Psychotherapists’ experiences of withdrawn psychotic patients

The Feared Therapist: On Being Part of the Psychotic Patient's Paranoid Delusion

“…Given the proposed importance of the delusion for the patient, what is the psychotherapist to do when not only faced with the delusion, but also implicated in it (Knafo & Selzer, 2015)? If an attempt at relieving the patient of their delusion without resolving their need for it is understood as largely unproductive, the psychotherapist may feel unsure as to how they are to proceed – a disturbing kind of uncertainty that can dissuade psychotherapists from engaging with psychotic and delusional patients (Aronson, 1989; Saayman, 2017, 2018, 2019). It has been well established in psychoanalytic theory that working with psychosis can be a confusing and disturbing experience for the psychotherapist (Bion, 1957; De Masi, 2009; Joannidis, 2013; Mills, 2017; Saayman, 2017, 2018, 2019; Schwartz & Summers, 2009).…”

“…If an attempt at relieving the patient of their delusion without resolving their need for it is understood as largely unproductive, the psychotherapist may feel unsure as to how they are to proceed – a disturbing kind of uncertainty that can dissuade psychotherapists from engaging with psychotic and delusional patients (Aronson, 1989; Saayman, 2017, 2018, 2019). It has been well established in psychoanalytic theory that working with psychosis can be a confusing and disturbing experience for the psychotherapist (Bion, 1957; De Masi, 2009; Joannidis, 2013; Mills, 2017; Saayman, 2017, 2018, 2019; Schwartz & Summers, 2009). There are many psychoanalytic accounts of how and why psychotic communication is often represented and conceptualized as bizarre, disturbing, un‐understandable, and seemingly devoid of meaning (Arieti, 1957; Benedetti, 1999; Bion, 1954, 1975; Cain, 2010; Calamandrei, 2009; De Masi, 2009; Freud, 1924; Hill, 1955; Karon, 1992; Leader, 2011; Lucas, 2003; Olanen, 2009; Rosenfeld, 1969; Searles, 1963, 1972, 1973, 1975; Winnicott, 1949).…”

“…As a result, distinctions between improbability, probability, possibility, impossibility, fantasy and reality are lost in the warped logic of the delusional system (De Masi, 2015). This implies that, when confronted with an uncontained delusional patient, the psychotherapist has to rely much less on their capacity to reason with the patient, and much more on their capacity to hold the patient's projections, and importantly, the capacity to hold and regulate their own experience of disturbance (Saayman, 2017(Saayman, , 2018(Saayman, , 2019. This is what I attempted to do with Leona when she was enraged and terrified in session 37: I allowed myself to experience the full force of her presence as well as the subsequent disturbance that it evoked in me.…”

“…Here the psychotherapist is often placed in a position where they are called on to look at some of the most ungraspable aspects of the patient's unconscious inscriptions, and to explore the early failures and injuries in the relationship between the care giver and infant that stand to disturb the primary processes of differentiation and subjectivation (Campoli, 2017). Moreover, the psychotherapist is also asked to hold and explore the often disturbing countertransferential reactions that this engagement can evoke (Saayman, 2017(Saayman, , 2018(Saayman, , 2019Searles, 1966).…”