think that the purported affective ‘flattening out’
(Bleuler, 1911) in schizophrenics like Carlos is more a reversible defensive
state than something remaining with them for life. But it is also possible
that, as the relationship with me is gaining in depth, the more mechanical

Int J Psychoanal (2014) Copyright © 2014 Institute of Psychoanalysis


A development of Freudian metapsychology for schizophrenia 23

and superficial contact with the prostitutes is becoming increasingly inade-


quate to him. The moment he begins to think about the prostitutes as
women with whom he may have a deeper relationship (as is taking place
with me), the intrapsychic conflict appears. The fact that we are able to
begin working on all these contents soon translates to him being able to
meet a proper girlfriend for the first time since he was 16 years old, both
soon coming to enjoy their sexual encounters. The anorgasmia first, and the
fact that a first real girlfriend comes onto the scene after working on it, rep-
resent real qualititative change.

Poverty of thought
While we have described a partial neurotization taking place in the patient,
determining the emergence of an intrapsychic conflict where previously
there was none, we have to assume that his overall mental functioning is
currently far removed from that of a neurotic. His speech continues to be
very focused upon the current and the factual, with difficulties in providing
associations of any relevance; his oneiric activity is very limited, and when
dreams do appear they are often mere reproductions of waking experiences,
with little process of elaboration. This is reminiscent of the operational-life-
type functioning of the Paris School (Marty and De M’Uzan, 1963; Pirlot
and Corcos, 2012), which certain authors have also described for other
types of non-neurotic cases such as borderline patients (Braier, 2012).
What I do not yet know is whether this is so, or whether there are ques-
tions of relevance that I am not yet able to think; whether I have once
again allowed myself to be caught up in the psychotic whiting-out. Only
with the progression of events and the process under way with Carlos will
we know more, and find out just how much we can achieve.

Conclusions
I believe that psychoanalysis has much to contribute to schizophrenia, spe-
cifically in the areas of understanding and treatment.
In terms of comprehension, taking as our point of departure a Freudian
metapsychology enriched by the contributions of a whole range of later
thinkers, we dealt with the psychopathological study of one session. The
patient hears voices and feels that he is being watched. More precisely, his
symptoms occur at the level of the heard word and the visual image – the
cornerstones of Freudian metapsychology and his understanding of the con-
stitution of the psyche. We went on to define the circuits of the word and
the image, describing a type of blockage in both, with what we have termed
positive symptoms on the near side of the blockage, and negative symptoms
on the far side of it. We consider as positive symptoms (“THEY ARE
TALKING TO ME, THEY ARE WATCHING ME”) the hallucinatory or
perceptive insistence at the afferent pole of the mental apparatus. And we
consider negative symptoms to be that which has not been constituted
beyond the blockage, specifically the absence of important components of a
post-oedipal superego and of a unified self-presentation, with its peculiar
modes of manifestation. Although we can say little of the aetiology, it seems

Copyright © 2014 Institute of Psychoanalysis Int J Psychoanal (2014)


24 J. F. Artaloytia

we can advance much on the aetiopathogenesis, since we have managed to


pinpoint, within the metapsychological schema, where the problem occurs
and the consequences which may derive from this.
In terms of treatment, we have shown how the psychotic symptomatology
improves in the patient in a quantitative way by the mere fact of coming
into contact with a psychoanalyst able to contain his material. This is an
improvement previously not achieved by pharmacological treatments with
more demonstrable success in this type of case. Furthermore, we have
described how with this patient, after two years of face-to-face work at a
frequency of one session per week, we go on to function better in a once-a-
week on-the-couch setting, later increasing to two weekly sessions. Finally,
we have demonstrated the qualitative improvement in the patient’s function-
ing. An intrapsychic conflict appears where previously there was none, and
for the first time he is able to sustain a stable romantic relationship.
Although this is the study of a single case, and this poses certain limita-
tions, we must remember that both in the history of medicine as well as of
psychoanalysis the in-depth study of isolated cases has often yielded great
advances. Nevertheless, we hope that our approach may be corroborated by
other clinicians who would also bring to bear their own experiences with
schizophrenic patients.

Translations of summary
Eine Entwicklung der Freudschen Metapsychologie der Schizophrenie. Der Autor vertritt die
These, dass die Psychoanalyse einen signifikanten Beitrag zur Theorie und Behandlung der Schizophrenie
leisten kann. Ausgehend von einer Entwicklung der Freudschen Metapsychologie, nimmt er eine gr€ undli-
che psychopathologische Untersuchung der ersten Couch-Sitzung eines schizophrenen Patienten vor, der
Stimmen h€ ort und u€berzeugt ist, von anderen Menschen angestarrt zu werden. Da die Symptome der
Ebene des geh€ orten Wortes und der visuellen Bilder – zentrale Aspekte der Freudschen Metapsychologie
– angeh€ oren, beschreibt der Verfasser einen Schalkreis f€ur das Wort und einen f€
ur das Bild und erl€autert
eine Unterbrechung in beiden Schaltkreisen mitsamt deren Folgen. Was das Behandlungsergebnis bet-
rifft, so beschreibt er andererseits eine zun€achst quantitative Besserung der Symptome mit sp€ater folgen-
den qualitativen Ver€ anderungen. Er erkl€art, dass sich der Patient nach zweij€ahriger Behandlung im
Sitzen in einer Phase mit einer Sitzung auf der Couch besser entwickelte.

Un Desarrollo de la Metapsicologıa Freudiana para la Esquizofrenia. El autor afirma que el psi-


coan alisis puede contribuir significativamente a la esquizofrenia. A partir del desarrollo de la metapsico-
logıa freudiana, expone un estudio psicopatol ogico profundo de una sesi on (la primera en el divan) con
un paciente que escucha voces y siente que la gente lo observa. Dado que los sıntomas aparecen en el ni-
vel de la palabra escuchada y de las imagenes visuales, que son puntos claves en la metapsicologıa freu-
diana, el autor describe un circuito para la palabra y la imagen y describe un bloqueo en ambos, con sus
consecuencias. Por otra parte, con respecto a los resultados con el paciente, este demuestra primero una
mejora cuantitativa de los sıntomas, y mas adelante, unos cambios cualitativos. El autor explica que dur-
ante un perıodo consigui o una evoluci on mejor del paciente con una sesi on por semana en el divan,
despues de dos a~ nos de tratamiento cara a cara.

Une contribution de la me  tapsychologie freudienne a  l’e


 tude de la schizophre
nie. L’auteur de cet
article considere que la psychanalyse contribue de facßon significative a l’etude de la schizophrenie. A
partir de la metapsychologie freudienne, il se livre a une etude psychopathologique poussee d’une seance
(la premiere sur le divan) d’un patient schizophrene qui entend des voix et se sent observe par autrui.
Dans la mesure o u les sympt^omes se manifestent au niveau des mots entendus et des images visuelles –
elements clefs de la metapsychologie freudienne – l’auteur decrit respectivement deux circuits, l’un propre
aux mots et l’autre aux images, ainsi que leur blocage et les consequences que cela entra^ıne. Il note
qu’on assiste tout d’abord chez le patient a une amelioration quantitative de ses sympt^ omes, puis a des
changements qualitatifs. La mise en place d’un nouveau cadre, c’est-a-dire le passage au divan a raison

Int J Psychoanal (2014) Copyright © 2014 Institute of Psychoanalysis


A development of Freudian metapsychology for schizophrenia 25
d’une seance par semaine, qui intervient a la suite d’un traitement en face a face pendant deux annees
consecutives, temoigne d’une evolution jugee meilleure.

Sviluppo della metapsicologia freudiana per la schizofrenia. L’autore sostiene che la psicoanalisi
puo dare un contributo significativo allo studio della schizofrenia. Partendo dallo sviluppo della metap-
sicologia freudiana, propone un approfondimento dello studio psicopatologico di una seduta (la prima
sul lettino) con un paziente schizofrenico che sente delle voci e si sente osservato dalla gente. Osservando
che I sintomi si manifestano al livello della parola udita e dell’immagine visiva, fenomeni chiave nella
metapsicologia freudiana, l’autore descrive un circuito della parola e uno dell’immagine, entrambi blocc-
ati, e descrive le conseguenze di tale blocco. D’altra parte, nell’esito del trattamento, l’autore mostra inn-
anzitutto un miglioramento quantitativo dei sintomi e poi i cambiamenti qualitativi. Mostra, inoltre, il
miglioramento evolutivo nel passaggio a una seduta la settimana, con l’uso del lettino, dopo due anni di
trattamento vis- a-vis.

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