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In Freudian metapsychology, there are two aspects with a key function: the
heard word and the visual image. And it is no coincidence that it is within
the sphere of these two elements where schizophrenia’s most striking symp-
toms occur: patients hear voices that speak to them and they feel as though
they are being watched.
In the following paper, I shall begin by revisiting the metapsychological
framework emerging from the study of the aphasias (Freud, 1891) which,
although progressively becoming complexified, persists nonetheless through-
out the Freudian oeuvre. My point of focus will be the examination of the
two key elements mentioned above. Keeping this metapsychological skele-
ton as a foundation, I shall build on it by adding a series of elements as set
out by post-Freudian authors which are noteworthy in this connection,
attempting to integrate them despite the fact that they are rooted in differ-
ent theoretical approaches. Later on, I shall address the clinical aspect: in
the first section I shall set out the complete raw material of one analytic ses-
sion – the first on the couch after almost two years of face-to-face work.
Here the patient’s auditory hallucinations appear firsthand, and there is an
abundance of material that, albeit confused and disorganized, has signifi-
cant affective impact. In the second clinical section, and from a more ‘sec-
ondarized’ discourse, I shall provide a brief overview of what took place
over eight years of treatment, the patient’s sexual life serving as a focus in
our study of his progress. After this I shall proceed to the discussion of
1
Translated by Caroline Williamson.
both clinical sections and in conclusion will establish the principal conclu-
sions of this study.
Thing-presentation
That said, the mnemic word–sound–image will rearrange nothing if it does
not have a firm handhold to fasten itself to. And as Freud has already sta-
ted (Strachey, 1957), the connection is established with the visual image,
which stands for the thing-presentation as the word–sound–image to the
word-presentation.
In my view, the visual image may be regarded as a kind of container able
to comprise a whole series of signs (indications) of perception as contents.
And here we find ourselves in the realm of Narcissus (Freud, 1914) and of
the mirror (Lacan, 1954b; Winnicott, 1967). And in the gaze of the mother
as mirror, which in the interplay of the drives – between looking, being
looked at and looking at oneself – permits at once the organization of a
thing-presentation of one’s own self and of the primary object, at first clo-
sely interrelated and intertwined. The Botellas (2001) attach great signifi-
cance to what they term ‘secondary autoeroticism’ and to the transition
from looking to being looked at and to looking at oneself. By secondary
autoeroticism, they refer to the capacity that may be gained by the infant,
through sucking its thumb, to join together in one unifying movement a
whole range of diffuse perceptions and sensations experienced in the
encounter with the primary object during breastfeeding. And they relate this
to the capacity to reproduce, in the sensory-motor sphere, what the baby
feels while the primary object is looking at him. In the autoerotic reproduc-
tion of this situation, one would move towards being able to look at oneself
(the ‘double-return’ of Green’s thought [Green, 1983, 2002], from the pas-
sive being looked at to the active looking, and thus reflexively, from looking
at the object to looking at oneself) as one had felt looked at. The connec-
tion with the Bionian model (Bion, 1962a) of the container/contained is also
evident. Roussillon (1999, 2001) refers to this as primary symbolization.
Just as the introduction of the sound–image of the word affords a rear-
rangement of that which went before – that which remains to the left in the
schematics of Letter 52 – under the oedipal symbolic order with all of its
consequences, the introduction of the visual image also implies a certain
rearrangement of what went before. In my view, what is imposed is the ten-
dency to establish the unicity of each thing-presentation. Certain thing-
presentations may be confused with others, but they will forever tend more
psychosis. Perhaps they may also at times be recovered through new visual
images, as mentioned in the previous section, by means of figurability in the
dream-work or in the double work during the session (Botella and Botella,
2001), or in the enactments in the transference–countertransference scene
(Sapisochin, 2013). Bion’s transformation of beta-elements into alpha-ele-
ments (Bion, 1962b) is also related to the subject matter.
-I have been fine since the last session during which, after finally laying down
on the couch, the voices showed up here. Today I went to renew my special
vehicles licence, and I’m not sure whether they’ll let me keep it going. . . the
normal class one is fine, but not the other one. The voices are coming back.
-THEY’RE TAKING ME.
-Who are they referring to?
-I don’t know, to me, to him. . . like they take you and they kill you.
-Perhaps it has something to do with what we touched on before, that if the
voices turn up here and we are able to understand them better, maybe they
can then disappear.
-THEY ARE BEING CURED. He’s saying, as if he’d heard what you said.
THEY’RE DROWNING. This is one of the usual remarks. THEY’RE
SWIMMING. CARLOS [patient’s first name] THEY’RE STABBING
YOU. They’re stabbing you again.
-We’ve spoken before about the verb ‘stab’ and the word ‘slit’2 . What do
you make of it?
2
Translator’s note: the Spanish verb rajar can also mean to slice, cut, slash or knife. It connotes slitting
open. The noun raja similarly can mean cut, gash, slit or slice. In its slang form, it can also mean “arse
crack”.
-That they’re sticking a dagger, a knife, in you. You know it’s something
they often say. WE HAVE YOU. [Here I feel something that surprises me,
a certain sexual excitation] They are still playing around inside of me.
CONDOMS, ANA USES. You know that Ana is the girl from the tae-
kwondo.
-Why are they talking about Ana now?
-Just that he’s heard it, it sticks with him and he brings it up. WE ARE
BEING CURED. As if someone were saying to him that we are being cured.
The same explanation as before.
-It seems as though they do not let you think in peace.
-They intrude upon my thinking. Sometimes they make me go blank. . . I think
something and then suddenly it goes out of my head. IT HURTS HIM
THERE. Before the session they had said that there was no need to talk
here. YOU ARE BEING CURED CARLOS CARLITOS [diminutive
form of Carlos] ADELA, WHAT’S UP? As if they were saying hello to her.
[Adela is the only girlfriend he had, when he was no more than 16 years
old.]
-What does this have to do with Adela, why are they talking about her
now?
-They almost always talk like that; I can’t make head or tail of it.3
THEY’RE TAKING.
-Again the ‘they’re taking me’ from before?
-THIS ONE, KILL HIM. THEY’RE SHITTING ON ME. THEY’RE
TAKING ME. Shall I explain the “they’re shitting on me”? For them, when
they killed that guy [in the days prior to the session a young man had been
stabbed in a nearby area, apparently for a settling of scores]. . . coke, blood,
nose. . . on top of killing him, they think about him when they shit, as if they
were shitting on top of him. Chucking the shit, the piss, the blood from the
coke on top of him. JUST KILL ME. This guy keeps going on about it. Like
when I’m in the gym I look and it seems as though they’re looking at me on
all sides and saying to me, one, and another, and another. . . it’s too much,
Fran. - THEY’RE HUNTING ME. Maybe they’ll kill him. ANA FOR
HIM, HUH? ‘Him’ refers to me, as if he’s making Ana be [the one] for me.
PERFECT YOU UNDERSTAND. He’s answered us just then. WHEN
DO TAKE ACTION?
-What do you think the voice is referring to?
-I don’t know, maybe to killing me.
-If Ana is the one for you, will they kill you?
3
Translator’s note: the Spanish phrase used by the patient is “sin pies ni cabeza”, literally, “without feet
or head”.
-Well, they haven’t been able to for ten years now. . . so they want to take
action to kill me. CARLOS IS GREAT, I KNOW. Like he helps people
who say it to him and he repeats it. There are other voices that say it to him.
-Great?
-It’s that there are other voices who think a lot of me, they care about me,
they know what I’m going through. It’s what gives me the strength to go on
fighting sometimes. CARLOS IS THE KING. He is thinking that it’s the
king.
-Over these last two years you hadn’t told me this about the king.
-Well yes, sometimes they talk about that. TO THIS ONE KISSES THEY
GIVE. DAGGER HUH? KILL HIM. . . Like they’re picking up a dagger
and killing me.
-In spite of that, you seem calm to me.
-Yes, if not I would have called you after the other session, don’t worry Fran,
I’m fine. HERE YOU LEAVE HIM. Maybe saying something like I
[should] stay here. . . I heard the voice and it said that to me. Apart from
this voice, there are other good and bad ones.
-You are becoming able to talk to me in more detail about what the voices
are telling you.
-And I am getting calmer. HOW GOOD CARLOS IS, HE IS THE ONE
FOR ANA. Here’s this one again like a parrot. . .. in delirium tremens. . .
[laughs] How come he’s so crazy, this voice? WHAT A PRICKLY ONE
HE IS, THIS ONE OF ANA’S. I don’t know what he means. Meaningless
words, I can’t make head or tail of it. THEY’RE KILLING ME. . . again
he’s said I don’t know what to him. . . and MAN! This guy was dying, like
this game, and he doesn’t believe it yet. [He suddenly starts to hiccup]. I
HAVE SEMEN OF YOURS, ANTONIO IS KEEPING IT. [Antonio is
Adela’s uncle, the only girlfriend mentioned before.] The one who is doing
all of this. . . the main voice, the one who made up. . .. the game of talking to
me. There is more than one voice caught up in this game. They call it a
game. . . but there’s nothing good or clean about it. TELL HIM MAN, I
don’t know what he’s referring to, THIS ONE WAS THE KING.
-How do you feel now that we are coming to the end of the session?
-Fine, happy because I am telling you about it. I am calm. . . I’m used to what
the voices say to me by now, Fran. The worst of it was when I was first
admitted. Now I don’t get shaken up by it. I feel more at ease because I’m
telling you to try to understand it. It’s like you’re more freed up.
had, Adela. He thinks that they are watching him and pursuing him, that they
do not want him to have any other romantic relationships; that they are going
to steal his semen from him and kill him. A component of filiation vaguely
appears, with the patient feeling that he comes from parents from another gal-
axy, although this does not quite mesh coherently with the above.
When we begin treatment, the patient displays from the outset some
transferential idealization, which I register but do not interpret. With regard
to his delusional interpretations, I suggest to him that we consider them as
attempts to understand what is happening to him, which I will respect, but
which we will weigh up, at the same time as I offer alternative explanations,
and that between the two of us we will try to better understand what is
happening to him. During the first months of treatment, his manifest psy-
chotic anxiety diminishes significantly, seemingly contained by the setting.
The patient decides to give up smoking tobacco, which he does without
pharmacological help, and his psychiatrist is able to reduce the clozapine to
600 mg/d. We are realizing that “the voices” do not show up in just any sit-
uation, rather they have a preference for certain ones. Thus, they do it, for
example, when he notices, or fantasizes about, women he may find sexually
attractive. If at night, in bed, he tries to come up with a fantasy so as to
become sexually aroused and to masturbate, the voices become very active
and prevent him from doing so. In fact, in order to masturbate, he devises
the following strategy: he goes to the only bathroom in the house with a
pornographic magazine and closes the latch, having previously chosen an
image to immediately arouse him sexually, and he masturbates hurriedly. In
his words: “That’s the only way I manage to trick the voices, and I feel
more fantastic than God4 “. The only bathroom in the house also holds
some significance as a result of a certain joke he keeps up with his father
about the smell that each of them leaves after defecating.
At more or less the year-and-a half mark of treatment, his clinical symp-
toms having greatly improved (quantitative decrease in intensity and fre-
quency, without qualitative changes), the sessions are beginning to feel very
long to me. I have the impression that the patient no longer has anything
else to tell me, nor do I have anything more to contribute. The hands of
the clock creep forward very slowly; I become very sleepy despite not feel-
ing so in previous or subsequent sessions. I endeavour to self-analyse; I
mention the case to several colleagues. . . but I am unable to resolve the sit-
uation. I increasingly think of Freud (1913) when he talks about not being
able to put up with being stared at by other people all day long, and finally
I propose a change of setting (two years after the beginning of treatment),
on the couch at a frequency of three sessions a week. There is a problem in
that the patient has only limited financial resources, which means in effect
charging for three sessions what he had been paying for one. In addition, at
precisely the moment when the matter had just been raised, his name is
4
Translator’s note: Here the choice of phrase used in the Spanish original: “me quedo m as a gusto que
Dios” is significant. The idiom “como Dios” in Spanish is used to indicate something superb or outstand-
ing – roughly equivalent to “pleased as punch” in the context above, for example. However, in the Span-
ish phrase used by the patient, it is important to note that contained within this “como Dios” is, once
again, an indirect allusion to the figure of the Father (God the father).
again tearfully, he turns over on the couch to look at me and tells me that he
never thought he would be able to have a girlfriend. Some ten months before
writing this, she announced to him that she did not want to be in such a com-
mitted relationship, that she is still young and she wants more out of life. She
suggests to the patient that they be friends who go to bed from time to time.
He says no to this as he wants a true girlfriend.
To date, we are continuing our work. The voices and the looks show up
very little and do not cause him a great deal of anxiety. His psychiatrist has
been able to reduce his medication to 350 mg/d of clozapine. His discourse
during the sessions tends to focus primarily upon current concrete events.
He dreams little and finds it difficult to make associations, but I continue
to feel that his work with me is mentally enriching to him. Just how much
we will be able to achieve, I cannot say.
First fragment
-I have been fine since the last session. . . the driving licence. . . I’m not sure
whether they’ll let me keep it going. . . THEY’RE TAKING ME. . . like they
take you and they kill you.
1896b) stored up within herself, had to be heard from the outside. Here we
are far from the model for ‘Meynert’s Amentia’ in which there is a break
with reality and the imposition of ‘friendly’ rather than ‘hostile’ hallucina-
tory activity, which we would say originates in the id rather than in the
superego. The woman who hallucinates the longed-for arrival of her
beloved (Freud, 1894) could be a paradigm for this other model. From the
vertex of this other model we may understand other types of voices, which
are much less present in this case, but nonetheless also appear during the
session, as “CARLOS IS THE KING”, which clearly represent the drive-
related rather than the censor part.
The patient lies down on the couch. As in the Freudian model of the
dream, sensory deprivation occurs and, when the erotic drive movement
breaks through, it demands a representation of the analyst with an erotic
component. I consider that we are coming into contact with something that
has been unable to be symbolized. It is precisely at this point when the
hostile auditory hallucinations break through. Here we might suppose that
“the voices” are reproaching, censoring and threatening the patient from the
external world as a result of his erotic transference movement. They bear
testimony to a faulty post-oedipal superego, at least in this area. Instead of
a post-oedipal superego that has organized a repressed unconscious, we find
ourselves up against the hostile auditory hallucinations.
Let us return to the metapsychology. The word that has been heard is
received passively at the afferent sentient pole and the child must take it on,
make it his own. The superego in part comes out of that which has been
heard. At a certain point, the child begins to actively emit at the efferent
motor pole (he says to himself inwardly, “reel”, “mama”). This circuit of
the word is fundamental to the introduction of the oedipal order and to the
restructuration of previous registrations along primarily neurotic lines. Nev-
ertheless, in one area at least, he lacks the symbolization required by a
developed post-oedipal superego. Something has not sufficiently transited
towards the efferent motor pole and appears to be blocked. Beyond the
blockage in the circuit of the word we encounter a faulty area of the super-
ego, with the absence of certain elements in his mental apparatus. Thus, for
example, he was not able to differentiate between forbidden and permitted
women for his sexual advances. During his adolescence he would fantasize
about having sexual relations with his sister for “practice”.5 On the near
side of the blockage, we encounter a hallucinatory insistence of the censor-
ing word, which acquires a hostile and threatening quality: “THEY’RE
TAKING ME”. And this does not appear at just any moment. It appears
when the (re)presentation of an erotic component in the relationship with
his analyst is required, which is missing. And it appears in the place of the
post-oedipal superego.
Albeit without taking up Freudian terminology sensu stricto, there are
various authors who appear to have developed parts of his thought from
5
In the “secondarized” clinical material we may note that any sexual approach to a woman is experi-
enced as an incestuous advance upon the mother, triggering an extreme hallucinatory defence, with the
hostile voice breaking through at the very place where a post-oedipal superego is missing.
the starting point of these formulations. Thus Klein (1932) speaks in terms
of schizophrenics projecting their superego. Lacan (1956), in his concep-
tion of ‘foreclosure’, considers that that which has not been integrated
internally returns from the external world. And Bion (1957) holds that
where, in the neurotic personality, the unconscious emerges, in the psy-
chotic part we find instead the world populated by strange objects, or
‘dream furniture’.
Second fragment
Like when I’m in the gym I look and it seems as though they’re looking at me on all
sides and saying to me, one, and another, and another. . . it’s too much, Fran.
THEY’RE HUNTING ME. Maybe they’ll kill him.
Third fragment
This relates to three hallucinatory expressions appearing at different times
during the session, which I have collected together because of the close
connection they show in content:
6
I would like to thank Rafael Cruz Roche who, during our discussion of the case, suggested the image
of the syncytium.
Strikingly, the language “of the voices” passes from THEY ARE BEING
CURED to WE ARE BEING CURED to arrive at YOU ARE BEING
CURED. There is a major lack of syntactical organization. It is difficult to
understand who is speaking, to whom they are referring or whom they are
addressing. Freud (1915) describes the ‘stilted’ or ‘precious’ speech with syn-
tactical disorders observable in schizophrenics, although he does not expand
much further upon this. To my knowledge, it is a loose thread of Freudian
thought yet to be pulled at by other psychoanalytic authors.
If we imagine the scene we see that in “THEY ARE BEING CURED”
apparently someone (the main voice according to the patient) is addressing
the patient in the second person to refer to a third group of persons. That
is to say, we may sketch out a triangular structure. However, in “WE ARE
BEING CURED”, the three elements merge into a collective unit. And fur-
ther on, in “YOU ARE BEING CURED” the subject addresses the patient
in the second person, that is to say, we may trace out a dual structure.
From a triangular structure, a collective unit is then formed, which finally
becomes a pair. While reflecting upon this question, the image of synctytial
magma comes to mind, transiting between triangular, unitary and dual
forms.
I recall that Freud (1914) uses the metaphor of the amoeba, with the
emission of the pseudopodia which it puts out, and may also reincorporate,
to account for the dynamism and the movements of object and narcissistic
libido. The amoeba is a unicellular organism, with a single nucleus (provid-
ing a “genetic identity”) and is bounded by a cytoplasmic membrane that
separates and distinguishes it from the external environment. What I find
problematic in this metaphor is that the unicity of the amoeba is guaranteed
from the outset, and at no point is it called into question. In Freudian
thought, the ego does not possess a priori unity, since Freud considers that
“we are bound to suppose that a unity comparable to the ego cannot exist
in the individual from the start” (Freud, 1914, pp. 76–7); it is something
that has to be developed by means of a new psychic action. And I consider
this psychic action to be the rearrangement of previous registrations around
the visual image, thus imposing the imperative of unicity. Only from this
point is the metaphor of the amoeba of service to us.
In contrast to an amoeba, a syncytium, in biological terms (I am thinking
namely of the placental trophoblast in mammals), is a structure in which
various nuclei coexist within a single cytoplasmic membrane; thus the unici-
ty of each cell is impossible to establish. During implantation into the endo-
metrium, the syncytial magma will incorporate certain elements and discard
others; it is striking in its mobility, dynamism and apparent lack of fixed
structure.
Let us imagine a triangle that holds an amoeba on each vertex. Let us
say that first we have fixed the unicity of each amoeba (this would be done
Fourth fragment
They intrude upon my thinking. Sometimes they make me go blank. . . I think some-
thing and then suddenly it goes out of my head. IT HURTS HIM THERE. Before
the session they had said that there was no need to talk here.
upon which a typical psychosis may appear. Later, Green (1983) would
develop their formulations on negative narcissism. He understands the
death drive as the tendency towards a zero degree of excitation, describing
it in terms of the ‘disobjectalizing function’, according to which all invest-
ment, or cathexis, is withdrawn from the object. But investment may also
be withdrawn from the self-presentation. In a subsequent recapitulation
(Green, 2002) he describes how one may even come to disinvest thinking or
indeed the entire process of investment. In light of all this we might define
as psychotic whiting-out the process of disinvesting anything which comes
close to the unthinkable.
Why the appearance of sexual excitation in the countertransference? I
believe that until then I had been unable to fully understand the entire sex-
ual aspect of the material. So much death, stabbing, blood, urine, faeces. . .
I had grasped these primarily in their most aggressive dimension, rooted in
a more secondarized thinking. While one theoretically knows about the
implication of sexuality in all of this, only by feeling it in my own body was
I able to grasp its crucial significance to a more in-depth understanding of
the material. Only a posteriori did I realize that the psychotic whiting-out or
attacks on thinking pointed precisely to the fact that the entire sexual com-
plexion of the material was unthinkable.
Poverty of thought
While we have described a partial neurotization taking place in the patient,
determining the emergence of an intrapsychic conflict where previously
there was none, we have to assume that his overall mental functioning is
currently far removed from that of a neurotic. His speech continues to be
very focused upon the current and the factual, with difficulties in providing
associations of any relevance; his oneiric activity is very limited, and when
dreams do appear they are often mere reproductions of waking experiences,
with little process of elaboration. This is reminiscent of the operational-life-
type functioning of the Paris School (Marty and De M’Uzan, 1963; Pirlot
and Corcos, 2012), which certain authors have also described for other
types of non-neurotic cases such as borderline patients (Braier, 2012).
What I do not yet know is whether this is so, or whether there are ques-
tions of relevance that I am not yet able to think; whether I have once
again allowed myself to be caught up in the psychotic whiting-out. Only
with the progression of events and the process under way with Carlos will
we know more, and find out just how much we can achieve.
Conclusions
I believe that psychoanalysis has much to contribute to schizophrenia, spe-
cifically in the areas of understanding and treatment.
In terms of comprehension, taking as our point of departure a Freudian
metapsychology enriched by the contributions of a whole range of later
thinkers, we dealt with the psychopathological study of one session. The
patient hears voices and feels that he is being watched. More precisely, his
symptoms occur at the level of the heard word and the visual image – the
cornerstones of Freudian metapsychology and his understanding of the con-
stitution of the psyche. We went on to define the circuits of the word and
the image, describing a type of blockage in both, with what we have termed
positive symptoms on the near side of the blockage, and negative symptoms
on the far side of it. We consider as positive symptoms (“THEY ARE
TALKING TO ME, THEY ARE WATCHING ME”) the hallucinatory or
perceptive insistence at the afferent pole of the mental apparatus. And we
consider negative symptoms to be that which has not been constituted
beyond the blockage, specifically the absence of important components of a
post-oedipal superego and of a unified self-presentation, with its peculiar
modes of manifestation. Although we can say little of the aetiology, it seems
Translations of summary
Eine Entwicklung der Freudschen Metapsychologie der Schizophrenie. Der Autor vertritt die
These, dass die Psychoanalyse einen signifikanten Beitrag zur Theorie und Behandlung der Schizophrenie
leisten kann. Ausgehend von einer Entwicklung der Freudschen Metapsychologie, nimmt er eine gr€ undli-
che psychopathologische Untersuchung der ersten Couch-Sitzung eines schizophrenen Patienten vor, der
Stimmen h€ ort und u€berzeugt ist, von anderen Menschen angestarrt zu werden. Da die Symptome der
Ebene des geh€ orten Wortes und der visuellen Bilder – zentrale Aspekte der Freudschen Metapsychologie
– angeh€ oren, beschreibt der Verfasser einen Schalkreis f€ur das Wort und einen f€
ur das Bild und erl€autert
eine Unterbrechung in beiden Schaltkreisen mitsamt deren Folgen. Was das Behandlungsergebnis bet-
rifft, so beschreibt er andererseits eine zun€achst quantitative Besserung der Symptome mit sp€ater folgen-
den qualitativen Ver€ anderungen. Er erkl€art, dass sich der Patient nach zweij€ahriger Behandlung im
Sitzen in einer Phase mit einer Sitzung auf der Couch besser entwickelte.
Sviluppo della metapsicologia freudiana per la schizofrenia. L’autore sostiene che la psicoanalisi
puo dare un contributo significativo allo studio della schizofrenia. Partendo dallo sviluppo della metap-
sicologia freudiana, propone un approfondimento dello studio psicopatologico di una seduta (la prima
sul lettino) con un paziente schizofrenico che sente delle voci e si sente osservato dalla gente. Osservando
che I sintomi si manifestano al livello della parola udita e dell’immagine visiva, fenomeni chiave nella
metapsicologia freudiana, l’autore descrive un circuito della parola e uno dell’immagine, entrambi blocc-
ati, e descrive le conseguenze di tale blocco. D’altra parte, nell’esito del trattamento, l’autore mostra inn-
anzitutto un miglioramento quantitativo dei sintomi e poi i cambiamenti qualitativi. Mostra, inoltre, il
miglioramento evolutivo nel passaggio a una seduta la settimana, con l’uso del lettino, dopo due anni di
trattamento vis- a-vis.
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