Psychoanalytic psychotherapists’ experiences of working with psychotic patients

Saayman, Nardus
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Therapeutic interventions with psychotic patients remain for many both a controversial and confusing area of clinical work. Yet there is very little research that has systematically investigated the experiences of psychotherapists concerning their engagement with psychotic phenomena. The established corpus of psychoanalytic theory proposes that managing countertransferential responses to a patient’s psychosis is a crucial component of the therapeutic process. In line with this view the aim of this study was to explore psychoanalytic psychotherapists’ experiences of countertransference when working with psychosis. Semi-structured interviews were conducted with eight psychoanalytic psychotherapists. Case material from my own clinical practice was also included. Various countertransference experiences are identified and linked to particular psychoanalytic notions of psychotic phenomena. These include: The strangeness of psychotic language use and the psychotherapist’s confused grappling with psychotic transference; The psychotherapist’s experiences of psychological and somatic disturbance in relation to psychotic projections; The psychotherapist’s experience of relatedness when engaging withdrawn psychotic patients and the ensuing discomfort, frustration, and fatigue; And the centrality of the therapeutic relationship, and how the relationship as well as the psychotherapist are affected when the psychotic patient subjugates the therapist via a paranoid delusion. The psychotherapist’s experiences are analysed and used to consider how psychosis can be treated within a psychoanalytic framework. The conclusions drawn suggest that psychotherapists who work with psychosis can have profoundly disturbing experiences that include: The fear of being overwhelmed; A failure of self-reflective function; The fragmentation of reality-testing; Intense bodily sensations; The frustration of interpersonal needs; and The loss of subjectivity
A thesis submitted in fulfillment of the requirements for the degree of Doctor of Philosophy in Psychology at the Faculty of Humanities, University of the Witwatersrand, 2021