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Pathological organizations of the personality: A clinical

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Article  in  British Journal of Psychotherapy · April 2007

DOI: 10.1111/j.1752-0118.2007.00035.x

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Clinical Practice

PATHOLOGICAL ORGANIZATIONS OF THE PERSONALITY:

A CLINICAL CASE STUDY

Marco Chiesa

abstract In this paper the author describes the features and clinical mani-
festations of specific states of mind, which functioned as psychic retreats in a
male homosexual patient. Two main types of retreats emerged in the course of
the analysis. The first took the shape of an inanimate object (a spaceship),
within which little human contact was allowed to exist. In the second retreat
some degree of relating was present, but that mental space was populated with
threatening homosexual figures which kept a strong hold on the patient’s ego
and attacked any meaningful contact established between patient and analyst.
The presence of these structures enabled the patient to evade awareness of the
injured, paralysed and damaged state in which his internal objects were kept,
and to bypass depressive anxieties connected to painful early oedipal conflicts,
which included a terrifying maternal introject. The attempt to recruit the
analysis into the patient’s psychic retreat constituted a central transference
manifestation.

In this paper I am going to describe two specific aspects of a patient’s patho-

logical organization as they emerged and developed in the course of a long
analytic treatment. The first had striking non-human characteristics and
exerted a powerful pull away from interpersonal contact. This was expressed
as living inside an inanimate object within which lively contact with other
human figures did not take place. The non-human retreat functioned as a
silent and deadly poison against efforts the patient made in his life and in
the analysis to achieve a more satisfactory internal and interpersonal life.
The impenetrability and imperviousness of the psychic retreat, portrayed in
dreams as inanimate containers, created a static and deadening atmosphere
in sessions and often led the analysis into long periods of impasse. The
patient’s constant withdrawal into the internal space provided by this patho-
logical organization dramatically limited the patient’s emotional availab-
ility and expression of affects.

marco chiesa md, frcpsych is a Consultant Psychiatrist in Psychotherapy, West

London Mental Health Trust, and Honorary Senior Lecturer at University College
London. Address for correspondence: The Cassel Hospital, Richmond, TW10 7JF.
[email: m.chiesa@ucl.ac.uk].
© The author
Journal compilation © 2007 BAP and Blackwell Publishing Ltd, 9600 Garsington Road,
Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. 395
396 BRITISH JOURNAL OF PSYCHOTHERAPY (2007) 23(3)

The second retreat was more lively and human, and provided the analysis
with more interesting and potentially rich material, and hence represented
an improvement, but was fraught with dangers connected with homosexual
part-object relationships. I hope to illustrate that one of the main functions
of the two pathological organizations was to bypass painful awareness of
the injured state of the patient’s internal objects, and to evade intense
depressive anxieties and early oedipal conflicts based on a frightening and
engulfing maternal representation.

Background
Clinical work with patients who present with considerable challenges to
analytic progress led to developments in the understanding of narcissism
(Abraham 1979), its connection with primary destructiveness (Freud 1937)
and character formation (Reich 1933). This pioneering work, built on the
concepts of resistance and defence as obstacles to clinical progress and pro-
ductive engagement in analytic work, opened the way to the study of areas
of the inner world in which complex defensive organizations underpin
severe personality psychopathology. Rosenfeld’s seminal paper on destruc-
tive narcissism (Rosenfeld 1971) constituted a milestone in the development
of the concept of pathological organization. By clarifying the interplay
between libidinal and destructive forces and the role played by envy, Rosen-
feld vividly described the building up in the internal world of narcissistic
object relationships based on the idealization of destructive self-object rep-
resentations, which may achieve a highly organized structure and be por-
trayed as a gang or Mafia, offering a protection against pain and suffering.
Rosenfeld’s work spurred further developments, and several authors have
made original contributions describing the organized nature of the defen-
sive structures, and the complex identifications and internalization of
specific object relationships that characterize pathological organizations
(Joseph 1985; Meltzer 1968; O’Shaughnessy 1981; Riesenberg-Malcolm
1999; Segal 1972). A number of other authors have made substantial con-
tributions to the literature of severe character disorders from different
perspectives, which have enriched our understanding of this kind of
psychopathological presentation (Akhtar 1992; Giovacchini 1984; Kernberg
1984; Kohut 1968; Winnicott 1963). However, Steiner has perhaps been the
author most dedicated to the study of pathological organizations over the
last 25 years (Steiner 1979, 1987, 1990, 1993). He coined the term ‘psychic
retreats’ to describe states of mind akin to pathological organizations, where
the ego withdraws to escape pain and anxieties, providing the patient with
a shelter from other states of mind felt to be unbearable and threatening of
his survival.Through a detailed description of the complex and highly organ-
ized nature of defences, object relationships, phantasies and affects, Steiner
postulates the existence of a ‘borderline position’ to complement the
MARCO CHIESA 397

‘paranoid schizoid’ and ‘depressive positions’ developed by Melanie Klein

(Klein 1975).
The importance of the concept of pathological organizations resides in its
clinical relevance, as it provides a theoretical framework for understanding
patients who withdraw from lively contact with the analyst and establish
long and drawn-out states of impasse in the analysis. In the clinical case I
will describe the presence in the patient’s internal world of two powerful
internal pathological organizations operated in a way to hinder his affective
life.These internal structures of the personality, which emerged in the course
of the analysis, formed the constant habitat for the patient’s ego, and were
experienced by the patient as protective against intense emotional experi-
ences and severe anxieties.
Homosexuality has been a highly controversial issue within psychoana-
lysis. The question whether homosexual object choice should be regarded
as the result and the expression of a psychopathological process has been
hotly debated. At an institutional level a consensus within several psycho-
analytic organizations to depathologize homosexuality and to end the un-
official discrimination against gay applicants for psychoanalytic training has
been recently reached (Goldberg 2001; Roughton 2002). In the psycho-
analytic domain the dissension on the nature of homosexuality has centred
on it being either conceptualized as a deviation from the path natural
sexuality takes or as non-pathological variant of psychosexual development
(Isay 1989). The central psychodynamic question seems to rest on whether
a separate psychosexual development exists in which the negotiation and
resolution of oedipal conflicts may not be included as an obligatory step.
The understanding of the many aspects and factors that contribute to homo-
sexual object choice is yet to be fully discovered and understood (Berman
1998). Clearly, the argument is very complex as cultural and, possibly,
biological factors (Le Vay 1991) may intertwine with psychosocial factors
(Kernberg 1992).
Although the issue of homosexuality is not the primary concern of this
paper, clinical indicators derived from the analysis of the patient I am going
to describe are suggestive that his homosexual choice involved the defen-
sive need to bypass the painful anxieties and conflicts inherent in the oedipal
situation.

Clinical Material
B was referred for psychological treatment at the age of 21, while he was a
university art student. He had been suffering from depression for over a
year, which had become progressively worse and was interfering with his
capacity to study. Despite antidepressant medication he experienced great
difficulties in getting up in the morning, frequently missed lectures, and
became increasingly isolated. He sought help from the local psychiatric
398 BRITISH JOURNAL OF PSYCHOTHERAPY (2007) 23(3)

services from where he was eventually referred to me for psychoanalytic

therapy. In the first consultation, B presented as a tall, slim and informally
dressed man, looking languid, cast down and clearly depressed. He de-
scribed the main features of his depression and how they impinged on his
leading a more productive life, and how he had become reliant on medica-
tion lest without it he might end up in a psychiatric hospital. Very early on
in the consultation he spoke of his mother, who had been suffering from a
form of epilepsy, developed soon after the birth of B’s elder brother. B
recalled how terrified he had become of his mother on account of her epi-
leptic seizures and of her sudden mood swings. B’s usual experience of his
mother as remote, distant and inaccessible was punctuated by unexpected
outbursts of rage against her husband or her children, which appeared
unjustified to B. His father was hardly mentioned but he came across as a
rather inconspicuous and dull figure who was overshadowed by B’s mother’s
dominant character. B’s relationship with his two older siblings had been
characterized by rivalry, and he remembered being bullied by his elder
brother. In the course of the analysis, B would find out that both his
brothers were homosexuals. Towards the end of the consultation he spoke
about his sexuality. Although in the past he had engaged in a one-off un-
satisfactory heterosexual experience and had no homosexual experiences,
he felt that he was gay. B felt more at ease with, and attracted to, men while
he felt uncomfortable in the company of women. After a year of twice-
weekly psychoanalytical psychotherapy, I saw B in four-times-weekly ana-
lysis for nine years.

Emergence of the Inanimate Pathological Organization

In the first year of therapy B’s depression rapidly improved, which helped
him to successfully complete his university studies and discontinue antide-
pressant medication. B always arrived well on time and rarely missed ses-
sions. He spoke in a restrained and at times robotic fashion with long silent
pauses in between sentences. B brought interesting, if concise, childhood
memories and conveyed a clear picture of the very stuffy atmosphere
present at home. His parents were portrayed as lifeless people unable to
share interests or communicate at an emotional level. B often complained
in a flat way that he resented his parents for the lack of warmth and love
they gave him. The several potentially meaningful dreams that B brought
to analysis were followed by either silence or stultified association, and my
subsequent interpretations appeared not to have any effect on him. For
example, he reported repeated dreams of plane, helicopter or car crashes,
of buildings on fire and of other natural disasters in which members of his
family featured. The content was very graphic and the details often chilling,
but they were reported factually, with no affective participation, while he
remained cold and distant. The likely distress he experienced during and
MARCO CHIESA 399

soon after the dream was not carried over into the session. As noted, asso-
ciations to such dreams were either absent or mechanical, as though pro-
vided to me out of a burdensome duty. In this phase of the analysis silences
were long, heavy and prominent only interrupted by slow, emotionless and
monotonous speech. Dreams, which he remembered well, became the main
vehicle for understanding his state of mind and communication, a feature
that remained constant throughout his analysis.
The long silences and the stifling of our contact seemed to actualize his
memories and experiences of his own parents, which were brought con-
cretely and ‘in action’ into the analysis. My interventions did not produce
much response and were followed by long silences or unconvincing agree-
ments. Consequently, the analysis was permeated with intense dullness and
deadness, which tended to generate in me a soporific reaction or a sense of
hopelessness. The still and emotionless type of relating was illustrated by a
dream in which:
He was watching an old lady sitting on a chair in front of a window. She moved
in a series of slow sequences of still images, which reminded him of a slow
motion version of an old times movie. Later in the dream B noticed that the
woman was dead, her colour had become ashen-grey and her flesh started
to rot.

This dream seems to illustrate the tight and asphyxiating control B was exer-
cising over the analysis. In the transference, I felt I was becoming like the
old lady in the dream, not allowed any movement or freedom, and domin-
ated by the patient’s control and passivity. Any movement and any meeting
of minds, which may have brought about progress in analytic work, anything
productive and creative was either not allowed to occur or to last, but would
end up crashed to destruction like the aeroplanes in B’s dreams.
A dream reported in the first phase of the analysis allowed some
understanding of the static situation, which had until then characterized the
analysis:
B was an astronaut floating in the stratosphere inside a spaceship. From there
he could see the earth thousands of miles away along with the bright stars in
the dark blue sky. B felt safe and protected, although alone and isolated; he
thought that he would die if he stepped outside the spaceship.

This dream seemed to illustrate the situation in the analysis in which B lived
inside his own bubble, unable or unwilling to step out and establish a more
lively emotional contact with me. In recreating the ambience of the space-
ship in the analysis, any movement that deviated from the status quo was
experienced as threatening and disruptive. This configuration seemed to find
a correspondence in my experience of being in the same room as B while
at the same time feeling miles away from him. As well as being unsure
400 BRITISH JOURNAL OF PSYCHOTHERAPY (2007) 23(3)

whether my words ever reached him, I often felt dull, heard his words as
though from a great distance, felt mentally lazy and unable to find passion
and motivation for analytic work.
The spaceship dream allowed greater understanding of his external func-
tioning. As noted, B was a loner, would shut himself in his room endlessly
watching videos and TV programmes, shying away from having a social life
and making friends. He found that this way of functioning safeguarded him
from more intimate interpersonal contact, which he found threatening and
disturbing. I started to conceptualize that the internal non-human retreat
was a protection against internal and external feelings, affects and config-
urations that B found too disturbing. However, further material two years
into the analysis indicated that B found the internal retreat (the spaceship),
as well as protective, trapping and suffocating, as the following dream may
illustrate:
He is in a five-storey building, which looked like a fortress or a castle. It’s all
rather bare, cold and uninviting. After a while he wants to get out but cannot
find an exit as all the doors are locked. He feels he is going to be trapped in
the fortress. In the end he goes downstairs into the basement and finds a group
of homosexual men sitting around a table. He asks them whether they know
where the exit is, but they reply that he should not leave and that he should
stay with them. They say that life is fine there and that they will have a great
time together. B knows that he will join them.

As usual associations were conspicuous for their absence, but this dream,
typical of a series in which B is inside a structure (house, church, bus, restaur-
ant, etc.) that he is unable or prevented from leaving, showed that B found
his retreat (the fortress) oppressive and feared that he may be trapped in
there. Here we have the first indication of a shift from a position in which
B considers the ‘spaceship’ as protective and endowing him with a sense of
self-sufficiency, to the emergence of material suggestive of the presence of
a different internal space in which he feels trapped and populated by spe-
cific figures of homosexual orientation.

Pathological Organization as Evasion of Depressive Anxieties

In the third and fourth year of the analysis B firmly established his homo-
sexual orientation and went out for a few months with a boyfriend as well
as having a series of brief homosexual encounters. During this period B
became more active in his social life and, after qualifying from university,
found an interesting position within a well-known design firm in London.
He became somewhat more communicative and managed to establish
periods of more lively contact in the analysis. However, these improvements
in his state of mind were short lasting and were followed by a relapse into
the more familiar sullen and negativistic states, particularly when analytic
work put him in touch with painful and anxiety-provoking feelings.
MARCO CHIESA 401

This phase of the analysis revealed the damaged state of his internal
primary objects, which frightened him intensely. His mental state oscillated
between the experiencing of depressive anxieties connected with the aware-
ness of internal damage and withdrawals into the safety of the psychic
retreat as a way to avoid pain and contact, as the following clinical obser-
vations, I hope, may illustrate.
B had done some work in analysis concerning the relationship with his
parents. He recovered unexpected warmer memories of his mother attend-
ing to him, holding him in her arms when he was upset, as well as for the
first time appreciating how difficult it must have been for her to bring up
three children while also suffering from a chronic neurological disorder. In
the following session (the last session of the week) he cried as he reported
the dreams he had the previous night:
He had a telephone call from the USA: a doctor informed him that his mother
had been taken to hospital critically ill, and that, unless money was found to
treat her, they would have to let her die. B at first was shocked by the news but
then he decided to ring the hospital and begged for his mother to be saved.

In the second part of the dream:

His mother came into B’s bedroom, sat next to him and gave him a warm
cuddle. He wanted to hold on to her as long as possible but she said that she
had to leave.

As B continued to sob, I interpreted that his usual experience of me as very

distant, like living in another continent across the Atlantic, had somewhat
changed. He felt that channels of communication had opened between us
and he had become aware of me as a human being better disposed towards
him. In the second part of the dream he experienced me as a warmer and
caring person with whom he needed greater closeness, even though in the
end he felt let down by his mother-me in the transference leaving him for
the weekend break. Up to this point I felt that I was making contact with
the soft and receptive part of the patient, who recognized the presence of a
good dying mother inside him, was in touch with the pain and sorrow this
entailed and with the need to save her.
B arrived late for the Monday session. He was silent for ten minutes, and
eventually started to talk in his usual monotonous, cold tone of voice. To my
comment that his mood seemed very different from the previous session, he
responded coldly that he had no idea what I was referring to, since he had
no recollection of how he had felt the previous week. After a pause he men-
tioned a dream he had over the weekend:
He was standing in the garden at his parents’ house. He saw a puppy dog lying
as though injured near the greenhouse. Although the puppy got up and walked
away, he realized that there was something very wrong. He walked towards
the greenhouse and saw two poisonous snakes in the tall grass. Horrified he
402 BRITISH JOURNAL OF PSYCHOTHERAPY (2007) 23(3)

realized that the snakes must have bitten the puppy and that its fate was sealed.
A rather disgusting smell and the sight of swarms of flies in the garden indi-
cated to him the presence of the hidden remains of animals that had been killed
and partly eaten by the snakes. He was surprised to see his mother walking
quite boldly in the garden seemingly undeterred by the presence of snakes.

B did not bring spontaneous associations. I interpreted that he felt that the
analytic work done the previous week, represented in the dream by the
growing and lively puppy, had been attacked by sinister forces and now he
feared that it was damaged beyond repair. Through the dream and his state
of mind in the session B conveyed that he felt hopeless that nothing could
be done to save the puppy part of him following the poisonous attacks. B
felt that the only solution was to detach from awareness and to take leave
mentally from the session. However, I pointed out that in the dream there
was a mother (me in the transference) who did not appear to be intimidated
by the snakes. The dream shows his awareness that he had felt helped by
the analysis over the previous week, and that a more lively part of himself
was emerging and growing. However, hidden internal menacing figures, rep-
resented by the poisonous snakes, were lurking ready to launch their deadly
attacks against life and improvement, and, specifically, to destroy the mean-
ingful and helpful aspects of the analytic relationship. B felt powerless and
frightened to face this scenario of death and damage, and felt that the only
available solution was to retreat and withdraw from contact and from
awareness of a painful and unbearable internal reality.
B’s great difficulties in gaining and sustaining insight into the damaged
state in which his ego and internal objects were experienced seemed to find
additional confirmation from a dream he had few days later:
He was in his flat and noticed a door, the existence of which he had been
unaware, and realized that it must lead to a room. He opened the door and
found an emaciated, starving dog near to his death. The room was bare,
unkempt and infested with mice. B felt utter disgust at what he saw and shut
the door. He wanted to help the dog but felt that there was nothing he could
do for him at this stage. However he also felt guilty: maybe it was not too late
and maybe the dog could be saved.

B dejectedly pondered that he really felt sorry for the dog and guilty that
he could not do anything to help him. He seemed puzzled as to why the dog
had done nothing to alert him of its presence in the room, so that help could
have been forthcoming much earlier.Through the dream B conveyed aware-
ness of the damaged and emaciated state of his internal life, which was intol-
erable. He became frightened by what he saw when the door was opened
in the recent session, namely the knowledge of the poisonous effects from
the internal snakes for which he found it unbearable to take responsibility.
For a moment he had become aware of the way his objects were reduced
MARCO CHIESA 403

to a state of starvation, and about the way in which this situation was
enacted in the therapeutic relationship, when B deprived me of analytic food
through his silences, tight control and lack of emotional availability needed
for a constructive psychoanalytic dialogue. B became frightened and was
unable to bear awareness of the horrors present in his emotional life, and
felt that the only option available to him was to close the door and not to
see. After interpreting along these lines, B responded in a low tone of voice
that he knew that he could not stay the way he is forever, as he would be
doomed and condemned like the emaciated dog in the dream.
B fell into silence and after a while, in a flat tone of voice, he said that
now he knew what he should do, he is aware of the situation, but still he
could not summon enough courage and energy to open the door. He felt
that he should be able to get on, but he could not bear to see what was
behind the door. This moving session clearly shows B’s sad predicament and
his fear that he may be condemned to being trapped in the filthy, bare and
infested room, with no-one able to help or rescue him. He felt that the only
alternative was to deny the seriousness of the situation as a way of escap-
ing the unbearable pain and suffering. B did not experience me as on his
side, as a figure who could offer him relief and sustenance, but, on the con-
trary, as a harsh and retaliating figure, losing my patience and ultimately
blaming him for the lack of progress. This could be partly explained by his
inability to tolerate guilt, which was turned into a persecutory situation in
which I then became the attacker, but also by the countertransferential
reality that made it problematic for me not to adopt a critical posture
towards him, during the many sessions in which I was confronted by the wall
of silence and passivity.
B went through a period of recurring shifts between painful insight and
withdrawal from contact, and retreat into the psychic retreat. At first B real-
ized that the part of him which wanted progress and growth was isolated
and split off, starved of contact. He reckoned that it was too late to free the
growing and lively (puppy) part of him for fear that the level of emaciation
was too extreme and irreversible. This gave him the rationale to stay put,
not to try and struggle in the analysis to challenge the tyranny of the patho-
logical organization that offered him a familiar and secure base. When
analytic work reached him, for a while he felt understood and more free to
experience a degree of sorrow, guilt and sadness, but then darker forces
seemed to be mobilized to attack progress, obliterate awareness and lead
him to eventual withdrawal from contact. The last dream of the starving dog
in the hidden room showed that B was caught between a wish for insight
and denial of internal reality. He wanted to know what was in the room,
however painful, yet he ended up shutting the door in disgust and pretend-
ing that the room did not exist, thereby evading the knowledge, which could
bring about severe anxiety and pain.
404 BRITISH JOURNAL OF PSYCHOTHERAPY (2007) 23(3)

Pathological Organization and Early Oedipal Conflicts

B found the notion of heterosexual intercourse extremely disturbing, and
interpretation of oedipal-related themes that either emerged in dreams or
were embedded in the analytic material were either dismissed as irrelevant
or responded to in a bland and robotic fashion – I suspected as a defence
against experiencing their disturbing emotional impact. As analysis pro-
gressed I formed the impression that he became identified with his patho-
logical organization and used overt homosexual functioning to bypass and
sedate the disturbance triggered by the awareness of a relationship between
a man and a woman, and of parents coming together in intercourse and in
other activities. His hidden difficulties with parental intercourse came to the
surface when two friends, who were sharing the same house as B, became a
couple and moved in the room next to his. From that point he became
increasingly agitated and brought into analysis a flood of complaints about
the noises suggestive of sexual activity that came from the friends’ room.
He felt that his private space was invaded, and he became increasingly
annoyed and hostile towards his friends. During analytic sessions he con-
veyed his tortured state of mind, as he developed insomnia, restlessness and
severe anxiety. The noises became like drills in his mind, and he felt that he
could not continue living in that house lest he became insane. Indeed the
noises became so incessant that I wondered whether he was hallucinating.
During that period he brought several dreams that indicated the inten-
sity of his feelings towards a persecuting heterosexual intercourse:
B is at a couple’s home; the place is very dirty, greasy and unkempt. He is
offered a drink, but he notices that the glass had been used before, it is dirty
and marked.

The session was then filled with his painful complaints about the couple in
the next room. He had spent the previous night awake, pacing up and down
the room, needing to go downstairs to the sitting room to read and have a
hot drink. B was seriously considering moving to different accommodation.
The following session he reported another disturbing dream of him:
being in a pub and seeing a big-breasted and overweight woman behind the
bar. She was monstrous and dressed like a prostitute. There was something
sinister about her. B realized that she offered presents to men in the pub in
return for sexual favours. She seems pregnant with twins.

In the second part of the dream:

The same woman was laying in bed besides B, and said to him that she had not
washed for 100 days; indeed she looked very dirty and smelled horribly. She
pointed to her genitals as a proof of her neglected state. B woke up disgusted
and feeling sick.
MARCO CHIESA 405

This dream material shows how B becomes persecuted as a result of feeling

at the receiving end of heterosexual intercourse, experienced as corrupt and
dirty. The sexual woman/mother becomes monstrous, disgusting, like a pros-
titute and her twin pregnancy, which brings to mind B’s two brothers, is at
the centre of the lurid ambience of the pub. He feels that this kind of
debased sexuality, which has a profound spoiling and poisoning effect on
him and his mind, could be imposed upon him, like the couple’s greasy glass
from which he is forced to drink. The dream offers a possible understand-
ing of my difficulties in establishing a more productive contact with B. In
the transference I may have been experienced as a mother contaminated by
heterosexual intercourse who would then feed him with dirty and poisonous
milk/interpretations. In his mind I could become the frightening and dirty
female prostitute from whom he needs desperately to run away to the safety
of the retreat and to his homosexual encounters. For B contact in this phase
of the analysis meant contact with an infected, contaminated and disgusting
figure. This material is also suggestive of B’s early disturbed relationship
with an unpredictable and damaged mother who was unable to offer him a
stable containing function. The threatening internalized maternal figure
emerges in his dreams in the shape of dirty and monstrous women. In the
transference, B was afraid of what I could offer, as he found my interven-
tions as disorganizing and attacking, as poison that could drive him to
madness. These dreams and other material indicated B’s fear of me as a per-
secutory maternal figure, an unpredictable and unstable object who could
threaten his very existence.
This retreat from contact, and B’s concurrent search for casual partners
during these stages in the analysis, worked as an antidote and an anaesthetic
to ward off unbearable states of mind. However, it is important to empha-
size that the retreat from contact was temporary and partial, as B moved
constantly between the two retreats throughout his analysis, which allowed
a degree of fruitful work and understanding to take place. It was at times
possible for B to gain insight when a shift took place, giving him a sense of
continuity of internal experience, which he could use to re-emerge from the
retreat to greater contact with the analyst.

Discussion
I hope that this clinical exploration can contribute to the understanding of
the complex functions that pathological organizations have in maintaining
chronic personality difficulties. B was an unhappy man who suffered from
depression and deeply unsatisfactory interpersonal relationships, unable to
establish true emotional contact. Although this situation felt painful at
times, B felt also very safe and protected, as he sought refuge within a mental
space experienced as a spaceship isolated and cut off from contact. This
retreat afforded him safety from experiences and affects that were felt as
406 BRITISH JOURNAL OF PSYCHOTHERAPY (2007) 23(3)

catastrophic and that he believed could not be survived, as the terrifying

disasters that repeatedly appeared in his dreams. During this phase of the
analysis it was very difficult for me to maintain an active interpretative
stance, to avoid being absorbed into the patient’s psychic retreat and not to
enact the role of his immobile and lifeless internal objects. I often found
myself repeating the same interpretations or being stuck in pursuing a line
of enquiry without a great deal of conviction, even though this might elicit
feeble agreement on B’s part. The result of this collusion was static and
unconvincing work, which did not seem to lead to any movement or change
in the atmosphere of the session. With hindsight, I might have been more
alert to the patient’s experience of me as a persecutory figure, connected to
his early disturbing experience with his mother, and could have directed
my interpretative focus onto his early attachment disturbances and early
environmental failures. The countertransference elicited in the work with
patients like B needs careful scrutiny, as the intense disturbance hidden
behind the more overt operation of the pathological defensive structure can
be very difficult to bear. The analyst may then react defensively and collude
with the patient in order not to face the emotional turmoil and the dread
that feels so unbearable to bring into the open. Ideally, the analyst should
be able to strike a balance between the analysis of the defensive structure,
based on his understanding of the level of the patient’s functioning and his
ability to tolerate anxiety-provoking interpretations. If this balance fails, the
patient may experience the analyst’s comment as an attack, an unbearable
intrusion and a hostile reprimand, as was sometimes the case with B. His
early deficits in internalizing a containing maternal object meant that, for
him, it was often difficult to take in and metabolize my comments, some of
which may have been premature and addressed at the wrong level.
B feared becoming aware of, and being more in touch with, his hostile
and aggressive affects, in particular, with his ‘poisonous’ effects on the part
of him that wanted to grow and connect with me. His attacks on the poten-
tial for a warmer, more friendly and productive contact frightened him
because it created unbearable guilt, which he could not face or process. The
retreat provided him with a refuge where he could disown any knowledge
of the emaciated and damaged state of his objects, as graphically depicted
by the discovery of the room inhabited by the imprisoned and starving dog
in his dream. The aftermath of the silently poisonous attacks, represented
by the deadly snakes in the garden he dreamt of, on the analytic work and
on the libidinal self could not be faced for they generated unbearable guilt
and despair. The function of the retreat was to spare him pain and terror
but, by preventing any possibility of mourning, it disabled the mobilization
of potential reparative capacities (Steiner 1990). At the same time, the
pathological organization offered him shelter against his fears of himself
being poisoned by another mind (his mother or mine in the transference),
experienced as unpredictable and damaged.
MARCO CHIESA 407

Analytic work on the non-human retreat gradually allowed for the emer-
gence of the second pathological organization, an area in which homo-
sexual object relationships took central stage. This move from a schizoid
mode in which no human relating was present represented an improvement,
as in this state B became more alive, brought more material into the ana-
lysis and became somewhat more engaged and responsive to the therapeu-
tic process. In those periods when his affective life became a little more
available he experienced a greater range of emotions and became sexually
active. However, the contact achieved by B was still rather limited and
restricted. In addition, the seductive and coercive homosexual figures
exerted their hold on the patient when he felt reached by analytic work and
when depressive anxieties were mobilized. B would then turn away from
contact, identify with the cruel homosexual figures and project his needy
side into me. This situation was clear, for example, when he discovered sad
and positive feelings for his mother (and for me in the transference), and
dreamt of her as critically ill in hospital. His contact with these softer aspects
of himself was soon wiped away by joining and identifying with the threat-
ening homosexual figures of his dreams. This situation at times shifted when
the helpless and co-operating part of B was not projected into me but was
kidnapped by forces that felt too strong and powerful to overcome. Because
of these shifts it was not easy to identify in my own mind which drama was
being played at each stage of the analysis before interpreting the prevalent
object relations and affects operating in the patient’s inner world.
B’s use of the pathological organizations became very marked when he
was faced with two objects coming together. The highly disturbed nature of
his reaction when the two people who were sharing the house with him
started a sexual relationship suggested that he was attempting to escape
madness by withdrawing into the retreat. B could not tolerate the idea of
a sexual mother who would give herself to his father and conceive other
children. He dreamt her as a prostitute and the sexual act as corrupt and
depraved. B’s response of seeking homosexual liaisons and of withdrawing
into the retreat and away from analytic contact seemed a desperate attempt
to retain sanity and to obliterate the maddening notion of parental relating
and especially of intercourse, but at the price of isolating himself from
important areas of his mind and from potentially productive analytic work.
The frightening and highly conflictual nature of the internalized, combined
object prevented B from a healthier introjective identification with his inter-
nal parental objects, which is an important precondition for adult hetero-
sexual development. Meltzer found that the quality of the:
. . . introjective identification with a combined object will create a thrust
towards the establishment of a similar, but not identical relationship towards a
beloved partner, and that these partners will necessarily possess different
genital organs and sexual qualities of mind. (Meltzer 1968, p. 121)
408 BRITISH JOURNAL OF PSYCHOTHERAPY (2007) 23(3)

It is likely that the working through of early oedipal constellations were

interfered with by his original traumatic and disturbing relationship with his
mother. Her sudden and inexplicable outbursts of anger, coupled with her
more usual remoteness and imperviousness, may have resulted in B becom-
ing terrified of his mother and introjecting her as a frightening, intimidating
and unpredictable figure. He feared that contact in the analysis would
expose him again to these early unbearable experiences. This case seems to
add evidence that depressive position anxieties and oedipal conflicts are
inextricably intertwined and that no resolution of one can occur without the
other (Britton 1999).
B used a complex defensive organization to bypass severe depressive
and early oedipal anxieties, and consequently was unable to establish a
more satisfactory contact with his internal and external reality. However,
some authors have questioned the universality of the classical oedipal
configuration. For example, Friedman and Downey (1995) offered a critique
of the concept that oedipal strivings are a biologically determined,
developmental norm, supporting their work with data from anthropology
(Erickson 1993) and evolutionary biology (Wright 1994), and suggested
that earlier attachment disturbance may determine later incestuous
phantasies.
This case also suggests that pathological organizations of the personality
are not a unitary entity occupying a uniform psychic space. In the same
patient we may find different, but related, internal spaces with specific char-
acteristics fulfilling different functions. Their developments as analytic work
proceeds need careful monitoring. These internal organizations may not be
completely separate and autonomous, but more probably organized along
a continuum of psychic development, with fluctuating movement occurring
between them in the course of the analysis. In B two predominant mental
areas with features of pathological organizations emerged in the course of
the analysis: the first characterized by his phantasy of inhabiting a space-
ship, a bare, lonely but safe island; the second a space populated with threat-
ening homosexual figures who actively seized the patient, but to whom at
other times the patient willingly offered himself as captive.

Conclusion
Advances in our knowledge of the complexities inherent in pathological
structures of the inner world are of critical importance for a better under-
standing of chronic and enduring resistance to psychic change. A fuller grasp
of the different features and of the specific defensive constellations and
complex object relations that are the building blocks of pathological organ-
izations will positively influence our clinical effectiveness in overcoming
the long states of impasse, which are far from being uncommon in our daily
clinical practice.
MARCO CHIESA 409

In B’s case the synergetic operation of two discrete psychic organizations

created a dense, deadening and paralysing atmosphere, which permeated
the analysis, which was not allowed to function for long periods. In the
material presented I focused on the way B recreated in the analytic setting
a relationship with an inanimate object, which he believed protected him
against the emergence of disturbing affects and experiences. The healthy
part of B’s ego was kept sealed off and prevented from establishing a pro-
ductive connection with the analyst by internal ‘homosexual’ figures belong-
ing to the pathological organization.

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