The Seeds of Madness: Constitution, Environment, and Fantasy in the Organization of the Psychotic Core

This is a gem of a book. Not only is it short and readable, but for any student of psychotherapy, it contains the kind of clinical pearls that one would savor during one's training. Volkan and Akhtar have assembled a wonderful group of contributors, from around the world, to discuss the deepest, most personal and profound experiences that one can have in working with very seriously disturbed patients in psychoanalysis or psychoanalytic psychotherapy.

In the first of the book's three sections, Laying the Groundwork, Dr. Volkan discusses what is, in essence, the psychological birth of the infant. The infant self is ready and eager to respond and engage, and Volkan immediately introduces us to one of his clinical conceptual pearls, that of the infant-mother "channel."

The genetic inheritance, the emotional temperament, the people interactions, cultural and linguistic variables, and even inadvertent traumas all pass through this gatekeeper-infant "channel" and infuse the seed of the self with its earliest psychic substrate. "If, however, the seed of self has not evolved, but remains undifferentiated or poorly differentiated and associated only with primitive ego mechanisms, we say that it is fixated as an infantile psychotic self, a 'seed of madness.'"

The next section of the book, entitled Theory, Clinical Illustrations, and Technique, contains six chapters by Johannes Lehtonen, Simo Salonen, Maurice Apprey, Volkan and Gabriele Ast, Ast alone, and L. Bryce Boyer. All are about cases, and all are riveting in their own ways.

Lehtonen looks at that first interface between soma and psyche that he calls the "body ego" and differentiates it from body image, which comes later. Here we have the initial matrix of libido, and we can see how essential satisfaction in hunger and sleep are fundamental to a groundwork wherein a nonpsychotic core can develop. There are only "vital" affects here, which makes the future range of all affects potentially bearable. If this area is not stable, one is left with the terror of to eat, to be eaten, and to die.

Simo Salonen writes on the relationship between dissociated or split-off parts of the ego and its correspondence to the patient's compromise of his or her own integrity and dignity. His focus is on pathology that results from a traumatic paralysis of the ego ideal. In an interesting parallel, he ties in the rupture in dignity and ego ideal trauma inflicted on the new Nazi doctors when they were first recruited into the concentration camps.

Maurice Apprey follows with a chapter on the "sense of disappearing in schizophrenia" in which he lays out a detailed phenomenological procedure for studying a sibling's report of her brother's psychosis. He proposes five steps to the disappearance: an injunction to die is established; a summons to submit to the injunction is rendered; an anterior (m)other seeks a constitutional or environmental fit to make the project of nonexistence feasible; the chosen subject submits; and a complicit project of the subject's adhering to the deadly injunction and an attendant but feigned attempt to repair the damage follows.

Two beautiful clinical chapters continue the second section. In the first, Volkan and Ast discuss the case of Lena and the concept of the psychotic personality organization. They clearly point out how the patient first attempts to encapsulate the psychotic core, then engages in activities to change the external world to fit the demands of her psychotic core so that a sense of reality is maintained, and finally hopes to libidinally saturate and rebuild her psychotic core in order to modify its nature.

Next, in "A Crocodile in a Pouch," Ast describes an obsessive-compulsive young man, Karl, whose pathology reflects what Volkan calls a "reaching up." Here a patient with a psychotic core pulls himself up to the next developmental level and, as a result, hides the deeper pathology. Ast eloquently unravels how his infantile psychotic seed had been saturated with the anxieties of his parents.

The final chapter in this section is by L. Bryce Boyer—"The Verbal Squiggle Game in Treating the Seriously Disturbed Patient." Boyer's writing is remarkable for its lucid explanations of what are the most difficult-to-describe experiences in the psychotherapy of psychosis. He is a talented writer as well as a masterful clinician.

His focus is on the bread and butter of what he considers to be essential in treating severely regressed patients—first, countertransference and, second, the establishment of a "play" or transitional space between patient and analyst wherein dissociated, split-off parts of the patient's deepest and earliest experiences can come together.

The case Boyer discusses illustrates his focus well, and he introduces a novel and clinically helpful idea. Boyer suggests that the dominant transference situation at each time in treatment precipitates the content of the session in the same way that an aspect of the patient's day (day residue) precipitates or is incorporated in each dream the patient has at night. Thus one can use techniques from dream analysis in listening to the content of each treatment session.

The third section of the book is one chapter by coeditor Salman Akhtar entitled "Constitution, Environment, and Fantasy in the Organization of the Psychotic Core," which is the book's subtitle. For newcomers to the psychotherapy of psychosis, it is an extremely understandable review of the role of heredity in psychosis. Akhtar goes on to discuss the facilitating environment in the development of object relations and the deficits that occur in this realm in psychosis such as psychic retreats, autism, a menacing superego, and the defensive filling up with bizarre fantasies. Affective turbulence, inadequate differentiation, deficient ego skills, thought disturbances, unassimilable contradictions, and deficient extrafamilial input all characterize problems in the environment. Finally, Akhtar also addresses the role of fantasy and its extremely frightening nature in the psychic life of psychosis.

In sum, what we have in The Seed of Madness is a unique collection of essays about ways of unearthing the seed so that it can be replanted or so that sustaining water and sunlight can contact the seed deep in the ground. Through this process of modifying the core or seed, the tree is able to reposition itself. Anyone interested in psychological work with disturbed patients will benefit greatly from reading this short gift of a collection.

Dr. Garfield is professor and director of residency training in psychiatry at Finch University of Health Sciences and the Chicago Medical School.