Abstract
Christopher Bollas, rightly described as “one of the most creative and inspiring writers in the history of psychoanalysis” (Jemstedt 2011, p. xii), recounts in this heartfelt and beautifully written book what he has learned from working with schizophrenic patients beginning in the 1960s and continuing over five decades of clinical experience. The book, which he describes as a companion piece to the earlier Catch Them before They Fall: The Psychoanalysis of Breakdown (Bollas 2013), takes the form of a chronological memoir of his entire career as a psychotherapist, beginning as a twenty-three-year-old graduate in history from the University of California working with autistic and schizophrenic children at the East Bay Activity Center in Oakland; through his introduction to being a psychotherapist while a graduate student in English literature at the University of Buffalo; his training in psychoanalysis at the London Institute for Psychoanalysis and the Tavistock Clinic in the mid-seventies; his twenty years of private practice in London, during which he treated mainly severely disturbed psychotic patients; his work at the Austen Riggs Center in the mid-eighties; and on into the present. The book closes with a portrait of his work with a patient living on a remote island in a Norwegian fjord, with whom he spoke five days a week on the telephone from his farmstead in Pekin, North Dakota, where he spends half the year. Over the course of these fifty years, Bollas has written over a dozen books, which in their cumulative effect amount to a uniquely original re-visioning of the psychoanalytic enterprise from the ground up.
Thus, the profound impact of his experience of working with schizophrenia appears to have marked the very beginning of his calling to become a psychoanalyst and to have persisted as a touchstone in the long development of his thought. As he says at the end of his introduction to this book, “The challenge of working with the schizophrenic remains, to my mind, a portal to further study of the human being. Perhaps it is to our time what the dream was to Freud” (p. 10). Throughout, one gets the palpable feeling of how much Bollas’s way of working and thinking is derived from his placing himself in the position of dedicated caretaker and student of his patients. As he is careful to point out at the beginning, the book is intended to be neither a textbook nor a review of the voluminous writings on the conceptualization and treatment of schizophrenia to be found in the psychoanalytic and psychiatric literature. It is rather a self-portrait of one analyst’s evolution in his way of thinking, being, listening, and interacting with patients suffering this devastating condition of psychic distress, an evolution he has found to be personally illuminating and clinically useful. His deep assimilation of a wide range of psychoanalytic theories, notably derivations from Freud, Winnicott, Bion, and Lacan, is so seamlessly interwoven in his own conceptualizations that there is never a point where the narrative momentum of the book is lost to abstract argumentation. Bollas’s voice has a natural eloquence derived from his exquisitely perceptive analytic ear in the consulting room, alone with the patient, and forged in what he describes elsewhere as his “private and isolated struggle” (Bollas 1987, p. 10) to understand what is being experienced, enacted, and transacted in that privileged sanctum. Thus, in keeping with his deep and hard-earned empathy with their plight, he dedicates the book to his schizophrenic patients, “to their brilliantly inventive solutions to their predicament and especially to their profound courage” (p. 10).
Going completely against the ever increasing trend toward the medicalization of psychiatry, its equation of mental illness with biological disorders of the brain, and its consequent antipathy to the efficacy of the “talking cures,” Bollas maintains that psychoanalysis is the treatment of choice for schizophrenia (as well as for manic-depression, and for people who are having a mental breakdown without having already become psychotic). “Although medications may prove invaluable in the course of psychotherapy, nothing helps schizophrenics more than a single one-on-one commitment by a fellow human being who has taken the time and endured the training to know how to read them, be with them, understand them, and talk to them” (p. 187). This is particularly important at the onset of the schizophrenic’s break with “reality,” before the schizophrenic process has taken over the whole of the patient’s personality: In the days after breakdown a person usually wants to talk and is reachable. If days give way to weeks and months and no one is there to talk to—intensely, deeply, madly, and at length—then all involved are in a different realm. The need to talk and to find help has not been met. The patient has been abandoned to another order and is now lost to what we term schizophrenia [p. 171].
What Bollas has in mind here is attending to the patient for long periods of time, perhaps several times a day for many days and possibly weeks on end. Elsewhere in the book he says that the process, which he describes as both a “restructuralization of the mind” and a “restoration of the self,” can take months or even years, depending on the willingness of the patient to engage with the analyst in the intersubjective, mutually transformative process of psychoanalysis. By this, he means to adhere to the Freudian paradigm—one person lying on the couch free to say whatever comes to mind or not to speak at all, the analyst sitting out of sight, saying nothing, or very little, but deeply listening. As free association will structure the patient’s cumulative transmission to the analyst, the analyst’s largely unconscious attunement to the patient will reveal meanings inherent in the sequence of the patient’s communications. Bollas extends Freud’s “free-floating attention” or state of “reverie” on the part of the analyst from its emphasis on what he calls the “logic of sequence” of the patient’s associations to include a receptivity to a wide range of unconscious communications by the patient, both verbal and nonverbal, that can be accessed by the analyst: unconscious thinking, unconscious perception, unconscious fantasy, unconsciously meaningful form, expressed in either speech or action. Bollas describes this elsewhere as the analyst’s becoming receptive to the “idiom” of patients, the “aesthetic of their being,” the unconscious expression of their whole way of experiencing themselves in the world. As Adam Phillips says of him, Bollas brings a much needed reminder of the unconsciousness of the psychoanalytic process itself. “The greater part of psychic change occurs unconsciously, and need not enter consciousness, either in the analyst or in the analysand” (Bollas, quoted by Phillips 2011, p. ix).
Bollas does not propose any theories as to the causation of schizophrenia. In fact, he claims, “We shall never know whether schizophrenia is the outcome of phylogenetic, genetic, intra-uterine, early infantile, infant-mother, linguistic, sex shock, family, or accident-in-the-real causes” (p. 181). We can observe, nevertheless, how the person who has become schizophrenic perceives reality, thinks, behaves, and relates. “Whatever the genesis of schizophrenia, the first distinct outcome is a split in the self in which one part functions in an ordinary manner and another part develops a radically different way of perceiving, thinking, and relating” (p. 181). Schizophrenics may experience profound alterations in their way of seeing, hearing, thinking, experiencing their bodies, and interpreting what is going on in the world around them. Everything changes. The world is not the same. The person becomes a stranger to himself and unrecognizable to his family and friends. “The ‘I’—the speaker of being—has departed” (p. 76). Bollas makes an important distinction between slow and acute onset of schizophrenia, with the general admonition that the earlier the schizophrenic can be brought into treatment, the more chance there is of reversing the process. Patients who, instead of being offered open-ended intensive psychotherapy at the beginning of their illness, have been heavily medicated, hospitalized for a long period, and left with no one to talk to are those who might have been saved but were instead abandoned.
In the schizophrenic breakdown, the relationship of the self to its historical past is experienced as forever broken. These patients have crossed over into another reality, one that totally absorbs their attention: an hallucinatory, terrifying world completely divorced from the common social order. In defending themselves from remembering or indeed reexperiencing unspeakably painful events in the past, schizophrenics may invent a mythological narrative as an alternative, often supernatural, account of who, where, and what they are.
The creation of a mythic self allows for schizophrenic transcendence in which one rises above the scene of catastrophe to an alternative reality inhabited by an avatar with an invented past. Schizophrenic transcendence does not eliminate mental pain or terror—the mythic world is inhabited by dangerous voices, visions, and demons—but it does provide the self with some way of structuring its past, present experience, and future. During this period in the analysis of a schizophrenic, the psychoanalyst may become a sort of cultural anthropologist, attending carefully to the patient’s myths. Inside the story of the self’s past and the characters that populate this world are encoded memories, both of the self’s fantasy life and his actual existence. . . . The myths are profound dreams stored throughout the lifetime of the self, and they are precious. The analyst has to accept that these myths may define the work for a long time, and they must be treated with great respect [pp. 89–90].
In addition to the eradication of history and the invention of a personal mythology, the analyst may also observe the schizophrenic’s having entered into a “semi-mystical union with inert objects,” a kind of animism in which objects become alive while at the same time the human element of the patient has been projected, banished, and transposed into the object world. The schizophrenic may also evince what Bollas calls “metasexuality,” in which she evokes the unconscious fantasy or delusional conviction that she has become an amalgam of mother, father, and infant—that she is male, female, and newborn, all combined in one. She is in constant “metasexual” intercourse with, and between, objects in the nonhuman environment.
Schizophrenic metasexuality aims to eliminate the disturbing psychic effects of the primal scene by incorporating it, and all of its unconscious derivatives, thereby nullifying the reality of sexuality altogether. This is achieved, paradoxically, by omnisciently treating all connections in life—person to person, a person to an idea, an object to any other object—as sexual. By sexualizing everything, the schizophrenic proactively eradicates the specificity of erotic fantasy life and the reality of sexual engagement with a specific other. . . . The result is a divided self, split in two, but with the infantile and adult parts of the personality also existing in parallel. The schizophrenic has joined two eras and two selves into one and has evoked the power of sexuality to accomplish this defense. However, he believes that there are higher forms of intercourse than mere sexual union. By incorporating sexuality, and thereby neutralizing it, the schizophrenic feels he has attained a higher realm of intercourse in which attracting opposites are combined into new forms of bliss, which are sometimes experienced as intense spiritual communions [pp. 97, 99].
All of these radical alterations of the structure of experience are unconsciously motivated to protect the schizophrenic person from experiencing terrifying, catastrophic, and annihilating thoughts and feelings. They are part of “an unconscious effort to move away from people and especially to transcend the intensity of human relations” (p. 91). The schizophrenic thus withdraws from his own humanity, projecting elements of his own mind into external objects. The world is a dangerous, threatening, and painful place. But he cannot get hurt if he is not there to begin with.
In keeping with his focus on the articulation, alteration, and transformation of the schizophrenic’s subjective experience of being, Bollas attends very carefully to her use, or avoidance, of the personal pronoun “I.” “I” is the self’s speaking position. He proposes the idea that the schizophrenic may have abandoned the conventions of self-other discourse, relinquishing the I so that there is no speaker to re-present the self. Those listening to the schizophrenic are therefore left witnessing the way thought occurs originally, unmediated by what Freud termed “secondary process thinking” or “revision.” However, schizophrenic speech does also include clear units of sensible articulation, so I believe that this schizophrenic action may also reflect something else: an action that I term psychotic revelation. This involves the feeling that more truths are being expressed in the here-and-now than are uttered by normal conscious verbalization [p. 117].
This understanding of the phenomenon of schizophrenic speech is consistent with Bollas’s more general view that we have very little conscious knowledge of what is taking place in the unconscious mind, and that the “normal” experience of thinking, feeling, perceiving, and knowing is a “dumbed-down” version of what, in fact, is there to be registered and experienced. By far the greater part of what we call thinking, feeling, and perceiving is operating below the level of conscious awareness: “We have no direct experience of unconscious perception except in the dream, and even this is a highly organized sample from, but not of, the unconscious. Consciousness does not otherwise see its world through unconscious mentation, except now and then in the schizophrenic’s world of perception” (p. 122). And, Bollas would add, in the minds of artists, poets, and mystics, who also have found their way beyond the veils of ordinary perception, though often at great cost to their sanity.
Bollas considers the characteristic delusions, visions, and hallucinations of the schizophrenic as intrusions into consciousness of thoughts, images, feelings, and perceptions derived from the stream of unconscious ideation: Those unconscious processes of thought that have woven our own idiomatic pattern through the materials of our world now, for the schizophrenic, punch their way into consciousness—as vivid visual images, powerful bodily dispositions, the sound of accusing voices, or as a smelling of the world, shifting from moment to moment. . . . Whatever the individual quality of this breach—delusion, vision, hallucination—such patterns are attempts to organize and make sense of the sudden flooding of the self with unconscious thinking that penetrates consciousness [p. 122].
These elements of unconscious mental process are bits and pieces of the fragmented self, which have been projected into the environment and now penetrate consciousness as though coming from an external source. This projective process, when it occurs, is ultimately defensive in nature, a radical way of ridding the mind of thoughts that threaten to annihilate it. In the deepest states of schizophrenic withdrawal, the person is ultimately seeking to become mindless altogether. And in becoming mindless, the patient also becomes objectless. The clinician working with a schizophrenic cannot assume that the patient will be at all able or willing to admit a fully human presence into awareness. The analyst must be prepared to be consigned to the nonhuman environment, assuming the position of an inert object. Nothing can be interpreted, confronted, or challenged. On the contrary, the delusions, hallucinations, visions, and other bizarre construals of “reality” must be respected and understood as vital at this time to the patient’s psychic survival: One becomes aware of a kind of psychotic minefield in which both words and things may be dangerous, and over time one develops a kind of mariner’s chart of how to navigate in the individual’s world in order to avoid these dangerous objects. Unless one respects this defensive structure to begin with, I do not think it is possible to earn the patient’s trust. But when he realizes that the analyst understands that he experiences certain things as terrifying, and that the other will not impose his will on those objects, he may feel increasingly safe [p. 139].
Bollas describes phases in the treatment of a schizophrenic in which he “had to be diminished to a point where I understood nothing and where all we shared was an insensible affinity. We were to be reduced from linguistic creatures to selves with only nonverbal forms of communion” (p. 144). This is a purely “sensorial,” nonverbal order akin to that between mother and infant, in which silence can encompass core truths, “a form of communication that existed before the wording of the self ” (p. 144).
In Bollas’s way of comprehending the uncanny phenomenon of schizophrenic breakdown, “the integrity of the ‘I’ is fragmented and projected into the environment for safekeeping” (p. 169). The goal of therapy is conceived as a restoration of the self, a process that is also understood as facilitating alteration and change in the patient’s psychic structure. In order to accomplish this, the patient must be allowed to talk, at length, and from within a therapeutic alliance based on trust and safety. The aim of the analyst is not to do something to the patient, but to gradually become something for the patient. Although Bollas does not use the term in this book, that “something” is what he has elsewhere called a “transformational object” (Bollas 1987), a presence less identifiable as a person than as a signifier of transformation, the total environment provided by the analyst that is experienced by the patient as a matrix of processes that alter self-experience.
Narrating the self invariably strengthens the “I.” As well as being informative in itself, the simple act of talking and talking and talking, recounting in minute detail the events of the previous days, is structurally efficacious. As the “I” speaks, again and again, it resumes its representative function. Consciousness begins its return to the self. Any person who is dissolved by schizophrenia must be given substantial amounts of time to speak, to utter the word “I,” in order to feel the restoration of the narrative core. When the patient speaks to the analyst, the clinician proceeds to link emotional states to actual events (symbolic nodal points), and the patient has a chance to become recontextualized, returned to the historical self. He then avoids being left to invent a new person and a new myth [p. 170].
As he describes with regard to nonpsychotic forms of mental breakdown in Catch Them before They Fall (Bollas 2013), it matters enormously whether the opportunity for intensive psychotherapeutic intervention is provided near the onset of the schizophrenic break with “reality” or later, once the patient has become more firmly habituated to living in a parallel universe: “With the schizophrenic, engaging his ‘I,’ the subjective position, is crucial. If he has not given up, there is time to get him to shore. If he does give up and is drowning in a psychotic process, he may be revived by medication, but he will not be the person one could have reached before this self-abandonment and fragmentation” (p. 171).
In the chronic schizophrenic, the person has become organized against introspection, memory, and willing recognition and perception of his surroundings, because “to look within the self, from his point of view, is to invite the catastrophe of the arrival of thoughts” (p. 172). He harbors intense fears and fantasies of annihilation. The therapist is then faced with the task of transforming defensive fear into intersubjective engagement. Bollas describes this as a gradual movement from a kind of autistic, solipsistic alienation from the basic humanity of the analyst to a point where the patient expresses curiosity about him. In narrating the “I” to a gradually emerging “you,” the patient is involved in the crucial process of reclaiming into consciousness all those aspects of mind that have been fragmented and projected into the nonhuman environment, leaving the speaking subject devoid of a sense of his integrity as a person and having no sense of identification and continuity with his own history: “Initially, the schizophrenic will usually regard any relationship as highly dangerous—it will evoke affect and mental content, and is therefore liable to elicit psychotic anxieties. However, after working in this way for some time, psychologists generally encounter schizophrenic curiosity. The person may become curious about the therapist” (p. 173).
One can judge the severity of schizophrenic withdrawal by the degree of impermeability that has been erected to intersubjective communion of any kind. The discovery of the singularity and “otherness” of the analyst will then reflect a parallel process of the restoration of the patient’s self as the locus of thoughts, feelings, memories, and perceptions that are experienced as his own. The patient’s use of “I,” “me,” and “mine” becomes newly meaningful in parallel to his use of “you” and “yours.” This movement, from objectlessness to intersubjective relatedness, is the first great milestone in the building of psychic structure.
This curiosity may take months or years to develop, and with some patients it may never happen. But if the psychologist has engaged the patient soon enough after the breakdown, then there is a fair chance that it will develop, and when it does it is an important step in their human relations. Patient and analyst meet at a crossroads: can they develop curiosity about each other, or are they to remain as fortified islands of independence, simply passing commonalities back and forth? . . . After a while, the patient may abandon the schizophrenic gaze and no longer use the optical black hole to rid the self of here-and-now experience. He may begin to listen to the analyst and take in what is said. If and when curiosity segues into affection, this marks another important moment in the evolution of the relationship. It is a subtle but discernible step. Over time, the patient finds the therapist’s traits reliable, then reassuring, then somewhat amusing, and finally endearing [p. 174].
From this position of intersubjectivity between analyst and patient, a shared narrative is created, what Bollas describes as a shared reverie based on the recounting of the details of everyday life and the associations they each have to what is being talked about. “The psychoanalyst and the schizophrenic find refuge in the everyday, they begin to benefit from the reverie intrinsic to indexing that day . . .” (p. 179).
The reverie that is history has not only transformed the inchoate nature of the past by putting it into a shared narrative; it has generated a receptive attitude in the mind so that the emotional experience that shocked the self into a schizophrenic reaction can be accessed. It is impossible to describe how meaningful this is to both persons. There is no need for celebration or emphasis. The recalled event has already spoken for itself in the here and now, and from this point forward analyst and patient will work from a shared emotional epiphany that binds them together in a deeply moving search for the meanings behind that event and why it was so deeply disturbing [p. 180].
Psychic change occurs when what Bollas calls the schizophrenic’s “unconscious axioms of being” are brought within the realm of thought (p. 181). This is where the analyst’s interpretive work enters the picture as the catalyst of the patient’s engagement with the fundamental premises and assumptions that underlie their entire experience of living.
The ordinary axioms of the mind are those paradigms of perceptual organization that are generated by innate features of the human species and those acquired in the course of human relations, especially in the first year of life. We are governed by thousands of unthought known axioms that we never think because they formed before we had concepts with which to think them, when our idiom met with thousands of experiences that established our unconscious decisions about how to be and relate. It would be impossible to provide an inclusive index of the axioms that govern mental structure, but in psychoanalysis and psychotherapy some become available for knowing [pp. 181–182].
One such axiomatic structure is the unconscious establishment of the boundaries of the self: what is “me” as opposed to “not-me.”
To give one simple example, we believe that we are separate from the objects that we perceive around us. If I walk down a street and see a car I assume I see something that is not myself. The car and I are distinctly different phenomena. A schizophrenic might see a car and assume that the car is a part of the self. If the car is a Volvo and the schizophrenic a female who believes her vulva organizes her orientation to reality, then the sight of a Volvo might be experienced as a manifestation of her vulva. Because of designification and the return from the symbolic to the sensorial order, words are often used by schizophrenics because of their sound meaning. Vulva is close in sound to Volvo [p. 182].
The core of Bollas’s conception of how psychoanalysis works is that psychic structure is changed by the analysis of disturbed, psychotic axioms of the schizophrenic’s mind:
Mental structure is composed of countless assumptions that constitute the predicates of mind. When I am engaged to help change the mental structure of a schizophrenic, I begin by trying to identify those axioms that constitute their psychotic assumptions. I then put them into words in order to change their status from that of a given to that of a view. Psychotherapy of the schizophrenic works through the careful personal anthropology of the individual’s core convictions, those that seem to govern his mentality. This book has outlined the many differing preconditions for the effectiveness of interpretations, especially the crucial role of the analyst’s way of listening, his empathy, and his basic human presentation. At some point, however, he will begin to analyze disturbed axioms in order to effect structural change [pp. 182–183].
Bollas’s conception of what counts as an effective interpretation in this regard is related to his use of what he calls “acts of lucidity” and the provision of “lucid explanations” in Catch Them before They Fall. Lucid explanations are simple, clear statements of some core dynamic apprehended by the analyst as a result of his having absorbed the unspoken premises and assumptions that organize the patient’s mental world. Bollas describes the making of such an interpretation as rather like the analyst’s spoken reveries for the patient: I think it is one form of unconscious communication between the analysand and the analyst, as if the analyst’s commentary is a verbal matrix within which the patient can imagine something completely different. . . . I tend to challenge the analysand’s mental axioms, and the analysand benefits from these mentally engaging encounters with the analyst. The intention is to introduce another perspective that loosens up the patient’s ability to engage in generative self-reflexivity [Bollas 2013, p. 122].
A good interpretation is a verbal communication from the analyst to the patient that brings a previously held unconscious tenet of the patient’s understanding of self and world into consciousness as a viewpoint to which there may be alternatives. It opens a portal to a heretofore unthought but now possible new world of experience: “Any good interpretation that makes an unconscious assumption conscious creates a potential space. The potential is that through wording and understanding, a previous axiom can now change, transformed by the relief delivered through that understanding and its withstanding of many challenges to it over time” (p. 184). Bollas illustrates such an axiom-oriented interpretation in working with a teenager suffering from anorexia: For example, an anorectic who is functioning, let us say, according to many disturbed axioms may transform all of them as the result of a single axiomatic change. One such axiom—“I suffer an illness called anorexia that has taken me over and I can do nothing about it,” say—might be subjected to the inter-pretation “You prefer to call the change from being a child to becoming an adult an illness, because you are distressed by inevitable changes in your body.” Over time, if this interpretation is accepted by the analysand, then she may not only emerge from the anorectic behavior, but many other assumptions about being and relating may be unconsciously transformed as well. Schizophrenics too can embark on many changes as a result of intensive psychotherapy, but such changes will take longer for them than for the non-psychotic personality [p. 186].
The so-called therapeutic action of psychoanalysis, particularly but not exclusively, as applied to the treatment of schizophrenia, is here reconceptualized by Bollas in terms of structural change of the patient’s unconscious mind as catalyzed by the effect, over time, of the analysis of pathological “axioms” that organize the patient’s self-experience.
When working with a schizophrenic, core axioms exist that need transformation through interpretation. (I have discussed many of those in this book, for example the axioms of metasexuality, animism, projective identification, and senselessness). Ordinarily a time will arrive when the patient is ready to think about one or another of these core action-thoughts. As with any patient, it may be months or years before this process of thought—in which unconscious assumptions are placed in the potential space inherent to consciousness—brings about change. What proof do we have that the person is no longer schizophrenic? The evidence resides in the altered assumptions that now govern this person’s mental life and behavior. It is not a question of adding something to the self that was missing; it is a matter of transforming a psychotic axiom into its non-psychotic alternate. The process is not mysterious but quite ordinary. As infants become toddlers, many axioms change. The assumption that food arrives if we cry is eventually replaced by the notion that in order to get food we must speak. As we grow older that recognition will change to a realization that in order to eat something we may have to get the food for ourself from the refrigerator or cupboard. In adolescence and then in adult life, axioms will alter again, as we come to realize that in order to get food we need to earn money, go to the stores, purchase the food, prepare it at home, and so forth. In other words, although we are governed by axioms, they alter over time. We are thus unconsciously accustomed to notional change: to restructuralizations of the mind. Indeed this simple, inevitable fact of human mental life is the foundation of any success to be found in clinical psychoanalysis. Unfortunately, for whatever reasons, schizophrenics have found many of those ordinary changes traumatic, and a vital condition of therapeutic effectiveness will be whether the analyst can reintroduce the analysand to the generative potential of change. He will have to earn the person’s trust that the trauma of change has some benefit to it [pp. 185–186].
The patient’s mind is truly changed when viable alternatives to his psychotic, pathological axioms of being, originally presented to him in the analyst’s act of lucidity, have become internalized and experienced as thoughts and feelings of his own, not simply foreign ideas proposed to him by the analyst. This, in Bollas’s original idiom, is a reconceptualization of Freud’s notion of “working through,” which he regarded as a touchstone of the cumulative effect of the analyst’s interpretive activity on effecting psychic change in the patient. The adoption of an alternative view of reality is not made by conscious decision, however. The process is much more subtle and mysterious, and is largely transacted unconsciously, over a significant amount of time.
It is only when the analysand changes her mental position and her behavior, no longer referring to the analyst but now presenting her new point of view as her own, that we know the conscious interpretation has become a new axiom in the mind. This is what is meant by structuralization. Something put into words, objectified in the transitional fields of consciousness, held within the patient as an internal object of thought associated with the analyst, is now assimilated into the patient’s mind. It is a new form within the self’s unconscious [p. 185].
The psychoanalytic treatment that Bollas describes can take months and years. Every case is different, and there is no way of predicting the outcome. At the very beginning of this remarkable book, Bollas asks himself the question, “What does a schizophrenic look like after what I consider to be a successful analysis?”
There is no ready answer to this any more than there is to the question frequently posed to non-psychotic analysands: “What did you get out of your analysis?” Schizophrenics vary in their own idioms as much as non-schizophrenic people, but I consider it a successful analysis if the person has turned away from hallucinations and psychotic defenses, relates and functions in non-psychotic ways, and is no longer suffering the mental pain of being schizophrenic. I do not think a person who has had a schizophrenic breakdown will ever forget it, nor do I think anyone is ever entirely free of it, any more than a person can recover from childhood to the point of no longer recollecting it or being influenced by it. However, I shall quote one schizophrenic who, some fifteen years after his last schizophrenic episodes (hearing voices, intense paranoid withdrawal, speechlessness), said, “Well, I was schizophrenic and now I think I am just schizoid” [p. 5].
There is no way of conveying the richness and originality of this book. The clinical material around which Bollas’s theoretical narrative is woven must be read in tandem with the exposition of his comprehensions in order to appreciate what he has accomplished. One then can get very close to how the actual schizophrenics he has treated think, feel, behave, suffer, relate, and change, and also very close to how one of the great clinicians of our time works with them.
I know of no better account of what the clinician is up against when confronted by schizophrenia and of what is involved in facilitating a possible recovery. Bollas manages to convey not only profound insight into what it means to “lose one’s mind,” but also how and why psychoanalysis is uniquely well suited to restoring it. In the course of his doing this, one can catch a glimpse beyond this most devastating of all mental illnesses to a revisioning of the structure and dynamics of the psychoanalytic process itself. It is a stunning achievement, based on a lifetime of clinical experience and deep reflection, taking nothing for granted, as one must when delving into the unending mysteries of the human mind.