W.R. Bion's Second Thoughts on Schizophrenia

Introduction: 

When I was discovering the Middle/Independent and object relations schools in Her Majesty's United Kingdom in the 1990s, Bion's name came up several times. Both then and since I tried, in an admittedly desultory way, to read a bit of him, but finding the experience infelicitous, did not persist in my attempts.

Recently, however, I have made some in-roads with him, and it is through his papers on schizophrenia, most of them collected in Second Thoughts, that I have found some material to latch onto as it were. My method in reading this book was admittedly rough: I ransacked it for only such material as struck me as being clinically useful and broadly in accord with what I have previously read, much of it noted on here already.

The chapters in this book that focus on schizophrenia draw their material from his work with six patients. Bion says he did not depart from analytic technique, taking note of positive and negative transference (about which more presently). 

Bion notes that Melanie Klein's work plays a central part in his attempt to understand schizophrenia, especially his insistence that the schizophrenic is making constant use of projective identification and splitting to navigate the world. This leads him to claim, early in the book, that "the peculiarity of the schizophrenic's object relations is the outstanding feature of schizophrenia" (p.23). 

Centrality (if not Singularity) of the Counter-Transference: 

Bion also notes  that "counter-transference has to play an important part in analysis of the schizophrenic" (p.24). Bion is writing this well over half a century ago, but his point has been given even stronger emphasis in a recent and fascinating essay I read tonight by the Columbia psychiatrist Andrew C. Lotterman ("Psychotherapy Techniques for Patients Diagnosed with Schizophrenia," American Journal of Psychotherapy 70 [2016]), who insists on the absolutely irreplaceable value of the counter-transference, saying that sometimes this may be the only tool the therapist has at his disposal for understanding fragmented speech, hallucinations, and other psychotic manifestations. Lotterman:

In many cases, the countertransference is the only place where some of the patient’s crucial emotions and fantasies will appear in the treatment. The patient often projects or induces these experiences into the therapist to rid himself of the burden of feeling them, and of the work of becoming conscious of them by capturing them in words or images.

Frequency of Splitting: 

Back to Bion, and so to Klein, on the centrality of splitting in the schizophrenic: he notes that they may often try to split the therapist in a variety of ways you might not appreciate for some time. Some examples: to overstimulate and to make you so drowsy you fall asleep; to ask two incompatible demands of you (longer and shorter sessions). Insofar as the patient can move from splitting to the depressive position, Bion says, we may see this as a sign of progress and increasing health. But the patient may fight this and return to a more primitive position precisely because of the inability to deal with the psychic pain of being in touch with 'reality' (which depresses us all, psychotic and non-psychotic alike!). 

It is not just that objects are split, but Bion insists that many objects are often pulverized into fragments, and then compressed and agglomerated: they cannot be synthesized. Insertion of them into the patient's mind is felt to be violation and an assault.

Later on Bion returns to this, advising the psychotherapist that you not allow yourself to be confused in thinking too high: that when a patient mentions and attacks an object, they have the full object clearly in mind. They do not. You, the clinician, would assume this, but in reality the patient does not have the full object clearly in mind. They are attacking only fragments, residues, etc. They resent these objects and do not have sufficient curiosity to investigate and know them in their fullness. 

Projective Identification:

For Klein, splitting is a key part of the phenomenon of projective identification, of which Bion makes much in this book. He says that for the schizophrenic, projective identification is widespread and key; it replaces repression. Ordinarily objects that are unpleasant may be repressed but the schizophrenic cannot do this and so the objects are split off and identified in particles in and with other objects. 

In turn, this makes the introjection of those objects impossible. One consequence of this is that excessive projective identification at an early stage prevents "smooth introjection and assimilation of sense impressions and so denies the personality a firm base on which the inception of pre-verbal thought can proceed" (p.61). 

Attacks on Linking:

I have previously read Bion's essay, "Attacks on Linking," but did not, at the time, pay attention to the fact that it was so focused on psychosis and schizophrenia. But now, having read it in this context, and in light of other recent reading, this chapter makes a very great deal more sense.

The patient attacks anything that feels like a link between objects. They may even attack links to such fragments of feelings they feel, or need to feel: thus they can hate their hatred, etc.

One helpful way to begin to notice these attacks on linking, Bion says, is the frequency with which they often resort to "it seems" language rather than such firmer declaratives as "it is" or "I think." 

Because it is difficult for the schizophrenic to accept links, Bion strongly advises (and others do, as we have seen) that the therapist avoid why questions: the patient will have little understanding of causation, those links having been severed also. So do not ask why or try to induce the patient to offer some speculation on how A might have caused B.

This lack of understanding of causation, on a much larger and 'structural' scale, comes up later in the book when Bion says we must not expect to meet material that has been filtered and mediated by the patient's personality:

Psycho-analysis of the psychotic personality thus has a quality which makes it so different from the analysis of the non-psychotic personality. Conversely, the relationship with external reality undergoes a transformation parallel to the relationship with psychic reality which lacks an intervening (or "interceding") model. There is no "personality" intervening between the psycho- analyst and the "unconscious" (p.147).

A Lack of Dreams:

Bion seems to accept--as other authors noted on here also do--that hallucinations and delusions are, and are to be discussed and treated as, wide-awake dreams. Their prevalence may explain the striking absence of actual nocturnal dreams. In some schizophrenic people, conventional nocturnal dreams might well be found to be rare: "The psychotic patient appears to have no dreams, or at least not to report any, until comparatively late in the analysis" (p.98). 

Primitive Disaster and Ever-Shifting Psychotherapy:

Bion engages in some useful repurposing of Freud's famous analogy, saying that "I suggested that Freud's analogy of an archaeological investigation with a psycho-analysis was helpful if it were considered that we were exposing evidence not so much of a primitive civilization as of a primitive disaster"(p.101). The problem, he elaborates, with the metaphor of an archaeological dig site is that it presupposes a static and settled site, but an analysis/therapy is no such thing: it is a moving thing of many parts. (A realization of this lies behind his strong deprecation of the therapist entering a session with memory or desire, which may weigh down and hold the session back from moving in the direction it wishes.)

In particular terms, Bion notes that this is true of the use to which hallucinations are put: such use is often constantly changing so one must not assume a once-and-for all grasp of the hallucinations and their purpose in the patient's life.  

In general, and overall Bion advises--as many others do--that the therapist prepare for lots of ambivalence: the patient may come, eventually in his own way, to manifest some gratitude that the therapy gives occasion for or provides things the pt. was denied growing up, but that same patient will also manifest resentment/hostility, also directed toward you, that he was deprived in the first place. 

So you are--in Kleinian terms--both the good and bad breast. This may well arouse in you a regular feeling of being uncertain and confused, as the patient will seek to attack your peace of mind, and any links in your mind between the work you are attempting and the changes you hope to see. Others I have read all make note of this, and advise that the clinician must be very comfortable with going for long stretches where things do not seem clear. 

Here is where Coltart's words come back to mind for me when she advocates that we have "faith; faith in ourselves and in this strange process which we daily create with our patients." Such faith will carry us through the long stretches of fog during which we long, in Newman's felicitous words, to see the "kindly light" but are denied it, instead being forced to accept "one step enough for me." 

To preserve and protect that faith, and even more the freedom of the patient, Bion, at the end of the book, it seems to me, goes on what I regard as a radical Fromm-like tear about absolutely respecting the freedom of all your patients, the schizophrenics especially. This requires your getting rid of any desire for "cure" or "improvements" or "results" in your patients (the neurotics as well as psychotics). If you have no such desires, then there is one less thing for the psychotic patient to attack. Moreover, of course, Bion thinks having those desires--whether they are attacked or not--is a hindrance to the patient and an impingement on her freedom. In this he is joined by other members of the British school, including Nina Coltart, who also strongly disdains the language of cure. 

Overall, for those undertaking this difficult and lengthy work with these types of patients, Bion's book offers some helpful counsel encouraging freedom and creativity: "The psycho-analyst who undertakes a schizophrenic analysis undergoes an experience for which he must improvise and adapt the mental apparatus he requires" (p.146).