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Int J Psychoanal (2009) 90:6992 69

On understanding projective identification in the


treatment of psychotic states of mind: The publishing
cohort of H. Rosenfeld, H. Segal and W. Bion
(19461957)

Joseph Aguayo
11849 West Olympic Blvd., Suite 202, Los Angeles, California 90064, USA
joseph.aguayo@gmail.com

(Final version accepted 6 November 2008)

A publishing cohort of Kleinian analysts Rosenfeld, Segal and Bion implemented


Kleins (1946) notions of projective identification and the paranoid and schizoid
positions in the understanding of a group of psychotic disorders. The author differen-
tiates Kleins (1946) Notes on some schizoid mechanisms paper from its revised
version of 1952, maintaining that it was Rosenfelds clinical work during this period
that helped to centralize Kleins redefinition of projective identification. The stage
was set for Segal s contribution in terms of symbolic equations, where the
psychotics attack on the breast left him incarcerated in internal torment and
persecution, where things-in-themselves were confused with what they symbolically
represented. Segal in turn linked psychotic to normal, paranoidschizoid to depres-
sive positions, where by means of projective identification and symbolic imagination,
the patient could arouse feelings in the analyst related to sadness, guilt and loss. Bion
assumed that psychotic pathology reflected disordered thinking, when the severely
disturbed used language as a mode of action. The psychotic was profoundly confused
between the use of thought and action in the natural world where thought was
required, he preferred action and vice versa. Bion also drew upon projective identifi-
cation in a new, broader way, so that analysis could now become more of an inter-
subjective, bi-directional field of projective and communicational influence between
patient and analyst. The paper concludes with the impact of the work of Rosenfeld,
Segal and Bion and variations on the technique of analyzing psychotic states in terms
of the patients early history, transference and countertransference.

Keywords: countertransference, history of psychoanalysis, psychoanalytic technique,


psychosis, reconstruction, research

The post-war Kleinian view of psychotic states of mind


Any contribution that elucidates the early efforts made by Herbert Rosen-
feld, Hanna Segal and Wilfred Bion in the understanding and psychoana-
lytic treatment of psychotic states of mind must begin with Melanie Kleins
(1946) paper, Notes on some schizoid mechanisms. In this centrally defining
paper, Klein postulated that a group of psychotic disorders could be under-
stood through the structural psychic processes of the paranoid and
schizoid positions. In this paper, I discuss how these three analysts both
responded to Kleins hypotheses, but also influenced her to reconsider some
of her earlier formulations, especially in the area of projective identification
and psychoanalytic technique. This trio of analysts formed what I term a
publishing cohort that essentially worked on the same problem in order to

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70 J. Aguayo

make a more substantive contribution. By investigating Kleins leads, they


also addressed Freuds therapeutic pessimism regarding the psychoses (or
what he termed the narcissistic neuroses).1 In effect, they contributed in
extending psychoanalytic technique to include the treatment of the psychoti-
cally-disturbed patient.
My analysis of this issue is both historical and textual, focusing on both
the understanding and treatment of psychotic disorders, based primarily on
15 papers written by the trio after the end of the internal, theoretical war
known as the Controversial Discussions (King and Steiner, 1991) at the Brit-
ish Psycho-Analytical Society (Bion, 1954, 1955a, 1955b, 1956, 1957; Rosen-
feld, 1947, 1949, 1950, 1952a, 1952b, 1954; Segal, 1950, 1954, 1956, 1957). In
the post-war atmosphere, where three separate training tracks were estab-
lished and co-existed within the same institute, this Kleinian cohort took as
an orienting point of departure Kleins (1946) complex notion that the
infants psychic and emotional development proceeded along a single contin-
uum that united normal, neurotic and psychotic individuals. More particu-
larly, the trio examined a notion inspired by Kleins own analyst, Karl
Abraham, namely that the persistence of or regression to early psychosexual
fixations was most prominent amongst the psychotic disorders: the more dis-
turbed the patient, the more severe the regression to early fixation points.
While Klein herself postulated that normal and neurotic infants navigated the
paranoid and schizoid positions into the depressive position, garnering
and integrating more good experiences of the breast over bad, frustrating
ones, she assumed the experience of the psychotic patient had to be different.
To rehearse Kleins (1946) clinical argument regarding the understanding
of psychotic disturbances, one must search for footing in the post-war con-
text in which she worked, delineating clearly what she actually wrote in 1946
and not confuse this with what she wrote later on (Klein, 1952) in a some-
what revised version of the same paper.2 First of all, it was clear that analysts

1
Both Rosenfeld (1952b, p. 457) and Segal (1950, p. 275) directly referred to Freuds bleak view of the
analyzability of the psychotic disorders. While Kleins (1946) paper certainly hypothesized that psychotic
patients could form a treatable transference in analysis, she also emphasized in the Appendix to her 1946
paper how continuous her work was with Freuds and in many ways agreed with his analysis of the
paranoid Dr Schreber (Klein, 1946, pp. 10810) This continuity was also a remnant of the era of the
Controversial Discussions (194144), during which time she took pains to show how her work was
completely consistent indeed, extended from that of Freud (Steiner, 2000, p. 73). Kleins (1946) paper,
however, left it open to her students to provide case material that might justify her claims to have made
an innovative contribution to the treatment of the psychoses. Their effort also addressed a central
ambiguity of Freuds (1911) analysis of Schreber: how could Freud explicate the unconscious dynamics
of paranoid psychosis yet maintain that these types of cases were psychoanalytically untreatable?
2
I have briefly set out the importance of a textual analysis of Kleins two versions of the Notes on some
schizoid mechanisms paper in a Letter to the Editors (Aguayo, 2008). In contrast to other works in this
area (e.g. Goretti, 2007), one clear implication of comparing these texts is that they allow us to measure
how far the Kleinian analysis of psychotic states had come between 1946 and 1952. It is also a reflection
of how the work of the Klein group had become consolidated during the post-war period into a school
of thought, complete with its own specific terminology and celebrated in a 1952 issue of the International
Journal of Psychoanalysis (1952,33, part 2). This entire issue was dedicated to a consideration of Kleins
work on the occasion of her 70th birthday and included a congratulatory Preface from Ernest Jones
(ibid., p. 83). It is also significant that the editor during those years (19471959) of the Journal (Willi
Hoffer, a Freudian) was assisted by Marjorie Brierley (an Independent) and W.C.M. Scott (a Kleinian),
which also represented the three recently established training tracks at the British Psycho-Analytical
Society.

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On understanding projective identification in the treatment of psychotic states of mind 71

in the Kleinist camp (a term used by contemporaries such as Winnicott)


had treated psychotic disorders just as Klein herself had.3 Rosenfeld (1947)
and Clifford Scott (1947) had analyzed both schizoid and manic-depressive
disorders, but for various reasons had waited until after the war to publish
their results.4 Grosskurth (1986, p. 372) reported that Klein had asked
Rosenfeld (1947) to postpone publishing his case of a schizoid patient until
after her own paper appeared on schizoid mechanisms. Secondly, by synthe-
sizing her own work on the paranoid position with that of W.D. Fairbairns
work on the schizoid disorders, this unification would result in conceptual-
izations of a group of psychotic disorders that began early in infantile life.
In her hypotheses about the early stages of normal ego development, Klein
posited that the projection of the infants early oralsadistic and often
destructive attacks on the breast resulted in the introjection of persecutory
fears and in the case of the psychotic disorders, there was an infinite dia-
lectical potentiality for these processes to cycle and re-cycle in a most self-
destructive fashion. These disorders also shared an excessive splitting of the
ego, which profoundly disturbed the interplay between projection and intro-
jection with the resulting detrimental effect on the relation between the
inner and outer world. For the paranoid, the early projective attacks could
result in a regressive fixation of persecutory fears. For the schizophrenic, the
imbalance of more bad to good experiences of the breast led to diminished
or weakened ego functioning. (Klein, 1946, p. 104) By contrast, Klein
regarded the schizoid patient as withdrawn, lacking in emotional spontaneity
and evincing noticeable narcissistic elements in their object relations. Split-
ting off their aggressive affects in an often quiet but violent way, the schizoid
patient distanced and in effect said to the analyst: I know what you are say-
ing. You may be right, but it has no meaning for me (ibid., p. 107).
Klein also advocated for a primary instinct theory over and above a more
environmentally mediated set of formative influences favored by W.D. Fairb-
airn in his definition of schizoid disorders. Klein regarded her own work as
continuous and consistent with that of both Sigmund Freud and Karl Abra-
ham, who had originally discussed the infants initial destructive impulses
projected outwards in the form of oral aggression (ibid., p. 100).
Lastly, Klein wondered if there might be psychiatric colleagues who could
test out these hypotheses on psychotic disorders: She wrote: I should be
grateful if further light could be thrown on any hypothesis by colleagues who
3
I think that it was also during this early period that the term Kleinian also originated. From the
slightly pejorative use of the term Kleinist by Winnicott, he seemed to differentiate the creative work of
Melanie Klein from what he thought of as the relatively moribund language employed by some of her
followers during that time. Acting on his freedom to state his analytic findings in a language of his own,
he wrote a letter to Klein on 17 November 1952: I personally think that it is very important that your
work be restated by people discovering in their own way and presenting what they discover in their own
language If you make the stipulation that in the future only your language shall be used for the
statement of other peoples discoveries then the language becomes a dead language, as it has already
become in the <British> Society. You would be surprised at the sighs and groans that accompany every
restatement of the internal object clichs by what I am going to call Kleinians (Rodman, 1987, p. 34;
also Rodman, 2003, p. 176).
4
In Notes on some schizoid mechanisms, Klein (1946) wrote about her own treatment experience with
both a manic-depressive patient (ibid., p. 106) and a schizoid patient (ibid., p. 107). She had of course
treated a childhood schizophrenic earlier on (Klein, 1930).

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72 J. Aguayo

have had ample material for psychiatric observation (ibid., p. 107). In this
regard, it is of interest that Rosenfeld, Segal and Bion all of them
psychiatrists were all in analysis with Klein when her 1946 paper
appeared.5
In order to explicate what she regarded as one of the primary mental
mechanisms underlying the psychoses, Klein also offered a rudimentary
sketch of projective identification. In her archival research on Klein, Eliza-
beth Spillius (2007, p. 107) has noted that where Klein first mentioned the
term projective identification (Klein, 1946, p. 104) the concept was not spe-
cifically defined; where it was described (ibid., p. 102) it was not named.
Kleins original description:
Together with these harmful excrements, expelled in hatred, split off parts of the
ego are also projected on to the mother or, as I would rather call it, into the
mother. These excrements and bad parts of the self are meant not only to injure
the object but also to control it and take possession of it. In so far as the mother
comes to contain the bad parts of the self, she is not felt to be a separate individual
but is felt to be the bad self. Much of the hatred against parts of the self is now
directed towards the mother. This leads to a particular kind of identification which
establishes the prototype of an aggressive object relation. Also, since the projection
derives from the infants impulses to harm or control the mother he feels her to be
a persecutor. It is, however, not only the bad parts of the self which have expelled
and projected, but also good parts of the self. Excrements can have the significance
of gifts.
(Klein, 1946, p. 102)

Rosenfelds contributions to the understanding of psychosis


and projective identification (19471952)
I take up how each member of the Kleinian trio made their own distinctive
contributions by treating various psychotic disorders, beginning with
Herbert Rosenfeld (1947, 1949, 1950, 1952a, 1952b) who wrote many of the
initial papers in this area. He drew his cases from both schizoid and acute
schizophrenics treated analytically with few modifications of technique.
He evolved his treatment approach from his understanding of the attendant

5
During this time when the London Klein group treated psychotically-disturbed patients, it is important to
bear in mind the broad diagnostic distinctions within which they worked. Their diagnostic categories were
in effect psychotic versus non-psychotic (Bion, 1957), and did not include the diagnoses that would be of
greater interest to subsequent generations of practitioners the so-called borderline, narcissistic and
sexually perverse disorders. While the post-war Kleinians treated and subsequently theorized about their
work with briefly hospitalized schizophrenics and non-hospitalized schizoid and paranoid disorders, their
findings and conceptual methods have been more usefully applied to patients with near-psychotic or
borderline narcissistic diagnoses. The Klein group also did not subsequently provide much by way of
follow-up data to substantiate enduring treatment changes in the patients seen. In this sense, their overall
findings are broadly comparable to those of the American Interpersonal School: H.S. Sullivan. F. Fromm-
Reichmann and H. Searles also treated hospitalized schizophrenics, but also found that their long-term
results were more beneficial to those less disturbed than chronically hospitalized, poor pre-morbid
schizophrenics. One broad measure of this change can be seen in the shift by analysts such as Searles, who
moved from working with hospitalized chronic schizophrenics (Searles, 1965) to patients with borderline
conditions (Searles, 1986). Needless to say, the Klein group also did not factor into the treatment or
explanatory equation the effect of psychiatric medication, another variable that would take on greater
significance amongst subsequent generations of psychiatric and psychoanalytic practitioners.

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On understanding projective identification in the treatment of psychotic states of mind 73

psychotic mechanisms stemming from the earliest stages of the paranoid


and schizoid positions.
While Klein made it clear that normal and neurotic individuals would
developmentally attempt to remain identified with the good, gratifying
breast, while expelling or projecting the frustrations associated with the bad
absent one, she also left considerable room for her students to fill out what
the subjective experience might be like for the psychotic disorders. Rosenfeld
(1947, 1949, 1950) made his own defining contributions, postulating that, in
the earliest developmental stages, the psychotic patient was subject to a mas-
sive confusion of self and other to such a profound extent that ordinary split-
ting could not occur. Whether schizoid, paranoid or acutely schizophrenic
(Rosenfeld, 1947, 1949, 1950), such patients lived in states of perpetual unin-
tegration. Good and bad experiences, libidinal and aggressive instincts con-
glomerated in what Rosenfeld postulated as an innovative variation on what
Klein had described as projective identification. Massive states of confusion
were actually a defense against splitting and in the ensuing circular insane
cycles, the psychotic actually projected what little bits of good breast experi-
ence he had while remaining habitually identified with the bad, poisonous
and persecuting breast. Good and bad, libidinal and aggressive impulses were
so inextricably fused together that the infantile states of confusion became
the confusional schizophrenic and paranoid states of the adult (Rosenfeld,
1950, p. 133). So, while Rosenfeld used the form of the mechanism of projec-
tive identification, he added new and defining content based on his treatment
experiences with a variety of psychotically disturbed patients (ibid., p. 135).6
In my view, what was innovative about this work was that in massive con-
fusional states there was a profound loss of the sense of other as separate.
In this mixed-up conglomeration, it was primarily left to the analyst to
carry the ego discriminating function, differentiating libidinal from aggres-
sive, good from bad, all of which would help the patient approximate some-
thing closer to a more ordinary experience of splitting. When libidinal and
aggressive were more regularly sorted out, it made it possible for reparative
tendencies to operate, where objects that were formerly attacked could now
be the object of repair and concern (Rosenfeld, 1950, p. 137).
Through out these early contributions, Rosenfeld consistently referenced
Kleins preliminary work on projective identification. In his published work

6
A brief clinical illustration: in Rosenfelds (1947) treatment of Mildred, who was depersonalized,
withdrawn and paranoid, she manifested confusional states, phantasizing being kept prisoner in a
dungeon by a devil. In a paranoid psychotic transference, she concretely thought her analyst needed to
keep her captive, forcing her to think his way to the point of no longer knowing what she herself thought.
In Rosenfelds (1947, p. 134) words, the central anxiety was a phantasy of the persecuting analyst
forcing himself into her to control her and rob her, not only of her inner possessions, for instance, her
babies and her feelings, but her very self. For a time, she warded off persecutory fears that rendered him
not only invasive, but attacking and controlling as well. When reminded of her sadistic envious
attacks of the devil who in her phantasy, always attacked the good objects , it then became easier to
demonstrate that she herself behaved like a sadistic devil: it was in fact the patients own denied intrusive
attacks that were levied against the analyst as a productive, envied and admired mother (ibid., p. 135).
In Riccardo Steiners (2008) analysis of this case, he also emphasized an erotized aspect of her delusional paranoid
transference, but at a primitive, part-object level, reflecting a concreteness of functioning rather than a whole
object, genitaloedipal conflict. Because of this concreteness, she often misheard the analysts interpretations as an
invitation to act, a seductiveness that frightened her and sometimes caused her to miss her sessions.

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74 J. Aguayo

from 1947 to 1952, Rosenfeld stood alone in fleshing out the clinically use-
ful aspects of projective identification with psychotic patients. To cite other
examples: Rosenfeld (1949) discussed what he thought was at the basis of
projective identification he traced its origins to what Klein had originally
termed the paranoid position, to the early oral sadistic impulses of the
forcing of the self into another object (ibid., p. 49).
In theorizing about some of his findings, Rosenfeld (1952a) associated the
operation of projective identification as a primary psychic operation of the
paranoid and schizoid positions, where the splitting of both the ego and its
objects into good and bad could be caused by aggression turned against the
self; and the projection of parts or the whole of the self into internal or
external objects. Whereas for Klein, this process rooted itself in the infants
libidinal and aggressive phantasies about entering mothers body, Rosenfeld
refined Kleins definition of projective identification insofar as it took on
other properties in acutely schizophrenic patients. Rosenfeld wrote:
This confusion seems to be due not only to the fantasies of oral incorporation lead-
ing to introjective identification, but at the same time to impulses and fantasies in
the patient of entering inside the object with the whole or parts of his self, leading
to projective identification.
(Rosenfeld, 1952a, p. 72)
Rosenfeld here called attention to projective identification as a develop-
mentally primitive form of object relationship something that psychotic
patients could either regress to or simply never quite outgrow and this fix-
ation in turn led him to postulate the existence of excessive projective identi-
fication in psychotic, confusional states. Put differently: unlike normals and
neurotics, these psychotic patients remained identified with an internally per-
secuting super-ego object in effect, a constant attack on their own selves,
while projecting good or idealized qualities onto external objects. Rosenfeld
(1952b) also centrally linked his definition of projective identification to the
infants initial difficulties in distinguishing the me from the not-me,
concluding on a somewhat optimistic note:
I suggest that the greater understanding of projective identification is beginning to
open up a new field of research and in this paper, I have attempted to show how
this made it possible to understand and interpret the transference phenomena of
this schizophrenic patient.
(Rosenfeld, 1952b, p. 116)

Kleins revision of Notes on schizoid mechanisms (1952)


In assessing the thesis regarding the impact that Rosenfelds work on projec-
tive identification had on Kleins revision of Notes on some schizoid mecha-
nisms, I take up what was different about the 1952 revision.
At the outset, Klein stated that the paper has been left unchanged as
then published, apart from a few slight alterations (in particular, the addi-
tion of one paragraph and some footnotes) (Klein, 1952, p. 292, n. 1). An
examination of this statement shows an underplaying of the significant revi-
sions and other explanatory paragraphs (by my count, three paragraphs,

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On understanding projective identification in the treatment of psychotic states of mind 75

totaling 30 lines; and seven new, rather full footnotes) added to the 1952
paper. Two of these new paragraphs were particularly significant insofar as
they reflected Kleins revised and more formal definition of projective iden-
tification (ibid., pp. 304, 305).
Indeed, for all the minor revisions of word usage, sentence clarity, there
are other more substantive issues for instance, the term paranoidschi-
zoid (hereafter, P S), so often associated with the 1946 paper, is never once
mentioned as such in that paper, but appears in at least a half dozen places
in the 1952 version (cf. Klein, 1946, pp. 99100; Klein, 1952, p. 294). In the
1946 version, the terms paranoid and schizoid position appeared separate
from one another, not amalgamated as they did in 1952, reflecting its more
complete conceptual consolidation.
While the earlier paper was a talk given at the British Psycho-Analytical
Society on 4 December 1946, the tone of the later paper is at once more for-
mal, with copious amounts of scholarly regalia added, such as footnotes
and citations of the psychoanalytic literature (Klein, 1952). The seven new
footnotes, some quite extensive, add much to our appreciation of Kleins
new formulations in 1952: these new footnotes themselves also read like a
whos who of colleagues who had once been close to Klein (Ferenczi, p. 297,
n. 1) or who were still on the closest professional terms with her (P. Hei-
mann, p. 292, n. 2; W.C.M. Scott, p. 298, n. 1, p. 301, n. 1; H. Rosenfeld,
p. 303, n. 1, p. 305, n.1; and J. Riviere, p. 305, n. 2).7 The 1952 paper also
marked the consolidation of the Kleinian school, a point of view identified
with the work of Klein and her students that had become firmly established
as a training track at the British Society.
In the 1952 paper, Klein implicated the work of Herbert Rosenfeld as cru-
cial insofar as she drew on his work in two new defining paragraphs and
footnotes to fill out what she now meant by projective identification.
Here then, is what Klein added about projective identification in 1952:
Projective identification is the basis of many anxiety-situations, of which I shall
mention a few. The phantasy of forcefully entering the object gives rise to anxieties
relating to the dangers threatening the subject from within the object. For instance,
the impulses to control an object from within it stir up the fear of being controlled
and persecuted inside it. By introjecting and re-introjecting the forcefully entered
object, the subjects feelings of inner persecution are strongly reinforced; all the
more since the re-introjected object is felt to contain the dangerous aspects of the
self. The accumulation of anxieties of this nature, in which the ego is, as it were,
caught between a variety of external and internal persecutions situations, is a basic
element in paranoia.
(Klein, 1952, pp. 3045)
In another new paragraph immediately following the previously cited one,
Klein continued:

7
When the names of these contributors are added to existing footnotes, which included the work of D.W.
Winnicott and M.G. Evans, there is only one exception, W.D. Fairbairn, who was not a close
collaborator of Mrs. Klein. This coterie of colleagues is vividly represented in photographic form as all
the above-mentioned analysts were present at a dinner party celebrating Melanie Kleins 70th birthday
on 30 March 1952 at Kettners Restaurant in London (Grosskurth, 1986, photograph between p. 372
and p. 373; also, cf. p. 392).

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76 J. Aguayo
I have previously described the infants phantasies of attacking and sadistically
entering the mothers body as giving rise to various anxiety-situations (particularly
the fear of being imprisoned and persecuted within her) which are at the bottom of
paranoia. I also showed that the fear of being imprisoned is an important factor in
later disturbances of male potency (impotence) and also underlies claustrophobia.
(ibid., p. 305)
What Klein here described in these new paragraphs appeared exactly where
she footnoted Rosenfelds recent research (Rosenfeld, 1947, 1949) which
sounds almost identical to Kleins new description. He had already detailed
how paranoid anxieties were connected with projective identification in psy-
chotic patients, which I think represents presumptive evidence that Rosen-
felds continued investigation of projective identification had apparent impact
on Kleins clinical thinking. Furthermore, in Developments in Psychoanalysis
(where Kleins revised Notes on some schizoid mechanisms first appeared
[Klein et al., 1952]), the sheer paucity of citations on projective identification
is quite striking in a book spanning some 300 pages, this term is cited just
twice by other authors: in the introduction by Joan Riviere (1952, p. 33), and
in Paula Heimanns (1952) article that referred to the projection of idealized
qualities (ibid., p. 327). Yet in the same volume, the term projection is abun-
dantly cited in dozens of different ways, certainly an indication that contem-
poraries did not apparently regard projective identification and projection
as one and the same. Centrally representative of this distinction was S.
Isaacss (1943) contribution, reprinted in this volume, On the nature and struc-
ture of phantasy. In Isaacss paper, she remained close to Freuds original defi-
nition of the term projection, which referred to aspects or elements of
the self [that] are often disowned and attributed to some person or group of
persons (ibid., pp. 989).
If Klein could now write in a more definite and formal sense about
projective identification in 1952, it was in some measure the result of Rosen-
felds clinical work:
Much of the hatred against parts of the self is now directed towards the mother. This
leads to a particular form of identification which establishes the prototype of an aggres-
sive object relation. I suggest for these processes the term projective identification.
(Klein, 1952, p. 300, italics added by Klein)
By contrast, in the few pieces written during this time by the other
members of the publishing cohort, the term projective identification did
not appear in either Segal (1950) or Bions work (1950) prior to Kleins
revised version of Notes on some schizoid mechanisms.8
8
R. Steiner (2007, p. 242) has pointed out that Hanna Segal (1950) in her initial paper on the treatment
of a schizophrenic did not use the term projective identification. I agree with his conjecture that Segal
did not use this term because Klein was still working out its definition. On the other hand, Rosenfeld
did develop and expand the definition of projective identification, but also emphasized the quantity of
the self invested in its use, thus leading to the forcefully violent manner in which the psychotic patient
projected into his objects. In 1952, Rosenfeld noted en passant Segals (1950) initial use of symbolic
equation and, in R. Steiners words, Rosenfeld stressed that the capacity to form symbols was very
present in his patients, and also temporarily lost, due to the violence of the projective identification
(Steiner, 2007, pp. 2423). In different words, the forcefully violent projections that resulted in the
patients fragmentation and splitting were fundamental, in Rosenfelds view, to why the psychotic patient
fell into symbolic equations and could not often rise above concrete thinking.

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On understanding projective identification in the treatment of psychotic states of mind 77

Segals contribution to the understanding of psychosis and


symbolization (19501957)
As the middle cohort member, Hanna Segals contributions and refine-
ments on the nature of psychotic thinking must be understood against the
longer backdrop of the history of symbolization in psychoanalytic thought.
Riccardo Steiners (2007) research on this question has shown how Freuds
emphasis on the activity of unconscious phantasy would become trans-
formed by Klein into the notion of symbolic function. Freuds initial
understanding posited that symbolization was a compromise between sex-
ual instinctual forces seeking release and the forces of repression that kept
them in check. Jones (1916) advocated for this topographical model, essen-
tially depicting symbolization as both a defensive and regressive process,
but also drew upon Ferenczis (1913) work, where he posited the existence
of symbolic equations. Ferenczi hypothesized that the child drew upon
parts of his body, equating his own organs with external objects, but also
equating his parents organs with his own and with external objects; thus
began the symbolization process, investing the world with new sexual
meanings.
When Klein (1930) took up this issue, she drew upon Freuds structural
model and emphasis on the death drive so that now there were inhib-
ited aggressive impulses (besides libidinal ones) seeking expression as well
as an epistemophilic instinct, an innate desire to know (Steiner, 2007). In
this new amalgamation, symbolization took on new meaning as the
unconscious activity of imagination itself. Klein applied this understanding
to a schizophrenic child who lived in a rigid world of symbolic equa-
tions, a term she used but meant in a slightly different sense from Segal:
his sadistic attacks on the maternal breast and paternal penis left him
incarcerated in a constricted persecutory internal world. For instance, he
could not play with a toy train because, to him, it symbolized a danger-
ous penis. All this clinical work further buttressed Kleins view that these
early developmental fixations had to be clues that would unlock the mys-
teries of psychosis.
Against the backdrop of Kleins (1946) work, Hanna Segal made further
incursions on the nature of psychotic thinking by her psychoanalytic treat-
ment of the first adult schizophrenic case in England. She addressed the
severe problems encountered in symbolization, most typified by the patients
tendency towards symbolic equations, where disordered thinking led to a
profound confusion of things-in-themselves with what the thing repre-
sented. With her patient Edward, Segal (1950) found that she could not
make interpretations regarding castration anxiety without being profoundly
misunderstood by the patient to mean that he felt actually castrated (Quino-
doz, 2008, pp. 623). On another occasion, he came to his session and
blushed over having made a stool in carpentry class: he equated the wood-
en stool he had made with a fecal stool, thus leaving him unable to discuss
it in analysis (Segal, 1957, p. 391). Segal (1952) also understood that what
particularly plagued his thought process also disturbed much higher func-
tioning patients, such as creative artists and writers. The inability, however,

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78 J. Aguayo

to distinguish between the spoken word and the actual reality severely con-
stricted the experiencing universe of the schizophrenic more so than the cre-
ative artist. Whereas the neurotic could symbolize their conflicts in dreams,
the schizophrenic tended to enact their phantasies, leading to the experience
of a pseudo-certain identity, an I do know who I am attitude, only inac-
curately with a pseudo-certainty. This false conflation of self and other
incarcerated the patient in an internal world that was largely unintelligible
to others.
Segal made another contribution by linking the symbolization process
to both the paranoidschizoid and depressive positions. In spite of per-
verse confusions in P S, Segal (1956) appreciated that severely disturbed
schizophrenics could on occasion approach the depressive position. A very
poignant example occurred with Segals (1956) patient, who enacted the
sadness of a girl by gathering up threads from the carpet and scattering
them about the room like so many flowers, reminding Segal of Shake-
speares Ophelia, someone who could induce genuine sadness in the on-
looker by means of projective identification. Amidst psychosis itself, there
could be islands of depressive sanity, both a diagnostic and redemptive
sign. Symbolic equations could potentially become symbolic formations,
where the schizophrenic could learn to feel ambivalently towards his
whole objects, experiencing sadness and loss. Klein (1960) herself recog-
nized Segals achievement, adding how schizophrenics by means of projec-
tive identification could project guilt into the analyst. However, since
re-introjection follows projective identification, in Kleins (1960, p. 266)
words, the attempt towards a lasting projection of depression does
not succeed. Klein here appeared to be thinking of Segals Ophelia epi-
sode as she specifically referenced Segals (1956) paper and here I quote
Klein:

In that [1956] paper the author exemplifies the process of improvement in schizo-
phrenics by helping them, by the analysis of deep layers, to diminish the splitting
and projection and therefore to come nearer to experiencing the depressive position,
with ensuing guilt and urge for reparation.
(Klein, 1960, p. 266)

Bions contribution to the understanding of psychosis and the


psychotic mind (19501957)
Turning to the third member of the cohort, Bions contributions to the nat-
ure of schizophrenic thinking benefited from Kleins (1952) revised formula-
tions as well as the conceptual scaffolding provided by Rosenfeld and Segal.
There was a more complete shift in Bions work with psychotic patients
from the interpretation of their verbal content to their interpreting their
thought processes. In this respect, Bion augmented Segals symbolic equa-
tion formula by positing that parts of the self too could be compressed into
words-as-things and thereby be projected. This was the disordered use of
language as a mode of action and was illustrated by Bion (1954, p. 115) in
the following analytic exchange with a schizophrenic patient:

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On understanding projective identification in the treatment of psychotic states of mind 79
Patient: I picked a tiny piece of skin from my face and feel quite empty.
Analyst: The tiny piece of skin is your penis, which you have torn out, and all your
insides have come with it.
P: I do not understand penis only syllables.
A: You have split my word penis into syllables and now it has no meaning.
P: I dont know what it means, but I want to say, If I cant spell I cannot think.
A: The syllables have now been split into letters; you cannot spell that is to say
you cannot put the letters together again to make words. So now you cannot think.
Aiming at a more overarching theory of psychotic thinking, however, Bion
(1954) seized the moment, making the structural assumption that schizo-
phrenic language was a manifestation of disordered thinking. He thus set
about understanding the diverse ways in which the psychotically-disturbed
used language: the schizophrenic could confuse omnipotent thoughts with
action; yet where thoughtfulness was actually required, he preferred action.
In these reformulations, Bion did not concern himself with differential diag-
nosis: in fact, he did not differentiate psychotic from schizophrenic
(Blandonu, 1994, p. 120).
In a different yet more compact way, Bion also used projective identifica-
tion to implicate its communicational impact on the analyst. While still
mainly emphasizing the unconscious phantasied content of the patients pro-
jections, there was a newly emerging intersubjective field. Bions work began
to orient in the direction of the analysts response to what was projectively
and concretely induced in him. In his first published reference to projective
identification as a mode of action for concretistically getting into or out of
his objects, Bion wrote:
The first of these uses is in the service of projective identification. In this the patient
uses words as things or as split-off parts of himself, which he pushes forcibly into the
analyst. Typical of consequences of this behaviour is the experience of a patient who
felt he got inside me at the beginning of each session and had to be extricated from it.
(Bion, 1954, p. 113)
Soon thereafter, Bion (1955a) began to explore, albeit in a tentative way,
the communicative, organizing influence that forcibly ejected projections had
on the analyst. He found himself in unchartered analytic waters, drawing
upon projective identification as a way both to understand what the patient
was projecting as well as a guide to framing his own interpretative response:
about a troubling patient, who had aroused in him a fear of physical attack,
Bion wrote:
It will be noted that my interpretation depends on the use of Melanie Kleins theory
of projective identification, first to illuminate my countertransference, and then to
frame an interpretation which I gave the patient.
(Bion, 1955a, p. 224)
Organized to feel intruded into, the analyst here became a projective
receptacle, which, without his interpretative intervention, would result in the
re-introjected and more severely persecutory recycling of the patients origi-
nal projection. Of course, in this emerging two-person model of bi-direc-
tional influence, since the analyst also carried the ego-integrative function of
the meaning-maker, his interpretations could arouse envious antagonism in

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80 J. Aguayo

his patient who then levied strong annihilatory attacks on the mind and san-
ity of the analyst. In other words, since the analysts integrated verbal
thought reflected in his interpretations could be and was subjected to the
psychotics violent splitting and attacks that were often experienced in a
very concrete way by the analyst, it was left to the analyst to survive these
violent jolts and remain the repository of sane, integrative depressive posi-
tion thinking (Bion, 1954, p. 113).
Bion hypothesized that the schizophrenic attacked his own mind and thus
his capacity to communicate, one where the patient split himself up into
many fragmented pieces and then violently projected them into his objects.
This destroyed capacity allowed the patient to evacuate concretely his dis-
tress into the sane part of the analysts mind.
Yet on the other hand, once the splits and fragmented insane-making
communications were interpreted and somewhat successfully introjected by
the patient, there was another round of fragmenting realizations to be dealt
with: the patient could only be catastrophically depressed at the realization
that he had been acting and thinking insanely (ibid., p. 117). Put differ-
ently, violent disintegration could also occur at the cusp of the depressive
position. As a result, the recovering patient in the throes of encountering
the infantile depressive position could and did return to the paranoid
schizoid position and turn destructively on his embryonic capacity
for verbal thought as one of the elements which have led to his pain
(ibid., p. 118).
Bion (1956) further differentiated the non-psychotic from psychotic mind
whereas the non-psychotic surmounted his phantasies of attacks on the
breast, the psychotic augmented these attacks by attacking his own mind
and its sense organs yet because of so much internally generated destruc-
tiveness born of a hatred of reality, he could only fear annihilation as a
result of massive projective identification.
Since the psychotic characteristically shattered his objects into tiny frag-
ments then violently projected into its objects the patient strove for
a state that was neither dead nor alive. Little else was possible in a subjective
experience where the expelled particles of the ego lead an independent
and uncontrolled existence outside of the personality (ibid., p. 345). Thus,
not only was the breast mutilated, but also the mind as the apparatus of
perception as well, leaving the patient imprisoned in a fragmented world,
one where he could also be, in Bions words, in the grip of extremely
painful, tactile, auditory or visual hallucinations (ibid., p. 346).
Bion (1957) reiterated many of these themes and now summarized his
findings, integrating them more fully with the work of Freud and Klein
as well as Rosenfeld and Segal. Comparing the findings of the Klein
group with those of Freud, whereas Freud (1923) regarded the psychotics
ego as withdrawing from reality in the service of the id, Bion added two
points: (1) the ego is never completely withdrawn from reality; but some-
times, contact with reality can be masked by the operation of omnip-
otent phantasy that is intended to destroy either reality or the awareness
of it; (2) also stressed was that the withdrawal from reality is an
illusion, not a fact, and arises out of the deployment of projective identi-

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On understanding projective identification in the treatment of psychotic states of mind 81

fication against the mental apparatus listed by Freud. Such is the domi-
nance of this phantasy that it is evident that it is no phantasy, but a
fact, to the patient, who acts as if his perceptual apparatus could be split
into minute fragments and projected back into its objects (Bion, 1957,
p. 268). Bion now named these expelled particles bizarre objects, where
the particle projected becomes suffused with aspects of the natural object
with which it is identified.
Again, Bion quoted the work of Segal:
Since these particles are what the patient depends on for use as the prototypes of
ideas later to form the matrix from which words should spring this suffusion of
the piece of personality by the contained but controlling object leads the patient to
feel that words are the actual things they name and so adds to the confusions,
described by Segal, that arise because the patient equates, but does not symbolize.
(Bion, 1957, p. 268)
Persecuted by the re-introjected bizarre objects and denied access to what
might be more connected and integrated, the psychotic patient then
achieved an attack on reality by severing his link to it and by launching
destructive attacks on the link, whatever it is, that connects sense impres-
sions with consciousness (ibid., p. 268). So in going back to the earliest
phases of P S, Bion claimed that true early pre-verbal thought was bound
up with awareness of psychic reality. Consequently, if the psychotic infant
attacked both internal and external reality via massive projective identifica-
tion, he would be left only with bizarre objects. One other effect of the over-
arching attack by the psychotic on his own mind was also an attack on the
links between ideographs, so that two objects could not be brought together,
a later manifestation of which is the difficulty in the combining of words.
The patient was thus stuck in a world where the mental was hopelessly con-
fused with the physical; he could not escape it because he lacks the
apparatus of awareness of reality which is both the key to escape and the
freedom to which he would escape (ibid., p. 269).
To put the psychotic patient back on a firmer psychic footing, the pro-
cesses of massive projective identification had to be reversed, so that the
bizarre objects could be metabolized by the analyst and re-introjected
more successfully by the patient. In these efforts, Bion felt encouraged by
the improved functioning of the psychotic patients seen by Rosenfeld,
Segal and himself. He concluded modestly: I believe that the improve-
ments I have seen deserve psychoanalytic investigation (ibid., p. 266).

On treatment
To differentiate the technique of this Kleinian trio with psychotic
patients, we must first establish how Klein herself contemporaneously
defined her own approach along the dimensions of transference, counter-
transference and the role of early history or the patients past. Elizabeth
Spilliuss archival research has examined Kleins unpublished and pub-
lished thoughts on these matters, most especially on technique seminars
that are likely from either 1936 or 1945 46 (Spillius, 2007). What will
appear familiar is Kleins emphasis on the analysts maintaining an ana-

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82 J. Aguayo

lytic attitude, respecting whatever comes out of the human mind, e.g.
positive and negative transference reactions, evident from the initial inter-
view.
Less well known is how Klein was more like Freud with respect to matters
such as the countertransference, regarding it as personal interference of
which the analyst needed to remain mindful. Nowhere in her published work
did Klein regard countertransference as useful source of information
about the patient (Spillius, 2007, p. 72).
Also, in terms of the role of the patients view of the past, Spillius has
pointed out that Klein saw two processes transferred from the past to pres-
ent: (1) the patients remembered past, or the patients own unique and
mainly conscious view of their past (e.g. their parents, siblings and major
traumas); (2) also what Spillius terms the idealtypical model of infant
development (herein termed the unconscious past), or what Klein thought
of as the typical pattern of infantile phantasies, emotions and object rela-
tions, such as the primal relation  deux or motherinfant relationship.
Klein kept these general childhood situations in mind, by which she meant
love and hate of the breast; an epistemophilic instinct directed at mothers
body and its contents; reparative attempts for having attacked mother and
father; the primal scene; the Oedipus complex; and the fragmenting splits of
P S as well as the development of the depressive position (Spillius, 2007, p.
76). While the transfer of these past situations occurred in analysis, the
interpretations themselves were also what Klein termed feelers towards
early situations (ibid., p. 89). In her own clinical work, Klein interpreta-
tively linked the patients present and early life, urging analysts to make
explicit transference links between past and present (ibid., pp. 6776).

On technique
Rosenfeld (1952a; 1952b) borrowed from both Kleins general understanding
of psychosis as well as her technical approach and refined it in his treatment
of psychosis. In my view, these Kleinians were too busy treating the psychot-
ically-disturbed and writing up their results to have time to make program-
matic statements about technique that would have to wait for another
time. Rosenfeld interpreted positive and negative transference, relying on
neither reassurance nor suggestion, but centered his interventions on the
transference psychosis, which reflected what he thought was a regression to
the earliest P S levels of the first few months of life (Rosenfeld, 1952a, pp.
11112; 1952bb, p. 458).
Taking the Kleinian trios work on psychosis as a whole, in my view,
they made a structural assumption that the patients internal psychological
situation was the primary and enduring focus of analysis. In understand-
ing, clarifying and working through the patients confused and distorted
experiences, the stage was set for teasing out the effects of the environ-
ment as a distorted and perhaps secondary phenomenon. Put differently:
these Kleinians held the external or environmental factor constant while
examining the myriad fluctuations in the patients intrapsychic subjective
existence. Rosenfelds views were representative of this view, insofar as he

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On understanding projective identification in the treatment of psychotic states of mind 83

did not accord much value to environmentalist concepts (e.g. Fromm-


Reichmanns notion of the schizophrenogenic mother) held to by Ameri-
can colleagues: in his view, their modified psychoanalytic technique also
focused therapeutic attention on reassurance and re-education (e.g. the
work of analysts such as H.S. Sullivan, F. Fromm-Reichmann [Rosenfeld,
1952a, p. 111]). In his early papers, Bion too did not formally concern
himself with elucidating the environmental factor, and did not in fact
mention the work of American colleagues.

On the psychotic transference


So how did these Kleinians address the psychotic mind? Implicit in Kleins
notion of the infants object relatedness from the outset of life was a mar-
ginalization of Freuds notion of primary narcissism or a mindless sort of
auto-erotism. If Kleins notion of mindedness reached back to the first
year of life, then how was the analyst to analyze its manifestations? These
Kleinians agreed that it was through the technique of part-object interpre-
tations that contact could be made with a primitively constituted mind of
the schizophrenic. These interpretations represented subjective signifiers that
the core of the patients psychotic experience could be received, deciphered,
understood and returned back by the analyst to the patient in the form of a
subjectively attuned interpretation in my view, one mind could demon-
strate its understanding to another. In this respect, Rosenfeld (1952) expli-
cated most clearly how the psychotic patient concretistically lost his sense of
self via massive projective identification into his objects, (cf. his case of Mil-
dred, footnote 6) which at another level also represented the loss of the as-
if quality of transference reactions more regularly shown by neurotic
patients.
With the pooling of such concepts as Rosenfelds massive confusion of
self and other (external and or internal), Segals symbolic equations, and
Bions attacks on ones own mind all mediated through the fragmented
communications of a patient trapped in early P S, these raw materials now
made possible the analytic treatment of the transference psychosis. These
were the organizing structures at the core of the schizophrenics psychic
reality, or what he could not keep from projecting into his objects. The trio
varied in only a minor fashion on their overall agreement that there were
sufficient remnants of a primitive object relationship that now made possi-
ble the analysis of schizophrenics.

On countertransference
These Kleinians wrote very little about the countertransference during this
time, but their views are of some interest. Rosenfeld briefly broached the
subject in 1952 and acknowledged the work of Paula Heimann (1950). He
wrote: In my opinion the unconscious intuitive understanding by the
psycho-analyst of what a patient is conveying to him is an essential factor
in all analyses, and depends on the analysts capacity to use his counter-
transference as a kind of sensitive receiving set (Rosenfeld, 1952b, p.
116). Bion made an even briefer comment on countertransference at the

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84 J. Aguayo

IPA Congress in London in 1953: Evidence for interpretations has to be


sought in the countertransference and in the actions and free associations
of the patient. Countertransference has to play an important part in anal-
ysis of the schizophrenic, but I do not propose to discuss that today
(Bion, 1954, p. 113).
However sparse these comments, countertransference was also of inter-
est to Melanie Klein at that time as well. Robert Hinshelwood (2008) has
recently examined this issue and concurred with Spilliuss (2007) view that
Klein basically remained aligned with Freuds view of countertransference
as personal interference. There is evidence, however, that Klein also had
a more sophisticated view. Drawing on some notes Klein (Klein Archives,
PLE KLE D31) had written as an intended contribution and comment
on Bions (1954) Notes on a theory of schizophrenia at the same 1953
IPA Congress in London, Hinshelwood (2008, p. 102) points out that
Klein was well aware of the impact that the psychotics at times violent
and hostile splitting had on the analyst. Klein wrote in her unpublished
Remarks on countertransference: In addition to all this, there is a point
I wish to stress the particular processes of the schizophrenic of split-
ting his own ego and of the analysis of projective identification, a term
I coined to denote the tendency to split parts of the self and to put
them into the other person, stir in the analyst very strong countertrans-
ference feelings of a negative kind.
By 1955, Bion now became more persuaded that the countertransference
had to be considered more actively by the analyst. He wrote: The analyst
who essays, in our present state of ignorance, the treatment of such patients,
must be prepared to discover that for a considerable proportion of analytic
time the only evidence on which an interpretation can be based is that
which is afforded by the countertransference (Bion, 1955a, p. 225). And a
few sentences later: I would not have it thought that I advocate this use of
countertransference as a final solution; rather it is an expedient to which we
must resort until something better presents itself (ibid.).9

9
In his reconsideration of countertransference, I conjecture that Bion also had in mind his 1950
membership paper for the British Society and his new view made it possible to publish it later on as the
first paper in a collection of papers from this period (Bion, 1950). In effect, Bions 1950 case of a
middle-aged schoolteacher who had lived an unacknowledged pretend existence in and out of analysis
had unwittingly created a fetid and stale atmosphere in his analysis. It was only with Bions belated
understanding of the existence of the patients counterfeit self that helped to enliven the analysis. Yet it
was based on his comprehending a maddening psychic quadrille, where there was a stale-making
potential for meaninglessness at the juncture where the pseudo-patient encountered a pseudo-analyst.
This folie  deux finally became clear to the analyst: he was in fact experienced by his patient as an
imaginary twin. In different terms, I think Bion recognized the importance of the patients role as an
unreliable and self-subverting narrator. Once this was understood, Bion could in turn grasp more clearly
his own unconscious collusion with the patient, thus giving impetus to the importance of the active
consideration of the countertransference later on. It was from this countertransferential web that the
analyst had to extricate himself. By 1955, Bion came to the fuller realization of the broader importance
of the countertransference, and he indicated as such in a much revised version of his 1952 paper on
Group dynamics (Bion, 1952): The experience of countertransference appears to me to have quite a
distinct quality that should enable the analyst to differentiate the occasion when he is the object of a
projective identification from the occasion when he is not. The analyst feels he is being manipulated so
as to be playing a part, no matter how difficult to recognize, in someone elses phantasy (Bion, 1955b,
p. 446).

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On understanding projective identification in the treatment of psychotic states of mind 85

While Segal (1956) herself did not explicitly write about induced counter-
transference during this period, her clinical work ran parallel to Kleins
views. In the clinical example of Segals Ophelia patient, this incident poi-
gnantly reflected how Segal made use of her countertransference, as induced
by this very disturbed patient. Like Klein in this instance, Segal did not
explicitly write about her countertransference. When the patient danced
about the consulting room, Segal wrote:
it struck me that she must have been imagining that she was dancing in a mea-
dow, picking flowers and scattering them. And it occurred to me that she was
behaving exactly like an actress playing the part of Shakespeares Ophelia. The like-
ness to Ophelia was all the more remarkable in that in some peculiar way, the more
gaily and irresponsibly she was behaving, the sadder was the effect, as though her
gaiety itself was designed to produce sadness in the audience, just as Ophelias
pseudo-gay dancing and singing is designed to make the audience in the theater
sad.
(Segal, 1956, p. 341)
When other students of Klein, such as Money-Kyrle (1956) wrote more
explicitly and enthusiastically about Heimanns views, Klein finally made
her views on the subject more public by way of a seminar given to younger
colleagues in 1958 (Klein Archives, PP KLE C72; Spillius, 2007, pp.
7881). Recorded on audiotape, an otherwise amiable discussion became
somewhat heated on the topic of countertransference, when Klein said:
I have never found that the countertransference has helped me to under-
stand my patient better. If I may put it like this, I have found that it helped
me to understand myself better. By this late point in her career, Klein was
aware of the enthusiasm for the patient-induced view of countertransfer-
ence, but regarded it more as an error to be corrected. Klein apparently did
not want analysts getting carried away (in Spilliuss words), by their
transference to the patient and to regard this aspect of their character as
valid data about the patient (Spillius, 2007, p. 80). Like Hinshelwood, Spil-
lius also conjectures, however, that Klein did draw implicitly on her counter-
transference in working with patients.

On the importance of the patients early history


With respect to the role of the past, there are intriguing variations
amongst these three analysts, which in my view stem from Kleins various
understandings about the remembered past and the unconscious past. In
this regard, my personal view is that Hanna Segal comes closest to Kleins
technical practices at that time. By this, I mean the interpretative focus on
both the remembered past and the patients use of unconscious phantasy,
which, when exteriorized and symbolized, mediated his view of internal
and external reality. Segals emphasis on transference interpretations, how-
ever, meant something more than a here-and-now interpretation. In
Segals words: A full transference interpretation should include the cur-
rent external relationship to the analyst, and the relation between these
and the relationships with the parents in the past (Segal, 1964, pp. 1201).
In Segals articles during this period, one reads examples of her explicitly

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86 J. Aguayo

linking past with present, but is struck by their reconstructive brevity,


so that, like Klein, Segal appears to be more present-tense oriented in terms
of how the past shapes the patients view of the present (Segal, 1954,
p. 240).
By contrast, Rosenfeld emphasized a slightly more reconstructionist view,
linking the patients history with current manifestations in the transference.
Rosenfeld also seemed more interested in actually depicting his patients
conflictual experiences during the first years of life. For example, in the case
of Mildred, Rosenfeld interpreted her compulsion to repeat how her life
fell apart as a child when, at 19 months of age, a baby brother was born.
Rosenfeld thought this compulsion to repeat was even more important since
it happened to coincide with the 19th month of analysis (Rosenfeld, 1947,
pp. 1345).
Bion, on the other hand, seemed more idiosyncratic in terms of his impli-
cit views on the role of the patients past during the post-war years. Starting
with his membership paper on The imaginary twin, Bion (1950) gave a stan-
dard early history of his patient with plenty of detail. Yet after this
lengthy recitation, it is striking that he did not directly reference this
account during the rest of the treatment description. Even at this early date,
Bions clinical work compressed Kleins notions on the importance of early
history into interpretative work that was almost exclusively present-tense
oriented. In his published work, Bion apparently made no explicit transfer-
ence linkages between past and present, which in effect marginalized the sig-
nificance of the remembered past.
Since Bion continued to elucidate the phenomenology of schizophrenic
thinking, as it occurred in real time during the patients analytic sessions,
he then referred to his growing disenchantment with giving long clinical
examples (which implied extensive case histories), an experience related to
having presented at another IPA congress (Bion, 1956, p. 344).
By 1957, Bions thinking underwent another change, in which he lessened
the value of the analysts knowing much about the patients early history.
At this point, with a male psychotic patient, Bion wrote about how he was
more completely consumed with the present tense:
miniature dramatic presentations, preparations for a babys bath or feed, or a
change of nappies, or a sexual seduction. More often it would be correct to say that
the presentation was a conglomeration of bits out of a number of such scenes
that led me finally to suppose that I was watching an ideo-motor activity, that is to
say a means of expressing an idea without naming it.
(Bion, 1957, p. 271)

Bions absorption with what we today would regard as enactments left him
little room or interest in reconstructing the hypothetical early life of the
patient. Given his postulations about the psychotics propensity to attack his
own mind, which included memory, it implied a view of a self-subverting and
unreliable narrator, one whom would leave the analyst in the dark (as Bion
wrote) about what actually happened in the patients early life (ibid.). Bion
moved away from early developmental models of a there and then infantile
history perhaps they too could be used defensively as a way of projecting

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On understanding projective identification in the treatment of psychotic states of mind 87

unbearable anxieties in the present moment into a phantasy of a long ago


forgotten and buried infantile past. Could this be a factor in what was presum-
ably recreated in the transference and countertransference?
By contrast, I submit that Rosenfeld more than Segal at that time was
interested in differentiating somewhat the importance of early life experi-
ences (i.e. the remembered past), but both focused on the deep psycholog-
ical structures (as embedded in the unconscious past). In slightly different
terms, Segals clinical work maintained a balance between the importance of
early remembered history and deep psychological structures. For Bion,
early or remembered past and deep psychological structures became pro-
gressively more difficult to differentiate and soon became one, as he would
(in my view) soon compress early experiences into deep structures, becom-
ing more involved in analyzing them almost exclusively in the present ongo-
ing interaction. By now, Bion had effectively marginalized the
reconstruction of the patients early formative influences, which also meant
not making explicit transference links between past and present.

Conclusions
After 1957, the members of this particular publishing cohort more or less
went in separate directions, continuing to refine, re-think and reformulate
the leads opened by their analytic experience with psychotic patients. Rosen-
feld, for instance, took his work in the direction of summarizing the results
with treating schizophrenics, but now also included work with drug addicts,
alcoholics, hypochondriacs and narcissistic characters (Rosenfeld, 1965). He
concluded that Kleins approach had helped him deepen his understanding
of the psychotic process and at times would lead to a diminishment of the
patients schizophrenia. His work had received an endorsement from Ernest
Jones, who approved of the emphasis on the exploratory and research
aspects of Rosenfelds work (rather than the curative outcome process)
(ibid., p. 11).
On the other hand, Hanna Segal by and large moved away from publish-
ing on schizophrenia per se, but continued with her work on aesthetics and
literature, artistic creativity and freedom of thought. Her best-known work
that came just a few years after Melanie Kleins death in 1960 was An Intro-
duction to the Work of Melanie Klein, a collection of lectures that she had
given for years to the candidates in training at the British Psycho-Analytical
Institute (Segal, 1964). This widely known work has had a tremendous
impact over succeeding generations on the international community, often
serving as the primary orienting text for those interested in learning more
about Melanie Kleins theories and techniques.
It remained Wilfred Bions task to continue treating and writing about his
results with schizophrenic patients. In his extremely well-known writings on
hallucination, arrogance, attacks on linking, he gathered his work together
now in a more general direction of an over-arching theory of thinking
(Bion, 1967).
Yet what remained as a legacy to psychoanalysis were their collective
efforts to map out the complicated and hazardous terrain of schizophrenic

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88 J. Aguayo

disorders, something that would not only make possible the psychoanalytic
treatment of psychosis, but also make more apparent the psychotic islands
that existed in neurotic and normal individuals.
Although the conclusions I now propose are schematic and preliminary,
I offer them as a departure point for further consideration. With respect to
Kleins legacy, Rosenfelds post-war work secured Kleins connection to the
past, demonstrating at a number of different levels how continuous her work
was with that of Sigmund Freud. Historically speaking, since Rosenfelds
analysis came during the time of the Controversial Discussions, one might
say that he was more purely an analytic child of that time as demon-
strated with his interest in articulating the continuity between Klein and
Freuds clinical thought (e.g. his 1949 paper that tied together paranoia,
homosexuality and narcissistic object relations). More so than the others, in
his numerous bibliographic references that demonstrated a rich and keen
awareness of Freudian and neo-Freudian literature, his interest in recon-
struction and attempts to get at what really happened in the first years of
life made him eager to make explicit and detailed linkages in the transfer-
ence between past and present. Bion, of course, added to this with his inte-
gration of Freud and Kleins conceptualizations of psychotic thinking.
On the other hand, Hanna Segal seemed to most attune her clinical work
to Klein in the present. Since her analysis came at a time when the tumultu-
ous issues of the Controversial Discussions had been institutionally resolved
with the three-tiered training system, Segal proceeded (as relayed in a pri-
vate communication) in her analysis with Klein almost as if the Controver-
sial Discussions had never happened. In her analysis with Klein, Segal never
recalled it ever being a topic of conversation. I suggest that this temporal
factor essentially made Segal a post-Controversial Discussions analytic off-
spring. Segal focused on Kleins contemporary work, something that formed
her orienting point of departure and led her in the direction of reconciling
her own work on symbol formation and aesthetics with the corpus of
Kleins published work. Thus in spirit of a new Klein group that had
secured its own legitimate training track at the British Psycho-Analytical
Society in the post-war years and perhaps here, the ease facilitated by a
young female analysts identification with someone she experienced as a
sound mother figure also led Segal at that time to analyze most in the
spirit and technique of her analyst. It was equally as clear that both Rosen-
felds and Bions clinical work took their orienting focus from the work of
Klein.
While Segal, for instance, focused on linking past with present, her expli-
cations about the past were made with economy, not detailed elaboration as
one would have found in the work of her colleague, Herbert Rosenfeld. This
is neither criticism nor praise: it is more a matter of degree rather than a
qualitative difference. Likewise, Segals attitude about countertransference at
that time was aligned with Kleins view of it as personal interference. Like
Klein herself, Segal also drew upon her countertransference, but did not
explicitly write about it until later (Segal, 1981).
Turning to the third member: Bion was the last of the trio to be analyzed
by Klein and his work on psychotic thinking eventually opened up his

Int J Psychoanal (2009) 90 2009 Institute of Psychoanalysis


On understanding projective identification in the treatment of psychotic states of mind 89

explorations of a more overarching theory of thinking. It also secured and


extended Kleins relationship to the future. Almost from the beginning, Bion
eschewed a more orthodox path: his papers are sparse (in comparison to
Rosenfelds) in terms of bibliographic references. Very much like his
colleague, D.W. Winnicott, Bion did not evince much bibliographic interest
in formally linking his work to that of his predecessors. By differentiating
the psychotics mode of thinking, Bion placed this Kleinian understanding
within the reach of patients hitherto deemed untreatable by ordinary psy-
choanalysis. It is also true that Rosenfelds incursions into understanding
narcissism would also open fresh avenues of psychoanalytic research in the
years to come. These developments in turn allowed these analysts to build
upon the structure set out by Klein and thus safeguard the movements
openness to further differentiation and development.
In my view, the clinical work of Rosenfeld, Segal and Bion exemplified
the openness to allowing the existing Kleinian paradigm to be filled out,
challenged and revised anew. It represented what Ronald Britton (2001) has
characterized as the capacity of a psychoanalytic theorist to leave the theo-
retical certainty of the known paradigm allowing for creative but tolerable
fragmentation and uncertainty and then moving the paradigm forward by
new theoretical syntheses and integrations.

Acknowledgments
An earlier version of this paper was delivered at the Hanna Segal Today
Conference at University College London on 1 December 2007 (Mary
Target, Chair). The author also here gratefully acknowledges the support of
the International Psychoanalytical Associations Research Advisory Board
through its fellowships granted in the area of the history of psychoanalysis,
a number of publications (Aguayo, 1997, 2000, 2002, 2008; Spielman, 2006)
as well as research trips to the Melanie Klein Archives housed at the Well-
come Institute in London and to the archives of the British Psycho-Analyti-
cal Society have been made possible. The author also recognizes the helpful
support of a number of colleagues: Robert Hinshelwood, Riccardo Steiner,
Robert Westman, James Grotstein and Jon Tabakin. The responsibility for
the final paper is, of course, the authors own.

Translations of summary
Zum Verstandnis der projektiven Identifizierung in der Behandlung psychotischer psychischer
Zustande: die Publikationsgruppe H. Rosenfeld, H. Segal und W. Bion (1946-1957). Eine Publi-
kationsgruppe kleinianischer Psychoanalytiker Rosenfeld, Segal und Bion fhrte Kleins (1946) Kon-
zepte der projektiven Identifizierung und der paranoiden und schizoiden Position in das Verstndnis
einer Gruppe psychotischer Strungen ein. Der Autor unterscheidet Kleins Beitrag von 1946 von seiner
revidierten, 1952 erschienenen Fassung und behauptet, dass die klinische Arbeit, die Rosenfeld in dieser
Phase leistete, die Formulierung von Kleins Neudefinition der projektiven Identifizierung ermglichte.
Damit war die Bhne bereit fr Segals berlegungen zur symbolischen Gleichsetzung. Infolge des
Angriffs, den der Psychotiker auf die Brust vorgenommen hat, ist er innerer Qual und Verfolgung ausge-
setzt. In diesem Zustand werden die Dinge an sich mit dem, was sie symbolisch reprsentieren, verwech-
selt. Segal wiederum brachte die psychotische mit der normalen, die paranoid-schizoide mit der
depressiven Position in Verbindung und zeigte, wie der Patient durch projektive Identifizierung und sym-
bolische Imagination Traurigkeit, Schuld- und Verlustgefhle im Analytiker hervorrufen kann. Bion
nahm an, dass die psychotische Pathologie ein gestrtes Denken widerspiegele und der schwergestrte

2009 Institute of Psychoanalysis Int J Psychoanal (2009) 90


90 J. Aguayo
Patient die Sprache als einen Handlungsmodus benutze. Der Psychotiker, so Bion, vermag zwischen dem
Gebrauch des Denkens und dem Agieren in der ueren Welt nicht zu unterscheiden wo Denken not-
wendig ist, bevorzugt er Aktionen und umgekehrt. Auch Bion machte auf neue, erweitere Weise vom
Konzept der projektiven Identifizierung Gebrauch, so dass die Psychoanalyse tendenziell zu einem inter-
subjektiven Feld der wechselseitigen projektiven und kommunikativen Beeinflussung zwischen Patient
und Analytiker wurde. Der Beitrag schliet mit dem Einfluss von Rosenfelds, Segals und Bions Arbeiten
und Variationen ber die Technik der Analyse psychotischer Zustnde mit Blick auf die frhe Geschichte
des Patienten, die bertragung und die Gegenbertragung.

Sobre la comprension de la identificacion proyectiva en el tratamiento de estados psicoticos:


La cohorte de autores conformada por H. Rosenfeld, H. Segal y W. Bion, (1946-1957). La
cohorte de autores analistas kleinianos -Rosenfeld, Segal y Bion- implement las nociones de identifica-
cin proyectiva y las posiciones paranoide y esquizoide de Klein (1946) para la comprensin de un
grupo de desrdenes psicticos. El autor diferencia los trabajos de Klein (1946) respecto de su versin
revisada de 1952, y sostiene que fue el trabajo clnico de Rosenfeld durante este periodo el que ayud a
centralizar la redefinicin de identificacin proyectiva de Klein. El escenario estaba listo para el aporte
de Segal en trminos de ecuaciones simblicas, donde el ataque del psictico al pecho lo dejaba encar-
celado en la persecucin y el tormento internos, donde las cosas en s mismas eran confundidas con lo
que representaban simblicamente. Segal a su vez vincul psictico con normal, posicin esquizo-para-
noide con posicin depresiva, donde por medio de la identificacin proyectiva y la imaginacin simb-
lica, el paciente poda hacer surgir en el analista sentimientos relacionados con la tristeza, la culpa y la
prdida. Bion supuso que la patologa psictica reflejaba el pensamiento desordenado, cuando los severa-
mente perturbados usaban el lenguaje como un modo de accin. El psictico estaba profundamente con-
fundido entre el uso del pensamiento y la accin en el mundo natural; donde se requera el pensamiento,
l prefera la accin y viceversa. Bion tambin recurri a la identificacin proyectiva de una manera ms
amplia y nueva, de manera que el anlisis pudo volverse un campo algo ms intersubjetivo y bidireccio-
nal de influencia proyectiva y comunicacional entre paciente y analista. El trabajo concluye con el
impacto del trabajo de Rosenfeld, Segal y Bion y las variaciones sobre la tcnica del anlisis de estados
psicticos en relacin a la historia temprana del paciente, la transferencia y la contratransferencia.

Tentatives de comprehension de lidentification projective dans le traitement des etats


psychotiques de la personnalite: un collectif dauteurs, H. Rosenfeld, H. Segal et W. Bion
(19461957). Un collectif dauteurs et analystes kleiniens Rosenfeld, Segal et Bion appliqua la
notion didentification projective et de positions parano de et schizo de de Klein (1946)
la compr-
hension dune srie de troubles psychotiques. Lauteur diffrencie larticle de Klein (1946) de sa version
revue et corrige de 1952, soutenant que le travail clinique de Rosenfeld au cours de cette priode a con-
tribu
la redfinition de lidentification projective par Klein. La sc ne tait prte pour accueillir la con-
ceptualisation de Segal qui introduisit la notion dquation symbolique: lattaque du sein par le
psychotique refermait autour de ce dernier le cercle des angoisses de perscution o les choses en soi
devenaient identiques
ce quelles reprsentaient symboliquement. Segal relia
son tour les parties psy-
chotique et non psychotique, la position schizo-parano de et la position dpressive, dans la mesure o
par le biais de lidentification projective et limagination symbolique, le patient parvenait
susciter chez
lanalyste des sentiments lis
la tristesse, la culpabilit et la perte. Bion, quant
lui, dveloppa lide
selon laquelle la pathologie du psychotique refl te les troubles de la pense, le langage tant utilis ici
comme un mode daction. Le psychotique est en proie
une confusion entre lutilisation de la pense et
de laction dans le monde l
o il lui faudrait penser, il prf re agir, et vice-versa. Bion largit gale-
ment la conception de lidentification projective, mettant en vidence linfluence quelle exerce dans la
cure analytique sur le champ de la communication intersubjective et bidirectionnelle entre le patient et
lanalyste. Lauteur conclut son article en soulignant limpact des travaux respectifs de Rosenfeld, Segal
et Bion sur la technique de lanalyse des tats psychotiques sous langle de lhistoire prcoce du patient,
le transfert et le contre-transfert. Mots-cls: histoire de la psychanalyse, psychose, recherche, reconstruc-
tion, contre-transfert, technique psychanalytique.

La comprensione dellidentificazione proiettiva nella cura di stati mentali psicotici: il lavoro di


H. Rosenfeld, H. Segal e W. Bion (1946-1957). Un gruppo di autori Kleiniani Rosenfeld, Segal
and Bion hanno applicato il concetto di identificazione proiettiva e di posizioni schizoparanoide e
depressiva (Klein 1946) allo studio di una costellazione di disordini psicotici. Lautore confronta larti-
colo della Klein del 1946 con la sua versione rivista del 1952, affermando che fosse stato il lavoro clinico
di Rosenfeld nel corso di quegli stessi anni ad aver spinto la Klein a modificare il suo concetto di identi-
ficazione proiettiva. in questo contesto che Segal apporta il suo contributo in termini di equazione
simbolica, secondo il quale lattacco al seno da parte dellindividuo psicotico lascia questultimo impri-
gionato in uno stato di persecuzione interiore in cui la cosa in s viene confusa con la sua rappresenta-
zione simbolica. Segal pass poi a stabilire un nesso fra psicotico e normale, fra posizione

Int J Psychoanal (2009) 90 2009 Institute of Psychoanalysis


On understanding projective identification in the treatment of psychotic states of mind 91
schizoparanoide e posizione depressiva in cui mediante lidentificazione proiettiva e l immaginazione
simbolica il paziente suscita nellanalista emozioni quali tristezza, colpevolezza e perdita. Bion muove
dallassunto che i disturbi psicotici riflettano disordini del pensiero: lindividuo gravemente disturbato
usa il linguaggio come modo di azione. Lo psicotico profondamente confuso fra luso del pensiero e
dellazione nella realt
quotidiana: quando richiesto il pensiero preferisce lazione e viceversa. Lesten-
sione da parte di Bion del concetto di identificazione proiettiva ha portato a concepire lanalisi come
campo intersoggettivo e bi-direzionale di influenza proiettiva e comunicativa fra paziente e analista.
Larticolo si conclude trattando limpatto che lelaborazione del concetto di identificazione proiettiva,
effettuata, con le dovute variazioni, da Rosenfeld, Segal e Bion, ha avuto sullanalisi degli stati psicotici
in termini della storia infantile del paziente, del transfert e del controtransfert.

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