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ON DELUSIONAL TRANSFERENCE (TRANSFERENCE

PSYCHOSIS) 1
By
MARGARET LITTLE, LONDON

I be folies-a-deux in which each partner claims

In practice one finds certain patients who
cannot use transference interpretations; the
difference between these and other patients is
qualitative, not quantitative. They do not form
a defined group, but include people suffering
from character disorders, sexual perversions,
some psycho-somatic conditions, psychopaths,
etc., i.e. sane people with a great deal of both
persecutory and depressive anxiety.
When a transference interpretation is given
to such a patient, either: (i) it is experienced by
the patient as meaningless, and no use can be
made of it; or (ii) it is accepted by the patient,
with apparent understanding, but the analyst
realizes later that it has had no effect; no change
happens, and no insight has been gained.
In the analysis of these patients several other
characteristics are found.
(a) Ordinary analysis of their dreams does not
work. They bring dreams of two kinds; of one
the manifest content leads to innumerable
associations, but no meaningful latent content
can be found; nothing else exists in the dream
but the defensive mechanisms. In the other
type of dream the manifest and the latent
content are one, and the manifest content is the
dream thought.
(b) There are defects of thinking. The capacity
to symbolize is deficient, there is 'symbolic equa-
tion' (' primary process symbolization '), and con-
crete thinking, and the capacity to make accurate
deductions or inferences is largely lacking.
(c) Acting-out is violent, or the violenceappears
negatively as passivity. These patients call a
good deal of attention to themselves, involve
other people in their affairs, and interfere in the
.affairs of others.
(d) They tend to be very dependent, and find
someone else to carry out as many of their ego-
functions as possible. There is neither real
separateness, nor real fusion, no mutuality;
• tit-for-tat', 'you scratch my back and I'll
scratch yours'. Their relationships turn out to
1 Paper read at the 20th Congress of the International Psycho-Analytical Association, Paris, July-August, 1957.
134
preference and precedence; both are violent, or
one dominates and the other is passive, some-
times alternating.
The analytical relationship is only understood
on this kind of basis, and attempts are made to
establish a folie-a-deux with the analyst. Un-
equal relationship or give-and-take on some-
one else's terms, seems to be something
which has never happened before; the idea is
met with blank incomprehension, going on to
fury when the patient has to give way; if the
analyst gives way it may not be perceived at all,
but if it is perceived it produces great satis-
faction, and guilt.
(e) These patients seem to develop a sort of
addiction to analysis. They have an insatiable
need for love and attention by means of which
they seek magically to control their limitless
hate and destructiveness.
This 'addiction to analysis' leads to a
ruthless, repetitive searching for something, at
any cost to either patient or analyst; but this
very quality sometimes makes an unpromising-
looking analysis successful in the long run, if
only that ' something' can be recognized and
got, at least in token measure. The gap between
the need and what is got has to be fully
acknowledged by the analyst.
(f) These conditions seem to have arisen
out of a situation where the mother herself was
infantile, and as incapable of bearing either
separateness or fusion as her baby, a mother
whose anxiety and inadequacy acted as real
persecutions to the child. The depressive
position could not be reached, as in these
circumstances the ordinary mechanisms of
projection and introjection become ineffective.
(This is an oversimplification, of course, but I
cannot enlarge upon it here.)
II
In these patients the character of the trans-
ference is essentially delusional.
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ON DELUSIONAL TRANSFERENCE (TRANSFERENCE PSYCHOSIS) 135
As in neurotics, the transference is ambivalent,
and is therefore twofold, though it often appears
only in its positive aspect, as what has been called
, erotized transference " the purpose of which is
to keep only the idealization and to deny that
the opposite exists.
But a neurotic can recognize the analyst as a
real person, who for the time being symbolizes,
or 'stands-in' for his parents, either as they
actually were, or as he experienced them in his
childhood, and he is accessible to verbal inter-
pretation of the transference.
Where the transference is delusional there is
no such ' stand-in' or ' as-if' quality about it.
To such a patient the analyst is, in an absolute
way, with a quality of' authenticity', both the
idealized parents and their opposites, or rather,
the parents deified and diabolized, and also
himself (the patient) deified and diabolized, for
the analyst is assumed absolutely to be magical.
To resolve the transference the patient has to
be enabled to bring together his love and his
hate on to one person, to find both good and
bad aspects of his analyst, his parents, and him-
self as human beings, and to know the difference
between imaginative and objective reality.
The main mechanisms used in the production
and maintenance of a delusional transference
are splitting, denial, isolation, projection, and
repetition.
But it seems to be chiefly a failure of integra-
tion between psyche and soma (with consequent
failure of integration between weakly organized
ego and id) that makes the ego inaccessible to
transference interpretations, so that they cannot
result in altered behaviour or bodily activity,
or lead over from inner to outer reality. Their
false acceptance or rejection depends on the
insistence on identity between analyst and
parent-imago: 'Of course, how could it be
otherwise?'; or' Fancy thinking that!'
This failure of integration depends upon
very early body experience, when awareness is
essentially body-awareness, at a pre-ambivalent,
pre-verbal, pre-object-relation stage. Tension
is experienced as something intolerable, threaten-
ing life itself. Discharge is experienced accord-
ing to the setting in which it happens and its
effect on the environment. Response by the
environment may be felt to be good or bad;
absence of response of a positive or active kind
may be felt to be either, according to the patient's
need and his previous experience of response.
The transference delusion hides a state in the
patient which he both needs and fears to reach.
In it subject and object, all feeling, thought, and
movement are experienced as the same thing.
That is to say there is only a state of being or of
experiencing, and no sense of there being a
person; e.g. there is only an anger, fear, love,
movement, etc., but no person feeling anger,
fear or love, or moving. And since all these
things are one and the same, there is no separate-
ness or distinction between them. It is a state
of undifferentiatedness, both as regards psyche
and soma, experienced as chaos.
To reach this state is a terrifying thing, as it
means losing all sense of being a person, and
all sense of identity. The patient who reaches
it becomes for the moment only a pain, rage,
mess, scream, etc., and is wholly dependent on
the analyst for there being anywhere a person
who feels or acts. There is in fact, identification
with the analyst of primary kind, but the patient
cannot be aware of it.
This state has to be reached so that the un-
reality of these identities can be recognized, but
the reaching of it is felt as utter annihilation-
hence the need to maintain the delusion in the
transference. At the same time, the inner
reality of these identities has to be preserved.
In a neurotic, where the relation between inner
and outer reality is established, the inner reality
of these identities is already axiomatic, and
survival can be taken for granted, but in a
deluded person any fresh recognition of reality
is felt as a threatened destruction of everything,
and both inner and outer reality seem shaken to
their foundations when the delusion is disturbed.
The quality of the disturbance is cataclysmic,
and can be compared with orgasm; it might be
described as an ' orgasm of pain', with tension
rising to a climax, discharged in an impulsive
movement, and followed by relief. It is not an
agonal state, as there is no person suffering it,
no functioning ego. In effect it is a state of
frenzy, and the discharge, an acces de rage, may
take the form either of an attack upon the self,
self-injury or suicidal attempt, or of a maniacal
attack upon the analyst. It is a moment of very
real danger. When the movement is outward,
towards the analyst, contact is made with a
person who is separate from the feelings and
movements, and uninvolved in them; he
experiences them, but his experience is different
from the patient's, and this brings a new
situation. The delusion cannot be maintained
and is no longer needed.
With the movement has come differentiation.
The giving up of the delusion starts from the
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136 MARGARET LITTLE

discovery of a body moving in response to an Verbalization has to go back not only to
urge and finding contact. This is the beginning nursery and onomatopoeic words, but to very
of recovery, for the primary identification breaksprimitive sounds and mouth movements, from
up, secondary identification becomes possible, where other movements and body happenings
and through that again can come the ability to can be reached, so as to make the contact
take the consequences of a happening. between inner and outer reality, and to help the
change over from concrete and magical thinking
III to the acceptance of substitutes and symboliza-
It follows that the analysis depends upon tion.
breaking up the delusional transference. To do Since transference interpretation is found to
this reality must be presented undeniably and be ineffective, other ways of bringing the patient
inescapably, so that contact with it cannot be into touch with reality have to be found and used
refused, and in such ways that the patient does -ways that are out of place in the analysis of
not have to use either inference or deductive neurotics. In order to reach both pre-verbal
thinking. It might be compared with the and body levels and to enable the patient to
waking from a dream of a tiny child, but some- reach the state he dreads the analyst's ego-
one must be there to help the waking. function has to be maximal, and his object-
Regression to a very early dependent level is function minimal. He has ultimately only
unavoidable, and there are many patients who himself to use, since the help from the outer
cannot manage without some regressive illness. world is small, and has to be related to him;
In my experience this is usually so where an psychically it has to come from him.
existing folie-a-deux has to be destroyed for the The analyst's own instinctual impulses have
analysis to be carried out. Dependence is both to be used as fully and directly as possible. Very
demanded and rejected, and it is not always primitive emotions are suddenly aroused in him,
easy to get a patient to accept the care that is often leaving him no time for conscious thought
needed for safety. before he has to speak or act. Provided his own
Body memories of very early infantile ex- analysis has gone far enough for sublimations to
periences of primitive' orgiastic' quality, both be established; provided he is mature, knows
good and bad, have to be found; i.e. both of his limitations, and is not depending on, or
real satisfaction, and of real frenzy. These have exploiting his patient, the dangers which are
to be linked with experiences in the analytic admittedly there are fair risks, especially
situation, also of a body kind, otherwise both considering the seriousness of the illness.
the separation between psyche and soma, and He may sometimes have to use body activity
the limitless destructiveness and greed for love and movement, e.g. to hold a destructive patient
persist unchanged. The early experiences have in a frenzy; he may have to allow his feelings
to be reconstructed as convincingly as possible to be plainly seen, as the only meaningful way
and linked with the analytic experiences through of conveying the truth about a situation to a
whatever cover-memories can be found to serve patient to whom words cannot convey it, and
this purpose; any element of conjecture must who cannot make deductions from the less
be admitted. personal, less direct ' signs' to be found in the
The analytic set-up provides something to- analytic room and ordinary analytic technique.
wards these body experiences, though its There are times when nothing can reach a patient
importance in this respect is often overlooked; but a direct expression of what the analyst is
e.g. the couch, warmth, shaded light, quiet, etc. feeling at that instant, and times when such
Where there is regressive illness or a lasting expression has immediate and profound effect-
psychotic episode more may be needed; hospital just because it is meaningful.
or nursing care in intercurrent illness can give It is through these things-feeling and move-
a good deal in this way. These things need to ment-that the patient finds himself as a separate
be firmly linked with the transference, appearing person, with likenesses to and differences from
as and being used as extensions of the analyst other people, as his analyst is like others and
himself, on the delusional level, he taking full yet different from them. But the recognition
responsibility for them in the realm of psychic that it is true when the analyst says that feeling
reality, whatever may be the actual reality, and and its expression are right comes most clearly
however much the patient may be aware of it in when the patient finds it happening, experiences
another area of himself. his feelings and his analyst's separately, finds.
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ON DELUSIONAL TRANSFERENCE (TRANSFERENCE PSYCHOSIS) 137
who is feeling what, and that the relationship
is not destroyed as he had expected.
I have only touched on the question of tech-
nique in analysing a delusional transference.
Ordinary interpretative technique forms the
main part of the analysis; it cannot be super-
seded or replaced, but it can be supplemented
in the ways I have indicated, to make the ego
accessible to interpretation. The technique needs
to be flexible, with free use of imagination (and
flexibility does not mean sloppiness, any more
than rigidity means strength). The funda-
mentals of analysis must be observed, and the
analyst's own analysis must be continued,
actively, throughout.
POSTSCRIPT
A number of speakers at the recent Congress
(in particular those taking part in the discussion
on neurotic ego distortions) described patients
for whom it was impossible to make analysis
mean anything, patients whose ability to use it
appeared to be blocked in some way, for whom
some new method of approach seemed to be
needed.
I have tried to put forward something of a
new approach, and I want to link it with the
work of other analysts besides these. There are,
of course, many who have touched on these
problems either directly or indirectly. I will
only mention very shortly here two people,
Ernest Jones and Freud.
In the last number of the International Journal
of Psycho-Analysis, in a short communication
entitled 'Pain', Ernest Jones describes how
, when the white-heat peaks of intense pain are
reached localization disappears, and the entire
self is filled with nothing but pain', and he goes
on to describe the ego's reaction to it. This is
the state of a person suffering pain, but at this
point it borders on the state which I have
described above, where unbearable stimuli
break through the defensive barrier (Reizschutz)
at a very early level of ego development, and
the sense of being a person is lost. He speaks
elsewhere of 'aphanisis', giving the term
different meanings for the individual at different
stages of his ego development. He does not
refer to it in this communication.
But the state which I have described, in which
there is loss of all sense of being a person, is a
state in which the ego's defensive functioning is
temporarily suspended deliberately, through the
analytic process, and id drives are released.
In the New Introductory Lectures Freud
described the id as ' all that the ego is not ... a
chaos, a cauldron of seething excitement'.
'Instinctual cathexes seeking discharge', he
said, 'is all that the id contains.'
But Freud has also described the breaking up
of a delusion, and he has done so in much the
same way as I have. I have not consciously
followed him here; I read Delusion and Dream
during my training as an analyst. I have only
reread it in the last few weeks, and found that I
had forgotten it almost entirely. In Wilhelm
Jensen's novel Gradiva is told the story of a
young man's temporary delusion and its cure.
His sufferings when the delusion is disturbed
differ from those of a patient whose delusional
transference begins to break up only by being
less in degree. It is clear that he is in danger at
this time; he perceives a threat (real or
imagined) to the young girl whom he is both
seeking and avoiding, and in averting the danger,
by impulsively' swatting' the insect that might
sting her, he touches her arm with his hand, and
in doing so finds her reality. The final break-up
of the delusion, and his recovery, come about
as the result of this body movement and contact.
Freud traces in detail the processes involved,
in the light of psycho-analysis. His account is
penetrating, self-consistent, and convincing,
but he does not suggest the possibility of
resolving a fixed delusional state in this way. I
was astonished to find that the analysis of my
patients whose transference is delusional follows
this exact pattern, but of course, since the
delusion in these cases is neither temporary nor
recently developed (nor are the patients charac-
ters in a novel), recovery does not come about
through a single episode of this kind. It has to
happen repeatedly, and with each repetition it
becomes more meaningful and more effective.
This word 'meaningful' was often used by
speakers at the Congress, and I think that its
meaning for us in this context is really , ego-
enlarging'. It seems that in these delusional
cases the ego-enlargement can only come about
to all intents and purposes traumatically, which
partly accounts for the difficulties encountered.
I want to go on to something more about the
state of undifferentiatedness which the delusion
hides. It is a very complex subject, and calls for
a separate paper which I hope to be able to
write. It is not a new or original theme; only
my approach to it may be new.
The terms 'primary identification' and
, primary narcissism' to my mind do not fit it,
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138 MARGARET LITTLE

nor does 'paranoid-schizoid position'. I the basic unity, being at once indistinguishable,
would rather describe it as a state of primordial psychically, from the patient, and still preserving
undifferentiatedness, or of basic unity, in which his entity. He must find what he feels right for
a primitive identification might be said to be himself (i.e. what he wants to do or say), and
included. What I want to convey is that the assume that it is equally right for the patient.
undifferentiatedness is absolute, in both degree It is a point at which he must be able to commit
and extent. Nothing exists apart from anything himself, even sometimes risking making a
else, and the process of differentiation has to mistake, but remembering that the biggest
start from scratch. mistake of all at this point may be not doing
From this unity a body happening (such as just this. He has to be very plain and definite
movement, salivation, etc.), crystallizes out, and in saying certain things, but leave the patient
emotion follows it, according to the response of free to take or leave them. Refusal on the
the environment. These happenings are largely patient's part often only means delay until once
painful ones. The discovery of pain helps to more the basic state can be reached, when he
differentiate between self and not-self. Dis- feels ' If you think that, then I do.'
covery of positive pleasure seems to help only It is sometimes difficult to avoid the appear-
secondarily, by making the discovery of pain ance of' cashing-in' on the patient's compliance
tolerable at all; primarily it tends to increase the and dependence, but waiting usually brings
cohesion between the undifferentiated particles, acceptance (though this acceptance, of course,
and so to make for stability. But the discovery does not of itself guarantee the analyst's right-
of pain is already a differentiation in itself, and ness).
the process, once started, tends to continue, This state of basic unity is the unconscious
progressively and cumulatively, and can do so basis of the whole of the transference pheno-
as long as there is sufficient stability inside and mena; it can account, too, for such things as
outside the analyst-patient unit. suggestibility under hypnosis, and the mysterious
The analyst's task, then, is to enable the patient , confessions' we often hear about. Where
to suspend the defensive functioning of his own pleasure, promoting love, has contributed enough
ego, to let the analyst function for him, and let to its strengthening it is there, axiomatic, and
happen what happens, the analyst being in charge taken for granted; and it becomes the basis of
and looking after things, otherwise chaos marriage, mothering, and such sublimations as
develops. This process can come about through child-care and psycho-analysis itself.
this same basic unity, for the patient feels' What Where it has been too early or too extensively
you want is what I want, since you are me and disturbed by pain, of whatever kind, in infancy,
I am you.' We have here, too, I think, the with the balance of ambivalence tipped in the
explanation of the compliance which we so often direction of hate, and chaos develops, it can be
find in our patients, and its negative, defiance. seen for instance as the basis of the less attrac-
The further task, after the delusional trans- tive features of ideologies, and of class and
ference has begun to be resolved, is that of racial strifes. Where it has to be asserted (in
enabling the patient to take over his own ego order to deny its absence or insufficiency), we
function of suspending his defences, recognizing find bonhomie and brotherhoods.
for himself when he is deluded, and dealing with
what lies behind the delusion in his own indi- In this paper I have talked about 'what',
vidual version of the way in which his analyst and 'why', rather than about 'how'. The
has done so for him, before. , how' is not easily described in ways that convey
Being able to do this involves perception of meaning. Once one begins to describe ways of
the analyst and his ways of doing things, going doing things that are unfamiliar to one's hearers
on to internalization of him on the primitive anxiety is inevitably aroused, with consequent
pattern of eating (which is a body experience, misunderstanding and distortions. We have to
not magical introjection), digesting, absorbing, rely largely on empathy, which is relying on
building up into the self, so that the analyst is this basic state, but enlarged by experience.
no longer there recognizable, in his original, Each of us has to find his own ' how', by trial
unchanged form. All of this depends on separa- and error, letting happen what happens in him-
tion from the analyst, i.e. differentiation out of self, and finding out for himself the realities of
the basic unity. analysis.
For this purpose the analyst must accept fully
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