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Manic-depressive psychosis

a n i c - d e p r e s s i v e p s y c h o s i s is a n affective disorder
producing periodic disruption of apparently n o r m a l
moods by pathological depression or elation.
Although a single m a n i c state i n a lifetime is not u n c o m m o n ,
m a n i c - d e p r e s s i v e illness is u s u a l l y seriously disabling, h a r d to
u n d e r s t a n d , a n d often difficult to treat. Before the advent of
mood-stabilizing drugs, the most effective treatment w a s E C T ,
w h i c h is still occasionally u s e d i n dangerous crises a s a life­
saving strategy. Impressive anti-depressive a n d a n t i - m a n i c
medication, a n d compelling evidence for a genetic component
i n the illness, have focussed attention on biological aspects of
the disorder. E v e n w h e n allowing for s u c h genetic influences a s
a n e c e s s a r y c a u s a l factor, there exists a n equally compelling
c a s e for the parallel study of developmental psychology if a
sufficient c a u s a l explanation is to be found.
P s y c h o a n a l y s t s have long contributed to the u n d e r s t a n d i n g
of factors involved i n the predisposition to m a n i c - d e p r e s s i o n ,
to the precipitation of episodes, a n d to its p s y c h o d y n a m i c s .
A b r a h a m (1911, 1924) a n d F r e u d (1917e [1915]) laid the foun­
dations for the u n d e r s t a n d i n g of the n a t u r e of pathological


happiness a n d u n h a p p i n e s s . Recognizing the extreme abnor­

mality of the affections manifest during attacks, A b r a h a m
began with the simple statement that in s u c h states hatred
paralyses love. T h e hatred is unconscious a n d , like the love it
paralyses, h a s infantile origins. It represents a severe develop­
mental failure in the normal process of individuation. In
particular, emotional attachment is dreaded because of ex­
treme sensitivity to the loss that may follow. J e a l o u s y a n d
its precursor, envy, m a y be present in highly destructive form,
often very difficult to detect. Immature processes of identifica­
tion that are normally left behind persist a n d are regressively
reactivated under external stress or internal fears of loss of
the loved object. The prototypical object is obviously the mother
a n d , in later life, "security figures" who are invested with
maternal significance.
F r e u d discovered a form of identification i n melancholia
(psychotic depression) in w h i c h aggression aroused towards
the "bad" object is turned upon the self—a process that is also a
part of normal mourning. T h e extravagant protestations of self­
hatred by the severe depressive c a n be understood a s a defence
that preserves the loved object (felt to be too vulnerable) from
aggressive feelings (felt omnipotently to be too dangerous). At
the same time, the m e c h a n i s m serves unconsciously to protect
the subject from the full impact of loss, as the object continues
to exist in the guise of the suffering self. Melancholia w a s
t h u s recognized as a form of abnormal mourning. F r o m these
beginnings F r e u d developed h i s concept of the superego, the
unconscious conscience. He recognized that in melancholia
the superego possessed extreme h a r s h n e s s , w h i c h he regarded
as a n indication of its infantile origins. So unremitting is the
savagery of the melancholic superego that it not infrequently
leads to suicide (dynamically, a n act of self-murder). Many
studies have since illuminated the origins of this pathological
conscience a n d the reasons why a n infant may even experi­
ence a normal mother as similarly vulnerable to aggressive
feelings (see Klein, 1935: Rosenfeld, 1963: see also J a c k s o n ,
1993a, for a review of major contributors). F r e u d recognized
that m a n i a was in m a n y respects the opposite of melancholia.
Deadness a n d immobility is replaced by liveliness a n d over­

activity, severe depression by pathological elation. S e x u a l i m ­

p u l s e s , often of a childlike k i n d , are regularly present i n m a n i a .
F r e u d also observed the s w i t c h from depression to m a n i a a n d
recognized its defensiveness, expressed a s m a s s i v e denial.
Melanie K l e i n h a d a special interest i n the p s y c h o d y n a m i c s
of m a n i c - d e p r e s s i o n a n d studied, i n p a r t i c u l a r , the attitude of
t r i u m p h , contempt, a n d control in the m i n d of the m a n i c i n ­
dividual. T h i s gross form of devaluation is reserved for a n
object who a r o u s e s feelings of need a n d dependency i n the
subject, a n d for the healthy, dependent part of the subject's
own personality. T h e underlying developmental failure r e s p o n ­
sible w a s further illuminated b y B i o n ' s concept of m a t e r n a l
containment, to w h i c h we s h a l l r e t u r n . T h e degree of develop­
m e n t a l failure i n the m a n i c - d e p r e s s i v e , however severe, l a c k s
the extreme unintegration c h a r a c t e r i s t i c of s c h i z o p h r e n i c psy­
c h o s e s . F u r t h e r m o r e , the m a n i c - d e p r e s s i v e ' s w i s h to s p a r e
a n d preserve the object attests to a comparatively a d v a n c e d
level of development. Despite the fact that schizoid features
occur i n a significant proportion of m a n i c - d e p r e s s i v e patients,
most typical sufferers are potentially able to function at times
at the level of the depressive position (see Glossary) given the
right therapeutic conditions, w h i c h i s w h y well-conducted p s y ­
chotherapy c a n achieve good r e s u l t s .
M a n i c - d e p r e s s i v e patients are widely regarded by p s y c h i a ­
trists a s u n s u i t a b l e for psychotherapy. T h i s attitude is u n d e r ­
standable, given the high r i s k of suicide d u r i n g the depressive
p h a s e a n d the difficulty i n managing psychotic behaviour d u r ­
ing the m a n i c state. However, m a n y psychotherapists have
come to believe that a large proportion of s u c h patients c o u l d
benefit from psychotherapy u n d e r the right conditions. T h e
c a s e of Nicola i s a n example.


Nicola, a doctor, w a s 30 years old w h e n admitted to the u n i t for

a s s e s s m e n t . S h e h a d spent all b u t a few months of the pre­

vious five y e a r s i n mental hospitals, incapacitated by a c y c l i n g


manic-depressive psychosis. T h e breakdown that preceded her

admission to hospital on the first occasion h a d occurred whilst
she h a d been required to attend to late abortions soon after
graduation. S h e h a d made numerous serious, often near-fatal
suicide bids i n her life, the first at the age of 14, and she h a d
responded only briefly to medication a n d over 50 E C T treat­
ments. S h e suffered persistent persecutory hallucinations of
voices ordering her to kill herself, a n d she w a s regarded as a n
u n u s u a l l y resistant case. Leucotomy was considered as a last
resort. Psychotherapy h a d been ruled out because of the
prevailing psychiatric view of its potential for self-harm, which
in her case seemed reasonable. There h a d been a n attempt to
initiate psychotherapy at the beginning of her illness five years
earlier, but on the eve of her first appointment s h e made a
serious suicide attempt, which led to the abandonment of a n y
further attempt to use psychotherapy.
Nicola w a s admitted to the unit under intensive n u r s i n g
surveillance. Preliminary exploration of her history revealed a
highly disturbed family background. S h e w a s the eldest of
several siblings of a devoted but fragile mother, who w a s h e r ­
self the sole survivor of several siblings who h a d died peri­
natally of R h e s u s incompatibility. Her father was subject to
hypomanic episodes, a n d a paternal a u n t a n d grandmother
h a d suffered from manic-depressive psychosis. Her father was
capricious a n d u n j u s t in his behaviour a n d subject to violent
rages. Her childhood w a s marred by chronic domestic tension,
culminating i n the divorce of her parents during her adoles­
cence. Her illness began as a severe depression, after a distin­
guished graduation from medical school, and this led to the
first referral for psychotherapy. At a conscious level she h a d
been eager to begin therapy because she h a d long h a d disturb­
ing dreams w h i c h she could not understand. Later, w h e n she
w a s finally able to embark on psychotherapy, she showed u n ­
failing interest in the meaning of her dreams, and this often
helped s u s t a i n treatment. I [MJ] undertook the psychotherapy
myself, on a twice-weekly b a s i s , though in periods of crisis I
would see her more frequently for a shorter time, a n d some­
times daily during periods of crisis. T h e excerpts that follow are
from sessions that took place some months into the psycho­

First session
Nicola is depressed and withdrawn and sits motionless in her
chair. She is dressed in pyjamas and dressing gown and has
bandages on her wrists from a recent suicide attempt She had
smuggled a razor-blade onto the ward and cut herself badly.
This was one of many attempts and followed an incident in
which another patient had set fire to herself resulting in serious
harm. This had activated a hypomanic response in Nicola,
followed the next day by depression and suicidal behaviour.
The following excerpt begins 5 minutes into the interview and
finishes 15 minutes before the interview ends.

MJ: Do y o u remember w h a t we talked about last time?

Nicola: No.
M J : 111 r e m i n d y o u : you told me of a d r e a m i n w h i c h y o u were
i n E u s t o n Station, a n d a terrorist h a d planted a bomb b u t it
w a s too late to escape. It exploded, a n d y o u were c a u g h t
u n d e r the rubble. Y o u were crying out, b u t nobody c o u l d
h e a r y o u r voice. Do you r e m e m b e r ? [Pause.] Y o u were
c a u g h t u n d e r the rubble, trapped, all hope w a s gone, a n d
y o u told me you felt that you h a d destroyed y o u r p s y c h o ­
therapy a n d a n y c h a n c e of m y being able to help y o u .
Nicola: It's true.
M J : It's true that w a s the way y o u felt, y e s . Y o u felt a s y o u
s e e m to be feeling now. Hope is gone. W h a t y o u s e e m to be
s a y i n g to yourself is that I can't possibly help y o u .
Nicola nods.
M J : T h a t m u s t also m e a n that y o u feel that the p s y c h o ­
therapy is finished. {Pause.] I think that y o u are listening
to a side of y o u r s e l f that is telling you that everything is
finished. I also t h i n k that y o u are p e r h a p s listening to voices
that are telling you that you s h o u l d kill yourself b e c a u s e
you're so b a d .
Nicola nods.
MJ: T h a t is h a p p e n i n g at the moment?
Nicola: Yes.

M J : Do you remember in your dream that you were com­

plaining that you couldn't have a bath because it was full of
demolished rubble?
Nicola [nods]: Yes.
M J : You were complaining to your mother that there was no
room for you i n the bath because it was full of rubble. I
think you are feeling as you felt i n the dream. There is
nowhere safe for you. Everything's demolished a n d turned
to rubble. No hope. You c a n cry out a s m u c h a s you like, but
you feel nobody will hear you. B u t what you don't seem to be
noticing is that I a m hearing you and that the psychotherapy
is not over, however wicked you may feel yourself to be.
Nicola: Nobody c a n help me.
M J : Nobody c a n help you. What would you call the activity of
the staff who are b u s y keeping you alive? Is that help? They
are quite determined to do all they c a n not to allow a patient
to be killed. They are determined you s h o u l d stay alive a n d
for the psychotherapy between you a n d me to go on. Nothing
gets put right if something i n you says you're so wicked that
the only thing you m u s t do is die. Dying doesn't make the
trouble better. Not only is it not dealt with, you m a y even be
afraid that you'll go to hell a n d your trouble will go on . . .
Nicola: Hell can't be worse than this.
M J : Hell can't be worse than this. Yes. You know, you have
told me that there have been times when only the thought of
eternal torment in hell stopped you from killing yourself, I
c a n believe that nothing feels worse than being in a situation
where you're constantly being told that all hope is gone.
T h a t is absolute despair. Would that be the right word?
Nicola: Yes.
M J : Y e s . Nobody feels despair unless they've once h a d hope.
Where h a s your hope gone? Y o u can't answer that question
at the moment, I know. You have no hope. I'm the one who
h a s to have the hope. I believe it is a perfectly logical hope to
try to keep you alive. T h a t is our task. Your task is to try to
listen to me, instead of listening to the side of you that's
trying to demolish our work, turning anything hopeful into
rubble, even if necessary by telling you lies.

Nicola: I don't think it is lies.

M J : Y o u don't think it is lies. I u n d e r s t a n d that's the w a y y o u
experience it. W h a t y o u can't remember i s that i n the p a s t
you've been i n this state of m i n d , even worse, a n d you've
m a n a g e d to stay alive. You've p a s s e d through it, you've
recovered, b u t now you've gone b a c k into it again. T h a t is
how this h a p p e n s . Do you recognize it?
Nicola: I don't know that it's the same.
. . . Pause . . .
M J : W h e n you s a y to me, " I don't know that it's the s a m e " ,
you've taken a n important step. You've s h o w n something
called curiosity, a n d w h e n y o u show curiosity, there's a
c h a n c e that you c a n have hope. I think y o u r responsibility is
to try to c a r r y on with that thought, a n d tell me i n what way
it's not the same. Y o u have nearly died m a n y times. T h e
n u r s e s have managed to keep you alive until y o u r state of
m i n d h a s changed, but this time you think it's not quite the
Nicola: P e r h a p s there w a s some hope before.
M J : P e r h a p s there w a s some hope before. [Pause.] I wonder if
y o u c a n r e c a l l — I c a n r e c a l l — t h a t w h e n you started y o u r
psychotherapy with me, you were i n the s a m e state. Y o u h a d
no hope. T h e n you got some hope. You began to be inter­
ested i n how y o u r m i n d w o r k s . Now you feel hopeless again.
T h i s is how y o u r m i n d c a n change. Do y o u remember telling
me w h a t happened w h e n y o u d r a n k too m u c h a few weeks
ago, a n d something inside you told you you s h o u l d lie down
on the road i n front of a c a r , a n d how that's always there, i n
the b a c k g r o u n d ?
Nicola: Yes [nods].
M J : It m a k e s you feel hopeless. Now, if that is always there i n
the b a c k g r o u n d , how c a n we deal with it u n l e s s it comes
into the open? It's inevitable that it s h o u l d m a k e y o u feel
hopeless w h e n it comes out, b e c a u s e it's very upsetting.
[Pause.] If y o u remember, something very upsetting h a p ­
pened to y o u . It h a d to do with Mary setting herself on fire,
do y o u remember? Y o u were very upset. Y o u became m a n i c
a n d spoke with contempt about a n y efforts to u n d e r s t a n d

your feelings. I think you were frightened that you would

have to do to yourself what Mary did. It w a s a catastrophe,
a n d you felt that you might have to be the same a s her. It's
difficult to admit now how frightened a n d upset you were.
Nicola: I thought I h a d no feelings about it.
M J : T h a t would make sense, you know. I think you were so
upset a n d frightened that you h a d to get rid of those feelings
from y o u r m i n d . You became m a n i c . You laughed a n d j o k e d
about it a l l . When you get rid of feelings from your m i n d ,
there's no room in your mind for anything h u m a n , only for
accusations that you're terrible. A n upset person doesn't
hear voices telling her how wicked she i s . A n upset person
is alive a n d feels very upset that something awful h a s
happened: feels something painful that might be called
Nicola: S h e w a s very nice.
M J : S h e w a s very nice. You liked her. B u t you tried to destroy
your feelings of upset, a n d now your voices say that you
have to die. Mary is, in fact, going to live, a n d I'm hoping
that we c a n bring her back to the ward before too long.
[Pause.] It is very important that you live, a n d not follow the
s a m e path as somebody who h a s to do something so terrible
to themselves. T h e n u r s e s have to keep you alive. I have to
see you. Y o u r responsibility is to admit to yourself how
upset you c a n feel. We c a n see now why you have been ill for
so long. Whenever you have certain feelings, you try to get
rid of them, explode them, tear them up, a n d say you're too
weak to feel upset. You m u s t die instead. Your dreams tell
u s how this side of you prevents you from m a k i n g connec­
tions with feelings that are upsetting, but h u m a n . It tells
you that you are bad a n d that you s h o u l d die rather than
face feelings of loss a n d s a d n e s s . It's by turning away from
your feelings that you feel abandoned a n d in despair a n d
you lose hope.

, . . Pause . . .

Nicola seems to be more engaged. Her eyelids move rapidly and

her breathing rate increases. She appears to be concentrating.

MJ: C a n y o u remember the d r e a m you h a d l a s t night?

Nicola: I'm at home.
MJ: You're at home.
Nicola: A n d on the radio there's a bomb alert.
MJ: O n the radio there's a bomb alert.
Nicola: So I went to shelter in the cellar. T h e n I remember the
MJ: Y o u went to shelter i n the cellar with the cats.
Nicola: No, I forgot about the c a t s .
MJ: Y o u forgot about the cats.
Nicola: So I went u p into the garden to call them i n , b u t while
I'm doing that, the bomb goes off, a n d the h o u s e is r e d u c e d
to rubble. T h e street, everything is rubble.
MJ: H o u s e r e d u c e d to rubble, street r e d u c e d to rubble.
Nicola: My s k i n is b u r n t .
MJ: Your skin's burnt.
Nicola: A n d peeling off.
MJ: A n d peeling.
Nicola: So I think I m u s t go a n d find A d r i a n [her h u s b a n d ] .
MJ: Y o u look for A d r i a n .
Nicola: So I walk into the city. Everywhere is a s h a n d rubble.
MJ: T h e city's been r e d u c e d to a s h a n d rubble.
Nicola: A n d I find the street where Adrian's office i s , b u t the
b u i l d i n g is j u s t rubble.
M J : Y o u find the street where Adrian's office i s , a n d the
building he's i n is j u s t reduced to rubble.
Nicola: So I try to dig, dig in the rubble to find h i m , b u t I ' m
b u r n t a n d its too painful. I can't do it. [Pause.] T h a t ' s it.
M J : You're alive, you're trying to find h i m , but it's too painful.
Too painful to try to see if you c a n r e s c u e y o u r h u s b a n d
who's b u r i e d i n the rubble.
Nicola: Yes.

M J : Y o u h a d a thought about it? You were going to s a y some­

thing. [Pause: Nicola does not reply.] Isn't your dream about
what I have been saying? Always you're threatened by some­
thing trying to explode a n d prevent you feeling your feelings.
Nicola: Yes.
M J : You love your cats, a n d you're trying to preserve some­
one you love from exploding, destructive processes.
Somewhere, submerged in the rubble, you are struggling to
see if there is life left in your h u s b a n d , your partner. I would
also say, in the partnership of the psychotherapy. You are
doing something to help that aspect of yourself that might
be alive, but it's very painful. Some feelings are too painful
to bear, but in the dream you are prepared to try, even
though you have to give up in the end. You go on digging,
painful a s it is. You have to, I know. T h e consequence of not
digging, of getting rid of feelings that are too upsetting, like
about Mary, your cats, your h u s b a n d , or of getting rid of
feelings that you think are destructive, is that the voices
then tell you to kill yourself.

* * *

The purpose of the following brief excerpts is to demonstrate the

dramatic switch from depression to mania and back again. In
thejirst excerpt Nicola is slumped in her chair, withdrawn into
deep depression. She had apparently drawn her husband into
a collusion to blame the nursing staff for having failed to pre­
vent her from cutting herself. High-level complaints against the
staff followed, which put me in the position of having to defend
the nurses against criticism by the hospital managers. I was
irritated with her, and although I attempted to conceal it, I did
not succeed.

Second session

Nicola: Y o u sound angry.

MJ: Me . . . ?
Nicola: Y o u sound angry.

M J : I s o u n d angry. [Pause.] I think you're listening to me

now, if y o u think I s o u n d angry. You're also opening y o u r
eyes a little more. Now, if you think I s o u n d angry, w h y t h e n
do y o u think I s h o u l d be angry?

* * *

This was the first verbal acknowledgement she had made to me

in a week, and it came as a considerable surprise. When I
recovered my composure, I acknowledged my anger and the
reason for it. She spoke briefly about regretting the self cutting,
and shortly afterwards the session came to an end.

Immediately after the interview she cried, admitting to herself

and her primary nurse how upset she was. Within 90 minutes
she had become acutely manic. She came to the interview on the
following day in an over-active state, wearing a purple T-shirt
and fluorescent yellow trousers. She was manic and aggres­
sive, talking excitedly and contemptuously.

Third session
The following day. Nicola, MJ, and the ward psychiatrist are

Nicola [to psychiatrist]: W h a t are you doing h e r e ?

Psychiatrist: I s h a l l be sitting i n for a while.
Nicola: W h y ? I w a n t to know why.
MJ: Do y o u think you could talk to m e ?
Nicola: I don't know. I'm very angry with y o u .
MJ: C a n y o u tell me . . .
Nicola [interrupts]: Because you're keeping me in here
against my will.
MJ: Y o u feel there's no need to be here.
Nicola: No, there's no need to be i n here.

* * *


Fourth session
Two days later. Nicola strides into the room, grinning.
Nicola: You don't m i n d if I smoke, I hope? Is there a n a s h t r a y
around? No a s h t r a y ? O h dear. 111 have to throw it on the
floor. [Sits down.] What are you grinning about?
MJ: Well, your grinning is very sad, actually.
Nicola: My grinning isn't sad. I'm quite happy.
M J : I think you Ye trying to make yourself feel happy so you
won't feel s a d , really.
Nicola (shouts and points]: Why didn't you come a n d see me
at 1:15? And why couldn't I go over to the Institute?
MJ: Good question. Have you got any ideas?
Nicola: B e c a u s e I've r u n away, of course.
M J : We didn't have enough n u r s e s to make sure that you
wouldn't r u n away. So I've had to come to see you here [on a
locked ward].
Nicola: Well, that's a shame. I'm sure you didn't enjoy the
M J : I think it would be easier for you to think that I didn't
want to come a n d see you than to think that I actually did
want to come to see you.
Nicola gets up and walks round the room.
M J : I understood that you wanted to speak to me on the
Nicola [shouts]: Yes I did.
MJ: Could you try sitting down for a minute?
Nicola sits.
MJ: Do you remember . . .
Nicola: I don't know what I wanted to say now. I've forgotten.
M J : Your mood h a s changed. You weren't quite so excited
then a s you are . . .
Nicola [shouts]: I'm NOT excited. T h i s is a myth. [Gets up,
walks around.] I m u s t have a n ashtray. C a n you get me a n
a s h t r a y ? [Walks around looking for an ashtray.]

M J : I think it might be preferable to drop it on the floor t h a n

to go wandering a r o u n d i n the valuable time we've got.
Nicola: O h y e s , I'm so sorry, of c o u r s e . {Pause.] I don't like
doing it. It's m e s s y , [Pause.] Y o u don't s e e m convinced.
M J : I think it's one thing to m a k e a m e s s on the floor, b u t
another to m a k e a m e s s of y o u r m i n d .
Nicola: My m i n d ' s perfectly alright.
MJ: I don't know if you recall the l a s t time we met here.
Nicola gets up, walks around.

M J : Y o u s a i d the only trouble with you w a s that y o u r p s y c h o ­

therapist h a d the delusion that there w a s something wrong
with y o u .
Nicola [raucous laughter]: It's not only my psychotherapist.
It's the doctors a n d n u r s e s a s well! [Sits down.]
MJ: C a n you remember y o u r d r e a m s ?
Nicola: I didn't have a n y l a s t night. I didn't sleep the night
before. [Leans forward, shouts and points.] I didn't h a v e a n y
last night b e c a u s e they dosed me up with Haloperidol: c a n
y o u tell them to stop dosing me u p with Halperidol? T h e y
gave me 20 milligrams l a s t night. I don't like taking it.
MJ: Y o u remember the . . .
Nicola [interrupts]: Well, c a n y o u or can't y o u ?
M J : I think it would be easier for you to try to regard me a s
the one who prescribes the medicine r a t h e r t h a n the one
who tries to prescribe the sanity.

* * *

The fifth session is similar to the fourth Nicola walks round

the room, occasionally sitting. She laughs manically and is dis­
missive and contemptuous. The atmosphere also seems to be
sexualized, with Nicola approaching MJ, standing in front of him
in a provocative manner.

In the following, sixth session Nicola has come down from this
mood of pathological elation and is barely able to speak.

Sixth session
Three days later. Nicola sits crumpled and withdrawn.

M J : C a n you tell me how things have changed, since we last

. . . Pause . . .

Nicola [whispers]: I feel quite desperate.

M J : You feel quite desperate. Do you remember w h e n we met
last what your state was then?
. . . Pause. . .

Nicola: No.
M J : Do you try to remember, or is it that you try not to
. . . Pause . . .

Nicola: I try to remember . . . but I can't.

* * *

T h e s e excerpts began with a session in w h i c h the patient w a s

deeply depressed, listening to voices telling her s h e is wicked a n d
m u s t kill herself. T h i s w a s precipitated by the self-injury
of another patient to whom she h a d become attached. Her
extreme sensitivity to feelings of loss h a d already been observed
i n relation to departing n u r s e s who meant something to her. T h e
defensive-destructive organization i n her m i n d turned against
the healthy dependent part of her personality, promoting the idea
of suicide a n d serving to avoid attachments, w h i c h could lead to
the mental p a i n of envy, ofjealousy, a n d , above all, of separation
and loss. Her profound reaction to her friend's self-harm illus­
trates F r e u d ' s early contention that melancholia is a n abnormal
form of mourning. T h e patient spoke i n a low, almost inaudible
voice. My repetitions of her comments served to confirm that I h a d
h e a r d correctly, a n d also to provide a n intermission to think of
a n appropriate response. T h e reason for my repeated intervening
w a s that w h e n Nicola became so depressed, active contact
seemed the only way to r e a c h h e r — a s though h e r interest needed
to be stimulated and h e r normal self forcefully contacted, for

example through repetitive themes that emerged i n h e r d r e a m

life. M a k i n g contact d u r i n g the s e s s i o n s , i n the face of s u c h
depression a n d despair, required careful attention to the feelings
a r o u s e d i n myself. Anxiety, guilt, despair, irritation, a n d i n a d ­
equacy felt d u r i n g s e s s i o n s needed careful s c r u t i n y i n order to
differentiate between p e r s o n a l r e s p o n s e s to a difficult, frustrat­
ing situation, a n d countertransference c o m m u n i c a t i o n s that
c o u l d yield information about the patient's internal conflicts.
T h e concept of h e r m i n d being organized into different parts
m a d e h e r l e s s difficult to u n d e r s t a n d . At certain points, for
example, I felt s h e c o u l d become provocatively m a n i p u l a t i v e ,
yet I would p r e s s a h e a d i n order to support the s a n e p a r t of
herself—her fragile b u t functioning ego—against the p r o p a ­
g a n d a of h e r a r c h a i c superego. Nevertheless, it w a s often
difficult to k n o w w h a t w a s going on between u s . T h i s is inevit­
able, a n d it is important to be prepared to tolerate states of
ignorance a n d uncertainty, possibly for long periods, i n s u c h
work. W i t h this extremely ill w o m a n I h a d accepted from the
outset that w e were committed, for better or for worse, to a n
extremely difficult struggle w i t h her.pathology. T h i s commit­
m e n t proved to be of some value w h e n , later, a trial of strength
developed between h e r psychotic self a n d m e . T h e i n t r a - p s y ­
c h i c n a t u r e of this trial of strength involved h e r u s i n g me
for a time a s a container for h e r sanity, hope, a n d c a p a c i t y for
reflective thinking, w h i l s t s h e expressed a good deal of h e r
insanity. I explained w h a t w a s h a p p e n i n g to h e r i n order to
avoid a n idealization i n w h i c h I became the sole representative
of s a n i t y i n a world of m a d n e s s . T h i s w a s indeed the c a s e i n
one s e n s e , b u t if the prevailing situation were to have been
accepted concretely by the patient, it could have led to the
disowning of h e r destructive motivations, or to h e r s i m p l y
condemning h e r psychotic self a s evil. A deeper recognition b y
h e r of w h y psychotic defences arose i n the first place w a s
T h e manifest content of her d r e a m s w a s u s u a l l y a direct
expression of thoughts about devastating destruction, a n d the
endangered state of h e r loved objects. V a l u a b l e documents are
torn u p , s h e drops a precious vase that h a s been e n t r u s t e d to
h e r , railway stations a n d bridges are blown u p . I n the d r e a m
that I recalled i n the first s e s s i o n , the rubble-filled b a t h s y m ­

bolized the containing maternal space whose contents, the

siblings of her early life, h a d been destroyed, expressed i n the
transference a s my mind, creatively occupied i n providing her
with food for thought. T h e theme of attacking my work at those
times when it w a s good became increasingly familiar as the
therapy proceeded and evoked i n me a feeling of being secretly
derided, manipulated, a n d demolished. T h i s "negative thera­
peutic reaction" could be understood as a manic triumph over
the therapeutic work a n d its containing function, with w h i c h
her healthy self was struggling to cooperate. A formulation like
this helped to explain the dramatic switch from depression to
m a n i a within the course of a n hour and a half. W h e n she
succeeded in provoking me into losing my customary level of
reasonable c a l m , my " h u m a n " personal response had a dual
consequence. Her healthy self saw this as proof that I cared
personally about h e r , a n d she was briefly able to express deep

positive feeling associated with a memory of some past loss.

Within a n hour and a half her omnipotent self h a d l a u n c h e d
into a celebration of envious triumph and took over control of
her mind, until the manic mood h a d r u n its course one week
later. T h i s process was the basis for the dynamic switch from
deep depression to m a n i a . Switches on s u c h a scale are of
particular theoretical interest (Pao, 1968), and biochemical
studies have been inconclusive. L e s s dramatic changes, from
depression to hypomania, sometimes occurred during a pre­
m e n s t r u a l period but were more often precipitated by psycho­
dynamic factors and were often foreshadowed in dreams.
T h e subsequent two excerpts following the switch show her
in a typical manic state. S h e seems to be projecting her sane
self into me, a n d I try to restore her contact with the disaster
that is taking place beneath her manic belligerence. Her not
entirely convincing determination to show that it is her
therapist who is mad is also pointed out to her. T h e final
excerpt shows the collapse of the m a n i a three days later a n d
the r e t u r n of the depression.
There are very different dynamic states that earn the label
"depression". T h e depression in the first excerpt is a n e s s e n ­
tially paranoid state of inner persecution, characteristic of
psychotic depression. T h i s may be accompanied by "true"

depression, w h i c h i s the expression of despair a n d d i s ­

appointment, l i n k e d to feelings of deprivation, a b a n d o n ­
ment, a n d loss of self-esteem. T h e depression i n the final
excerpt appears to be of this more " t r u e " type t h a n that i n the
first excerpt, p e r h a p s the result of some s a n e recognition that
her belief i n h e r a b u n d a n t good health w h e n m a n i c w a s i n fact
serious pathology. Bion's (1957) concept of "psychotic part of
the personality" a n d Rosenfeld's (1971) definition of " d e s t r u c ­
tive n a r c i s s i s m " were, for me, the key concepts to allow
u n d e r s t a n d i n g of h e r desperate r e s i s t a n c e to help a n d growth.
A m a n i c u n d e r c u r r e n t discernible in some of Nicola's depres­
sive p h a s e s confirmed for me the subtle domination of h e r
personality by the psychotic part of her self, w h i c h exerted its
imprisoning effect through secret, t r i u m p h a n t contempt a n d
denigration of the sincerity of the therapeutic work a n d h e r
participation in it.


Despite the transitory n a t u r e of the breakthrough illustrated i n

the s e s s i o n s , a continuing improvement took place i n Nicola,
a n d h e r work i n the therapy became more productive a n d
reliable. Her mood swings began to flatten out, a n d s h e c a m e to
recognize a n d tolerate feelings of extreme emotional p a i n . A s
s h e became more aware of, a n d owned, h e r h a t r e d , envy, a n d
contempt, the persecuting voices receded, appearing only at
moments of extreme s t r e s s . After two y e a r s of twice-weekly
psychotherapy, conducted within the therapeutic a n d c o n t a i n ­
ing environment of the w a r d , s h e w a s discharged on a low dose
of medication. T h e genetic contribution to her mood instability
suggested that maintenance on l i t h i u m medication would be
advisable for a long time—perhaps indefinitely. B y the time of
h e r discharge, s h e h a d experienced a normal m e n t a l state for
several months, b u t there w a s no r e a s o n to think that this
improvement would r e m a i n stable u n d e r all c i r c u m s t a n c e s .
S h e w a s eager to continue to work at h e r problems in further
psychotherapy, a n d it proved possible to arrange for h e r to
continue i n long-term psychoanalytic treatment. S h e m a d e

further progress, punctuated by a few relapses, one of w h i c h

involved a brief period of hospitalization at her own request.
Her marriage improved, s h e negotiated a miscarriage without
severe consequences, and she then h a d a successful preg­
n a n c y . Five years after leaving hospital, s h e h a s returned to
work—albeit work of a non-medical n a t u r e — a n d is s u c c e s s ­
fully r a i s i n g her child. Her increased integration a n d insight
are likely to mean that if a relapse occurs in the future, it will
be more manageable. There also seems little doubt that psy­
chotherapy h a s prevented a successful suicide.
Her long-term psychotherapy w a s by no means trouble-free.
S h e w a s capable of evoking great anxiety by powerful acting
out, a n d on several occasions needed to be admitted briefly to
hospital w h e n her hallucinations threatened h e r safety. In the
first phase of her treatment, threats of suicide were common­
place, but it seemed that the survival of her therapy (past a n d
present) meant more to her than, dying, a n d she admitted how
important her experience on the unit h a d been to her. Under­
standing her psychotic states could be facilitated by thinking of
them a s analogous to dreams. In them, there often occurred a
woman persecuted by her mother for a mortal s i n s h e h a d
committed—the killing of babies in the wombs of their mothers.
As a result she should take her own life. T h i s a r c h a i c superego
w a s of unprecedented ferocity. T h e entire m u r d e r o u s / m u r ­
dered d r a m a was experienced repeatedly in the transference to
her therapist. I n reality, m a n y children on her mother's side of
the family, going back two generations, h a d died prematurely,
a n d this tragic background h a d affected the whole family. Work
on her superego w a s unceasing a n d productive, not least be­
c a u s e she eventually experienced her therapist as a separate
object able also to survive her murderous attacks. When, after
five years, she became pregnant, she felt a frightening impulse
to stab a knife into her stomach a s the voices were telling her
she was not fit to have a baby. B y this time she h a d some
understanding of separate, enduring objects, of dependency,
a n d therefore of a need to keep the baby alive. With the help of
good maternity staff she h a d a normal delivery of her baby.
After the birth, murderous impulses towards the baby required
continuous interpretation a n d succeeded in extricating her
from her identification with the cruel, murdering mother. S h e

began to appreciate the child's love for h e r a n d even to take

p l e a s u r e occasionally i n her relationship to h e r therapist.
Hospital a d m i s s i o n s ceased. Mother a n d child are doing well,
a n d h e r h u s b a n d h a s played a supportive role throughout. H e r
therapy continues, towards termination.