Site member, Dorothée Bonnigal-Katz, founder of the innovative and radical Psychosis Therapy Project, in association with Islington Mind, was interviewed by Patricia Gherovici and Manya Steinkholer last year to talk about her work with the Project. Full text below.
Psychosis Therapy Project: An Innovative Psychoanalytic Treatment Program // An Interview with Dorothée Bonnigal- Katz
By Patricia Gherovici and Manya Steinkoler
We met with the psychoanalyst Dorothée Bonnigal-Katz in March of 2017 in London on the occasion of a two-day conference, “Transgender, Gender and Psychoanalysis,” an event she organized with The SITE for Contemporary Psychoanalysis and the Freud Museum. We were intrigued by the Psychosis Therapy Project (PTP), an anglophone psychoanalytic treatment center for psychotic patients she directs, and asked her if she would be willing to be interviewed for Division Review to tell us about her current work.
MS & PG: What led you to open a treatment program for psychosis?
DBK: I started working with psychotic patients in the context of my psychoanalytic training at the Site for Contemporary Psychoanalysis in London. The Site was founded by former members of the Philadelphia Association and many of whom had direct involvement in the anti-psychiatry movement in the 1960s (Kingsley Hall, etc.). Psychosis is therefore an important interest at the Site and there is a tradition of working with psychosis there. The Site in fact includes outstanding clinicians who worked with R.D. Laing closely for years, including Haya Oakley whose guidance has been invaluable to me over the years. Haya is one of the key teachers and supervisors at the Psychosis Therapy Project, the clinic for psychosis that I launched in North London over four years ago. This is the immediate context of my personal interest in psychosis and the reference to Laing is an important one.
MS & PG: Can you tell us about your own trajectory?
Having trained in France before moving to the UK about ten years ago, my work has also been influenced by Jacques Lacan’s groundbreaking contribution to the psychoanalytic treatment of psychosis. Lacan was one of the greatest clinicians of psychosis; he was able to draw key insights into the treatment of psychosis from the Freudian corpus itself, despite and beyond Freud’s claim that psychoanalysis might not be relevant to psychosis. The work of Serge Leclaire, Jean Laplanche, François Roustang, Gisela Pankow and Evelyne Kestemberg, among others, make up important references in my approach as well. In the British context, I became acquainted with the work of Winnicott as well as with Bion’s theory of psychosis; in both cases, I found much inspiration to be found in the astute observations they make regarding their clinical experience of psychosis, even though they are speaking from a different psychoanalytic tradition and within very distinct metapsychological models.
During my training at the Site, one of my clinical placements took place at an Islington Mind day center, in a wonderful and chaotic house in Crouch Hill (North London), working with people with acute and underserved needs.
MS & PG: Was this the impetus to start the Psychosis Therapy Project?
DBK: Islington Mind is a mental health charity in North London that vitally supports people who require substantial to critical levels of care and are subject to socio- economic exclusion. I was given a lot of freedom in this placement, which I was grateful for as it gave me a chance to be as experimental as I wished. I made myself available as a therapist in the house and a few psychotic service users started visiting my consulting room on a weekly basis, seeking my ‘counsel’ as they put it. This turned out to be a good taster of what working with psychosis psychoanalytically might be like. I found the work instantly compelling. I was struck by the intensity of the encounter with psychotic subjects, the complexity of the transferential engagement with psychotic patients and the richness of the clinical material that arose from it.
This is how the Psychosis Therapy Project came about. When I got to the end of my placement, I felt that, instead of leaving this important work behind, I should formalize it, make it more widely available and turn it into a proper specialist therapy service; there was an obvious need for it as it simply did not exist. In the UK, people with a diagnosis of psychosis are generally not eligible for psychotherapy in statutory
services. Beyond medication and time-limited psychological therapies (CBT predominantly), long-term talking therapy remains widely unavailable to those who cannot afford private treatment. This is what makes the Psychosis Therapy Project a unique service in the British context, serving the complex needs of highly vulnerable and underprivileged service users. Peter Nevins, the director of Islington Mind (a psychoanalyst and a member of the Site), welcomed the initiative enthusiastically. The project quickly drew passionate trainees and volunteers and within a few months, I was able to put together a team. Referrals mainly came from within Islington Mind initially, especially from Islington Mind’s reputable Hearing Voices group.
MS & PG: How were you able to finance this project? Where did monetary support come from?
DBK: Apart from the generous hospitality of Islington Mind, the project started out with no funding. In fact, funding (or the lack thereof) remains one of the greatest difficulties this project has encountered since its foundation. There are obvious reasons for this and I might not have the space to get into them in detail in the present context but let us say that the therapeutic success we encounter in this kind of work is not easily measured by evidence-based standards. The kinds of interventions we offer at the project are beneficial, as recently confirmed by a satisfaction survey run among our service users; but the dominant model of ‘recovery and rehabilitation’ that presides over services’ eligibility for funding is ill-suited to the treatment of psychosis, if not persecutory.
MS & PG: This is a very important point that clinicians who work with psychotic patients would appreciate–the risks of imposing standardizing and normalizing models that do not reflect the complex clinical reality of psychosis, not just not undermining it but worsening it. Some have argued the saturated reality of psychosis requires a different therapeutic tempo. Is this your experience?
DBK: The work is very slow–it can take people years to dare take off their coat. Sometimes they never do. This is why we are committed to long-term open-ended work, and it has proven extremely therapeutic and effective. The point of long-term therapy is to provide much needed dependability, allowing individuals to rely on a steadfast yet flexible therapeutic setting that operates over time as an anchoring point.
But this generally does not sit well with funding requirements and criteria. At this stage, we rely on vital funding from Islington Mind for the day-to-day running of the service but we still operate on a shoestring budget and substantial long-term funding is very hard to get. Since 2017, the project has expanded to South London under the auspices of Lambeth & Southwark Mind. A pilot is currently running in Brixton but, there again and however needed such a service is in this underserved area of London, funding is a true challenge. I think the project has been very resilient all the same and we will find ways to keep it going but it is a constant struggle. The conditions we encounter are terrible due to the dire lack of funding and support. Our service users are vulnerable, we strive to maintain a mental health safety net for them, at all costs. But we should not underestimate the magnitude of the mental health crisis underway.
MS & PG: What is unique to the approach you propose? Have you been influenced by other psychoanalytic models of treatment for psychotics?
DBK: I did not really have a model in mind when I started the project. In a way, all the conditions were in place at Islington Mind and the project emerged quite organically. Psychoanalysis has a lot to gain from engaging with the community and tackling the devastating impact of social and economic exclusion. Its therapeutic approach has a lot to contribute to the community in turn, especially to the treatment of acute mental health problems, which are often inseparable—in the context of the work we do in London at least— from socio-economic discrimination. Once the project was launched, I discovered kindred projects in France and Canada which became a source of inspiration for us; they are long-established and belong to a rich tradition of psychoanalytic work with psychosis. The Kestemberg Centre in Paris was founded in 1974 and specializes in the psychoanalytic treatment of psychosis. Vassilis Kapsambelis, the director of the Kestemberg Centre, kindly invited me to attend one of their scientific meetings last spring and I was impressed by the quality of the contributions and by their facilities. The PTP team is hoping to go visit the centre next year. The other dream project I came across is the ‘388’ in Montreal, a psychoanalytic center devoted to the treatment of psychosis (young people, especially) and led by Willy Apollon and Danielle Bergeron. I am hoping to make contact with them.
MS & PG: We have been talking about the Psychosis Therapy Project, we are curious about how you define psychosis.
DBK: It is fair to say, from the outset, that psychosis is a challenge to psychoanalysis – psychoanalytic technique especially. The main reason, in my view, has to do with the impairment of the mechanisms of repression in psychosis. This is a distinct characteristic: I see psychosis as the site of the breakdown of repression, which logically leads to the failure of the metaphorical function. No repression, no return of the repressed, no remembering (at least, not in the conventional sense), no working- through: this leaves analysts rather bereft of their usual landmarks and tools. At the same time, working with psychosis yields privileged insights into primary process: there is a kind of literality that presides over the modalities of inscription and articulation of the unconscious. As such, it is a gold mine for theoreticians of psychoanalysis and a core term in metapsychology. This interestingly places psychosis at once on the margins and at the very heart of the psychoanalytic project.
MS & PG: While we agree with you about the centrality of psychosis to psychoanalysis, it has been our experience, in particular in the United States that often psychoanalysts retreat when facing psychosis, assuming that psychoanalysis has little to offer. Do you ever encounter resistance treating psychotic patients analytically?
DBK: The marginality of psychosis in psychoanalytic practice is one that can be questioned rather easily, in my view. Granted, Freud posits repression as the “cornerstone” upon which the whole edifice of psychoanalysis rests. But while this is actually true of the human psyche that crashes into the desubjectivating literality of the unconscious when repression breaks down, the edifice of psychoanalysis does not collapse when repression is faulty. The focus simply shifts to the flip side of repression, to the other side of the mirror where the whole ceases to be the sum of its parts and the clock freezes in obliterating timelessness. It is a very different landscape from the clinic of neurosis, a very impoverished one at times, desolate, a place where the Cartesian cogito is an unavailable luxury. Thinking and being are somewhat estranged, one no longer warrants the other. As for meaning, it is somehow trapped in the body, inscrutable scraps in an inscrutable whole: the word is simply not stitched to the flesh.
Working with psychosis therefore mobilizes fundamental questions about existence and subjectivity. When psychotic subjects seek our help, what they bring to us is their ontological precariousness, what they claim is subjective delineation and substantiality. Generally speaking, the work is very demanding, requiring an enormous amount of discipline and rigour on the part of the analyst. In psychosis, there is no room for two: 1 + 1 is in fact 1, a reality paradoxically rooted in a murderous dyad that it is the analyst’s job to avoid at all costs. The analyst must therefore strive to embody “subjectivity degree zero,” as I like to look at it. These are very hard demands to meet, impossible ones. But is the impossible not the terrain of psychosis?
This paradoxically makes psychosis the paragon of psychoanalytic technique. Beyond the apparent irrelevance of Freud’s technical guidance, the clinical encounter with psychosis involves what Freud sees as the foundation of the talking cure: he calls it truthfulness – “psychoanalytic treatment is founded on truthfulness” (Observations on Transference-Love, 1915 ). In the Freudian sense, truthfulness is by no means an ideal: it is a technical requirement rooted in the fundamental rule of abstinence, of neutrality and in the therapist’s consistent frustration of all forms of ego gratification. In the clinical setting, such a stance elicits the elaboration of a non-judgmental therapeutic space where the psychotic experience can be engaged with, safely and fruitfully. In this context, therapists are able to endow the psychotic experience with validity, which results in immediate therapeutic gains.
MS & PG: Can you tell us more about how such gains are accomplished?
DBK: The idea is to develop a therapeutic alliance predicated on the technical requirement of truthfulness. This is what the PTP seeks to implement and substantiate. This naturally applies to psychoanalytic practice in general, not only psychosis, but in the clinic of psychosis it is a vital requisite. Another related requisite consists in rejecting all forms of normalizing “reality” which would censor the psychic reality of psychotic subjects, thereby depriving the individual of his/her most precious safeguards. This is aligned with Freud’s acknowledgment that “the delusional formation, which we take to be the pathological product, is in reality an attempt at recovery, a process of reconstruction” (Psychoanalytic Notes on an Autobiographical Account of a Case of Paranoia, 1911). It is therefore imperative to work with and
within the psychotic experience with a view to advancing the individual’s “attempt at recovery” and contributing to the “process of reconstruction.”
MS & PG: Since, as you argue, psychotics do not have repression, one might conclude that they do not have an unconscious, and therefore would not be good candidates for psychoanalytic treatment. One the other hand, some psychoanalytic schools talk about psychotic phenomena or even psychotic experience, implying that psychosis is a potentially universal subjective state. What is your opinion about this?
DBK: My metapsychology is not Kleinian so I do not see psychosis as a universal phenomenon. I do not think we all have a psychotic core; I think we all have an unconscious, a core of negativity that draws us to death. Psychosis is, in my view, one of the defenses mobilized against this core or draw. It is a very deficient defense, granted, but a defense all the same, the only one available when repression has broken down. In neurosis, repression does not break down, it only fails and the consequences are very different. Gisela Pankow usefully distinguishes between destruction (psychosis) and distortion (neurosis) in this context. I personally think more theorization is needed in the area of psychosis, more metapsychological engagement. The experience of working with psychotic subjects is a distinct one and much of it remains to be symbolized. Evelyne Kestemberg talks about a duty to theorize. She has a point. I believe clinicians working with psychosis have a duty to do so just as psychoanalysis has the duty to address the underserved needs of the community.
Dorothée Bonnigal-Katz is a psychoanalyst and a translator in the field of psychoanalytic theory. She is a member of the College of Psychoanalysts – UK and the Site for Contemporary Psychoanalysis and one of the editors of Sitegeist: A Journal of Psychoanalysis and Philosophy. She is the founder and Clinical Director of the Psychosis Therapy Project in London and also works in private practice. She has translated a number of psychoanalytic works including Dominique Scarfone’s Laplanche: An Introduction (2015) and The Unpast: The Actual Unconscious (2016). She translates for the International Journal ofPsychoanalysis on a regular basis. She has a special interest in promoting the psychoanalytic treatment of psychosis in theory as well as in practice. Address for correspondence: firstname.lastname@example.org
Patricia Gherovici, Ph.D. is a psychoanalyst and analytic supervisor.
She is co-founder and director of the Philadelphia Lacan Group and Associate Faculty, Psychoanalytic Studies Minor, University ofPennsylvania (PSYS), Honorary Member at IPTAR the Institute for Psychoanalytic Training and Research in New York City, Member at Apres-Coup Psychoanalytic Association New York, and Founding Member of Das Unbehagen.
Her books include The Puerto Rican Syndrome (Other Press: 2003) winner of the Gradiva Award and the Boyer Prize, and Please Select Your Gender: From the Invention ofHysteria to the Democratizing ofTransgenderism (Routledge: 2010). She has published two edited collections (both with Manya Steinkoler) Lacan On Madness: Madness, Yes You Can’t ( Routledge: 2015) and Lacan, Psychoanalysis and Comedy (Cambridge University Press: 2016). Her new book Transgender Psychoanalysis: A Lacanian Perspective on Sexual Difference was published by Routledge in June 2017.
Manya Steinkoler, PhD, is an Associate Professor of English at Borough of Manhattan Community College and a psychoanalyst. She is co-editor, with Patricia Gherovici, of Lacan on Madness: Madness, yes you can’t (Routledge, 2015) and Lacan on Comedy (Cambridge University Press, 2016). Dr. Steinkoler was the coorganizer, with Dr. Michael Garfinkle, of “Psychoanalysis on Ice,” held in Reykjavik in 2014, and has organized many conferences on psychoanalysis in New York.