The Treatment of Severely Disturbed and Psychotic Patients
Outline of some Central Mechanisms in the Induction and Transference of Emotions

By:  Sverker Belin, Ph.D. Psychologist/Psychotherapist – Sweden

Even though we sometimes are reluctant to accept it, as therapists, environmental staff and other staff members sooner or later will become carriers of emotions, attitudes and even types of defense mechanisms that bear all the hallmarks of our patients.

The primitive (inductive or intensely charging) kinds of influence between people seem to be especially active in certain types of relationship.  Here I am thinking mostly of relationships where one person has a position of dependency on the other person.  An example of this is in various treatment relationships, as in psychotherapy, where the dependency of the patient easily activate and reawakens emotions and ways of relating to others from childhood dependency relationships and transports them into the present.

There are lots of unanimous clinical studies and observations which confirm an overrepresentation of typical ‘induction phenomena’ (named for example projective identification, unconscious identification etc.) in centers where severely disturbed and psychotic patients are treated. 

There are many feasible reasons why the projection and induction phenomena are so numerous in these treatment centers.  One of the reasons has to be that the patients by definition have a disturbed an immature relationship development.  This immaturity or disturbance often expresses itself in an inability to take the time to be filled with emotions, to distinguish between one’s own emotions and those belonging to others or to be able to think about oneself and the consequences of one’s behavior.

A precondition to be able to recreate a viable ‘mother and child’ – like and development –enhancing ‘soil/growing? Environment seems to be that patients somehow manage to secure some kind of symbiotic qualities in relationships to people close to them.  The hallmark for these symbiotic qualities is a dissolving of the ego-boundaries between both parties.  The patients’ lack of functioning ego limits and any mature capacity to contain emotions make them firstly search out carriers for the different emotions they cannot cope with.  Secondly their emotional distress and lack of emotional maturity create lots of large and small beneficial complementary reactions (Tanka 1982) in the form of care and child raising-like ambitions from the treatment and nursing staff.

In this situation the staff often have difficulties distinguishing themselves from their patients’ projected and induced inner worlds.  At the primary process level the patients communicate an undercurrent of frequently very clear and primitive needs, primitive defenses and intense ambivalence.  Through the dissolving of the ego-boundaries which occurs via the characteristic induction phenomena these traits also take hold in the staff close to them. 

Powerful Emotions

An important factor behind the already mentioned phenomena is the very powerful emotional influence which many patients have on the people around them.  There is no doubt that most of them are suffering from severe emotional privation.  Many patients also have an exceptional ability to reduce their inner privation by being very forceful and dynamic in their external relationships with other people.  It can take the shape of intense dramas with threats and violence or noisy and bewildering psychotic behavior.  It is easy to see that these emotions and expressions have a strong influence on most of the people nearby.  The people around cannot avoid sharing or becoming carriers for the patient’s overpowering inner situation.

Also patients who do not behave so forcefully or dramatically can bring an unnoticed but still very strong emotional influence to bear on the staff.  The more closed, self absorbed, psychotic and sometimes chronically ill patients can be examples of this.  Their closedness and inaccessibility create a situation where covert but still very strong emotions are induced completely unnoticed into people important to them by the patients.  A busy nurse in their contact can feel unbelievablypowerless, ostracized, confused, confused, chaotic, depressed or empty as a result of his or her contact with such a patient.

The Effect of being Emotionally Overwhelmed

The emotions, blocks, attitudes, defense mechanisms etc., which patients communicate and induce (e.g. via body language) often create an emotionally overwhelming effect on the staff on the receiving end.  This influence forces these persons to act out and display this unconscious and overwhelming burden in the next stage or situation (Bromberg 1982).  Bion (1962) coined the term beta element for this sort of unconsciously performed and frustrating experiences which have not been digested and processed into ‘thoughts usable for thinking’.  These beta elements make up what we can call uncontained experiences.  These can only be acted out or projected on someone else in the next stage.The therapist, contact person or someone else important for the patient who unconsciously absorb and unwanted, destructive or overpowering emotional experience thus unconsciously plays out the emotional content of it (this time often completely non-verbally) in a new situation.  This may happen when several people are going to discuss or work with the patient.  If the people working here are not aware of this phenomenon and if they lack the understanding of the chain of origin right back to the uncontained and unclear experiences in the patient, it is easy for something unmanageable and infective to enter into the collaboration situation.

The things induced from the patient and then acted out in the next stage by staff member can create very serious tensions and problems.  In the new context the staff member doing the acting out is really seen as disturbing, provocative undesirable, ridiculous, confused or something similar (even if less intensely than the patient) by the other members.  The person carrying these things forward is wrongly regarded as him or herself and not as a mixture of him or herself and a role figure of something close to the patient which stems from the patient.  It frequently happens that staff members working together get into a situation where many of the people unconsciously represent different moods, attitudes and feelings absorbed from an unconsciously carried for the patient.  This is the way the patient’s disastrous and difficult family conflicts are transported into the work of caring for the patient and these are accentuated when the subject of the patient comes up at meetings.
A solution to the cooperation problems that emerge is by breaking the chain of unconscious acting-out.  Our acting-out will decrease when we become aware of what is actually going on.  The staff therefore can need careful assistance in detecting the unconscious and complex patters of interplay which stem from the patient’s inner world.  The staff may need help in just becoming aware of that overwhelming aspect in what they feel when together with their patient, to be able to break the cycle of acting out in the next stage.  Only then will it be possible to create a stable assimilating situation for all the emotions which were so hard to deal with, which in turn were transferred onto someone else.  This is vital for the patient.

I will try to illustrate what I have just described with a typical example from an ordinary psychiatry cooperation situation.  A team of different staff members were working with a periodically psychotic male patient who had a very serious separation problem.  At a case conference, when they had just finished talking about the patient and had gone on to work out some schedule and administrations issues before the summer holidays the following took place:
To work out the coordination between the patient’s contact person and his male therapist, the therapist was asked when he had thought about taking his summer holidays.  The therapist seemed very embarrassed and blocked.  To everyone’s surprise, he could not say anything about it in an acceptable way.  His attempts to answer were very vague, hesitating and evasive.  He had no clear idea about the weeks involved in the summer, the dates and if he was going to have a holiday and so on.  These confused answers created an embarrassed atmosphere and a certain mood of irritation.When no concrete answer was forthcoming they went on to the next topic and the therapist was forthcoming they went on to the next topic and the therapist was then left out of the discussion and
neglected.  After a while however, a woman colleague, who did not normally attended these case conferences, took up what had just happened with the therapist.  She could not recognize this kind of behavior in the therapist and asked him if his inability to say anything definite about the summer holidays and his plans could possibly have anything to do with the severe problems his patient was struggling with. 

The therapist said that he had a real feeling of panic which was incomprehensible to him, when he was asked about his summer holiday plans.  He was completely bowled over by this reaction and felt ashamed, cornered and blocked.  He could not identify this reaction and behavior with his normal range of emotions either.  He understood that the patient had been giving hints recently that he was going to kill himself.  The suicide threats most probably had something to do with the summer holidays coming up.  However, the therapist had not realized or understood the intensity of the patient’s feelings.  Instead, he had unconsciously absorbed the patient’s shielding off defense mechanism.  The strength of the emotions and defense mechanisms passed over to him was so intense, that the therapist being emotionally overwhelmed had trouble even remembering that he was going to have any holiday (!).

When the therapist thought a little deeper, he remembered that the patient’s father had killed himself when the patient was only six years old.  There was no doubt that this had left the patient with a very complicated guilt problem.  He had hinted in various ways but had anxiously denied that it was his fault that his father had killed himself.  The therapist in his turn? Understood that part of the blockage and the shielding off? Which he had just felt, was to do with the fact that he might be responsible for the patient killing himself.This was the way the therapist’s completely unconscious identification with the patient’s hard struggle and guilty problem became apparent.  But that was not all.  On close analysis, it came out after several family therapy sessions that the staff’s reactions to the therapist’s blocks were found to strikingly similar to the way the family treated the patient.  It was noticed several times that the patient created an embarrassing atmosphere with his blocked and confused behavior and as a result, was ignored and left out of the group.  This interaction pattern had now emerged in the therapist’s relations with the rest of the staff.  It was quite clear that the therapist was regarded and treated by the other staff members just like the patient was treated by his family.  When the members of the staff could see these parallels and similarities, they could break the destructive interaction patterns which had just occurred.  In that way, it was possible to counteract any negative consequences on the ongoing work.
By bringing attention to the therapist’s transferred and parallel expressed emotions and defense mechanisms (and the staff’s reactions to all of this) and this being made apparent very important information was discovered about what was going on inside the patient.  Better plans could be made for the summer break which suited the patient’s needs.  As well as this it was possible to initiate a more open and supportive dialogue with the patient and his family.  It was agreed how the patient, his family and his contact person, could alert others and deal with the early signs of emotions which could lead to a suicide attempt or actual suicide.


References
Bion, W.R.: A Theory of Thinking.  International Journal of Psycho-Analysis 43, 1962
Bronberg, P.; The Supervisory Process and Paralled Process in Psychoanalysis, Contemporary

Psychoanalysis 13, 1982
Tahka, V.; Psykoanalytisk Psykoterapi Natur ock Kultur, Stockholm 1987