This paper describes psycho-analytic work on a sequence of dreams taken from key points in the long-term intensive treatment of a male patient in his mid-thirties. Living an active homosexual life, he was suffering from depression associated with the gap between his life-style and his desire to have a wife and a home and to become a father.

Waking fantasies which emerged as free associations in the sessions, usually as some form of transference material, are also described .

Bion's concept of attacks on linking and his differentiation of the psychotic from the non-psychotic part of the personality particularly in relation to the psychotic defence of fragmentation are used to help understand the material.

Unconscious phantasies about bodily structures and processes are explored in relation to specific material about the patient's homosexual/heterosexual conflict . These phantasies exemplify the patient's internal struggle between life and death instincts.

The patient has, over the last three years, developed a long-term relationship with a woman partner with whom he lives. She has recently given birth to their second child.

(clinical material omitted)

Bearing in mind the above clinical material, I shall briefly turn to this key paper of Bion's which illuminates the inner struggle of the patient and the transference and counter-transference experience which I have begun to describe.

In this paper, drawing on work he has described in an earlier paper on the Development of Schizophrenic Thought (Bion 1956), Bion makes a breakthrough in understanding psychotic thought processes and the kinds of mental organisation or structures with which they are associated. He does so by selecting key ideas from the work of Freud and Klein and bringing them together in a highly original way.

He refers to :

1 Freud's work on the mental apparatus associated with the reality principle, particularly 'that part of it which is associated with the sense-organs'

2 Klein's description of the phantasied sadistic attacks made on the breast during the paranoid-schizoid phase

3 Klein's discovery of projective identification (p43)

He then goes on to identify certain mental preconditions which provide the soil in which these psychotic mechanisms can flourish :

1 A preponderance of destructive impulses that turn love impulses into sadism

2 A hatred of internal and external reality 'extended to all that makes for awareness of it' (p44)

3 A dread of immanent annihilation associated with the re-introjection of what has been projected and suffused with unconscious phantasy

4 A premature and precipitate formation of object relations characterised by thinness and tenacity

This part of Bion's paper concludes with a consideration of the implications for the transference which, under the pressure of the struggle betwee n the life and death instincts, oscillates between a broader and a more restricted contact.Object relations, he writes, are characterised by massive fragmentation, projective identification and a withdrawal from reality. The ego also becomes structurally split and the psychotic part becomes fragmented, as the efforts to keep the two parts of the personality separate have to become increasingly strenuous.

Moving on from Freud's formulation, Bion emphasises the preponderance of omnipotent phantasy which is geared to destroying all links with and awareness of reality. .He points out that the patient who is in the grip of the psychotic part of the personality is actually suffering from the illusion that withdrawal is possible. This illusion he suggests, is based on a belief that it is possible to fragment perceptions in such a way that they can be got rid of by projecting them into objects which are then treated as if they were the 'furniture of dreams' . The patient then becomes the prisoner of the planetary system of projective identification he has created.

This split and fragmented mental structure carries important implications for the patient's capacity to think, to articulate and to be capable of creative imagination. Synthesis, Bion states, becomes hazardous involving as it would a re-introjection of what has been projected (p52).

In the clinical material I have described so far the patient describes the fragments in his psychic jigsaw : the transient homosexual encounters, the storybook 'family' for which he yearns and his vacant relations with women. Each fragment shares the qualities as described by Bion : a superficiality or 'thinness', a deep ambivalence which creates a 'make and break' pattern of relating, and a covert sadism saturated in contempt and expressed through control. Although at times he can recognise these fragments, and the object relations with which they are associated, as part of 'his story', they mostly feel to him like disconnected footnotes lacking substance or connection.

In the dream material, this state of mind is made transparent and though he is relieved to discover that sense can be made of his sadism, his relief is quickly followed in the transference by an attempt at further withdrawal into a phantasy that reveals psychic contortions of a sadistic and controlling kind.

I think this early phase of treatment established for the patient the beginning of a hope that sense might be made of his fragmented and contradictory inner world .However,that hope was accompanied by a reluctant recognition that I was essential to that sense-making process, even though I was seen as boringly mundane. I had to be suffered as an irritating but sometimes fascinating intruder on a mental landscape of which he was the only architect.

I in turn believed that I might understand the dangerously seductive allure of his exotic, silent and nihilistic inner world if I could bear his contempt whilst continuing to listen acutely to his unconscious communications.

I shall go on now to identify a critical turning point in the treatment with more clinical material

There is always so much that one can say about a treatment as long and as complicated as this one. Here all that I wish to do is to consider the changes in the mental structures and processes over time.

In the very early part of the treatment, the patient offered a veneer of order. His object relations were superficial and transparent : a series of heroic males with whom he could consort at will on a transient basis and a female friend whom I have not discussed in this paper but who was idealised from a distance and treated badly when he came near to her. The splitting was almost too obvious and the counter-tranference experience was that of a pseudo-alliance barely concealing his contempt for me and for all life outside of his own exotic dreams.

The second phase was characterised by a pre-occupation with bodily fluids and structures, either through direct material about the body or through material about buildings and the countryside. Here he was sorting out his confusion about bodily zones and functions at the most primitive of levels. The counter-transference experience was of someone seriously involved in a process which he does not fully understand and cannot control and in which he is led by his unconscious.

The final phase is one characterised by immense turbulence. The hated female objects and the projective identifications with which they are associated are reintrojected. They are rediscovered through a brief and caring apprenticeship to a heterosexual but very gentle male. This relationship mirrors the positive and containing transference and although it is understood within the reverie of the counter-transference it is not interpreted.

The patient returned to once a week psychotherapy recently in order, he said, to develop his professional life more fully. The focus is on work. He seems to have a good if complex relationship with his woman partner and to be painfully building, from fragments of experience and imagination, his own sense of what it means to be a good father.

References

Bion, W. (1956) Development of Schizophrenic Thought. Int.J. Psych.An Vol.37, Parts 4-5.

Bion, W . (1957) Differentiation of the Psychotic from the Non-psychotic Personalities. Int.J.Psych.An. Vol 38, Parts 3-4.

Freud,S. (1924) Neurosis and Psychosis. Standard Edition. Vol. 12.

Acknowledgements

I should like to thank the following for comments on the first draft of this paper : William Halton, Judith Trowell, Jane Temperley and Anne Kilcoyne. Time and space has not allowed me to do justice to their many helpful comments. I refer here particularly to Jane Temperley's observations on the counter-transference, and to William Halton's comments on how Bion and Meltzer's concept of the reversal of alpha function is exemplified in the patient's fantasy about the lace curtains .

I should also like to thank my good friend Dr Harriet Meek for the introduction to Dr. Sylvio Merciai whom she herself had met first through the Internet. Through Dr Merciai the paper found its way to the selection committee of the 1997 Turin conference W.R.Bion : Past and Future and thanks to their encouragement I was able to finish the paper and present it there.

Most of all I would like to express appreciation to the patient described for his courage and for his extraordinarily rich material from which I have learnt so much.