Masi 2003

Int J Psychoanal 2003; 84:1149–1169
On the nature of intuitive and delusional thought:
Its implications in clinical work with psychotic patients

FRANCO DE MASI
Via Bernardino Ramazzini 7, I-20129 Milano, Italy — francodemasi@libero.it
(Final version accepted 25 February 2003)
The author tries to differentiate intuitive imagination from delusional imagination and
hypothesises that psychosis alters the system of intuitive thinking, which consequently cannot
develop in a dynamic and selective way. Scholars of different disciplines, far removed from
psychoanalysis, such as Einstein, Hadamard or Poincaré, believe that intuitive thinking works in
the unconscious by means of hidden processes, which permit a creative meeting of ideas. Thanks
to Bion’s work, psychoanalysts have begun to understand that waking thinking is unconsciously
intertwined with dream-work. The delusional construction is similar to a dreamlike sensorial
production but, unlike a real dream, it remains in the waking memory and creates characters
which live independently of the ‘dreamer’s’ awareness. It is a dream that never ends. On the
contrary, the real dream disappears when it has brought its communicative task to an end. In the
analysis of psychotic patients it is very important to analyse the delusional imagination which
dominates the personality and continuously transforms the mental state, twisting emotional truth.
The delusional imagination is so deeply rooted in the patient’s mental functioning that, even
after systematic analysis, the delusional world, which had seemed to disappear, re-emerges under
new con gurations. The psychotic core remains encapsulated; it produces unsteadiness and may
induce further psychotic states in the patient. The author reports some analytic material of a
patient, who, after a delusional episode treated with drugs, shows a vivid psychotic functioning.
Some considerationsare added on the nature of the psychotic state and on the therapeutic approach
used to transform the delusional structure. This paper particularly deals with the dif culty in
working through the psychotic episode and in ‘deconstructing’the delusional experience because
of the terror connected with it. In the reported case, the analytic work changed the delusional
construction into a more benign one characterised by phobic qualities. The analysis of the
psychotic transference allowed the focus to be on the hidden work which had been continuously
in uencing the transferential picture of the analyst and the patient’s psychic reality.
Keywords: delusional imagination, intuitive thinking, psychotic transference, terror,

deconstruction of psychotic experience
I began having what I don’t think are dreams, since they were not like any dream I have
ever had, or read of … (Philip Dick, from an interview to Ursula Le Guin, July 1986, in
Sutin, 1989).
Schizophrenia cannot be understood simply in terms of traumata and deprivation, no matter
how grievous, in icted by the outer world upon the helpless child. The patient himself, no
matter how unwittingly, has an active part in the development and tenacious maintenance of
the illness, and only by making contact with this essentially assertive energy in him can one
help him to become well (Searles, 1979).
Mackey: How could you, a mathematician, a man devoted to reasoning and logical
demonstration … how could you have thought that extraterrestrials were sending you
©2003 Institute of Psychoanalysis

1150 FRANCO DE MASI
messages? How could you have believed that you had been recruited by aliens to save the
world? How could you?
Nash: Well, because … my ideas about supernatural beings came to me in exactly the same
way as my mathematical ideas. So I took them seriously (From a conversation between
George Mackey, professor at Harvard, and John Nash, Nobel laureate and distinguished
mathematician, who became psychotic, in Nasar, 1998, p. 11).
I am quoting the answer given by John Nash—whose disconcerting life has been
reconstructed in the lm The beautiful mind, not without a certain appeal, although
stylistically rather sickly sweet Hollywood—in order to emphasise how the person who
suffers from delusional experiences cannot distinguish between delusional imagination
and intuitive imagination.
In Nash’s case, his capacity for scienti c intuition and his capacity for delusion
were able to proceed side by side during the psychotic episode, without one interfering
too greatly with the other, up to a certain point. He could be in touch with the Martians
and at the same time carry out important mathematical research, but he was not able to
realise the difference.
The forming of the delusional system is still a dark area for which neither
psychiatry, which has studied it tenaciously, nor psychoanalysis, which perhaps
approached it too cautiously, has been able to provide satisfactory answers. Indeed, we
know very little about how thought and emotions are formed, the two functions that
‘burn out’ during delusion. The same areas and functions of our mind that make up our
subjective psychic experience are probably involved in the continuous formation of the
delusion which advances without limits when the dividing line between delusional and
intuitive imagination fails.
This paper originates from my own personal discomfort as an analyst engaged in
treating psychotic patients and explores certain aspects of the delusional formation in a
patient in analysis. My clinical experience leads me to believe that, in order to understand
the psychotic state, we need further knowledge about the aspects and functions of the
mind, which, because of their characteristics, have escaped systematic psychoanalytic
investigation up to now. Lack of this knowledge obstructs the path of the clinical
psychoanalyst wanting to analyse a delusional adult.
While neurotic functioning leaves the organisation and the structure of the
personality intact, the psychotic state tends to alter the unconscious functions of the
perception of identity, emotions and thought. Typical phases exist as the psychotic state
progresses, from the most organised to the least organised levels, in which increasing
transformations of the perceptual apparatus and self-awareness are produced.
It is helpful to get used to seeing the psychotic state as a ‘path’, trying to distinguish
the passages, phases or direction of a process that advances by degrees to reach stages of
development that are irreversible and resistant to every form of therapy. When beginning
therapy with a psychotic patient it is, in fact, important to gauge how far the psychotic
state has advanced.1
1
In this paper, by psychotic state I mean a pathological condition that does not include manic-depressive psychosis,
whose aetiology and pathogenesis have been amply illustrated by Freud and Abraham. This latter condition is
characterized by free intervals during which the patient returns to his/her previous psychic functioning. On the
contrary, the psychotic state accompanied by delusions and/or hallucinations is characterized by a ‘defective
recovery’. Split from awareness, the delusional nucleus continues to threaten the patient, albeit in an attenuated
form, even during a phase of apparent reintegration.
ON THE NATURE OF INTUITIVE AND DELUSIONAL THOUGHT 1151
I will now list what I consider to be the salient features in the progressive
advancement of the psychotic state:
1) Psychosis is a process that, once triggered off, is by and large unstoppable.
It concerns alterations of the self (the perception of continuity of individual identity),
followed by disperceptual, visual or auditory phenomena (hallucinations), or by thought
disorder. These phenomena are secondary to the alterations produced in the self.
2) Initial, central and nal phases of the psychotic state can be described. The rst
phases generally coincide with pleasant mental sensations.2 Only later do the perceptual
transformations become devastating and terrifying. In the nal phase, autarchic sensory
production is reached.
3) In psychosisthe psychesometimes takes pathsthat allow it to accede to ‘higher’mental
states (ecstatic, telepathic) where contact with the ‘divine’ and the ‘omnipotent’ is constant.
4) Psychosis often begins with the creation of an initially benevolent and
seductive object, which promises the patient a mental state of total happiness. This
object is subsequently transformed from benevolent gure into terrifying object, which
dictatorially dominates the patient’s mind, threatening him/her if he/she dares escape
its power.
5) The psychotic system is dynamically balanced with the non-psychotic part, but
this relationship inexorably shifts in favour of the former.
The alterations induced in the patient’s perceptive-emotive apparatus reduce his/her
awareness of the process under way and completes his/her state of imprisonment more fully.
In a previous paper (De Masi, 2000), I hypothesised that the psychotic state blinds the
intuitive-perceptive functions of the unconscious, that is, those functions of the emotional
perceptions and of intrapsychic communication that work on an unaware level.3 The
necessity to discover the areas to investigate and the task to nd the adequate analytical
answers, on the basis of the nature of the patient’s disorder, is the common task of every
analysis, but becomes particularly cogent in the psychotic patient because of the speci c
nature of his/her psychopathology. These introductory remarks are necessary to explain
how some aspects of the psychotic state can be analysed during analytic treatment.
In this paper I will discuss a patient who came to analysis after just one psychotic
episode, and whose psychotic symptoms would certainly have worsened without suitable
therapy. Starting from the clinical material, I will also make some observations on the
signi cance of the psychotic transference during the analytic process. During therapy,
it is not uncommon to observe the development of a psychotic transference or of a
transference psychosis, which needs to be adequately worked through and which is useful
for throwing light on the psychotic functioning.
2
This statement may seem to contradict the observations of some authors who maintain that the initial phase of the
delusional experience is always painful (for example, Ping-Nie Pao, 1979). In my opinion, feelings of catastrophic
anxiety grip the psychotic patient only when he/she ceases to experience the sensorial self-pleasure of grandiosity
and omnipotence, and becomes unable to control the transformation process of the perceptions that he/she had
set in motion. For example, before being overwhelmed by the catastrophic experience of world destruction
and the delusional persecution focused on Flechsig, President Schreber was caught in the sensual pleasure of
transformation into a woman during sexual intercourse. If we don’t admit the primitively seductive nature of the
psychotic experience, it is impossible to understand the patient’s attraction and ‘passive’ submission to it. Often, this
fascinating feature of the delusional state is hidden by the patient’s unwillingness to communicate it.
3
Freud was unable to systematically investigate the unconscious functions necessary for understanding emotions and
psychic reality. Nevertheless, he believed these functions to be fundamental: ‘Psychoanalysis has shown us that everyone
possesses in his unconscious mental activity an apparatus which enables him to interpret other people’s reactions, that is,
to undo the distortions which other people have imposed on the expression of their feelings’ (1913, p. 159).
1152 FRANCO DE MASI
Intuitive imagination and delusional imagination

Psychoanalyst and analysand work in similar mental conditions to those of an intuitive
scientist. The work in the analyst’s room involves sensing a link between an ensemble
of sense data, images, memories or emotions that had been unconnected and apparently
meaningless until that moment, through operations of conscious and unconscious thought.
Since the process is unconscious in the rst place, it is only possible to reconstruct in
retrospect the path and associative links that allowed a thought to be born. To come to
life, this intuition, an inevitable and comforting widening of vision and knowledge, needs
a long period of incubation.4
The functions of the unconscious in thought processes were identi ed by scholars in
elds quite removed from psychoanalysis, who did not cite Freud even once nor refer to
the unconscious as described by him. In studying the path that leads to an intuitive solution
of a scienti c problem, these scholars emphasised the unconscious matrixes of thought.
A scholar who has underlined the intuitive paths of the scienti c discovery,
the mathematician Hadamard (1945) states that the unconscious has the important
characteristic of being multiple and that various and probably numerous things can
simultaneously take place in it. This contrasts with the unitary, conscious ego. The
discovery, says Hadamard (who follows Poincaré in this), is not due to pure chance.
The importance of unconscious thought processes in the scienti c work has been
also underlined by Einstein (1949) who af rms that it is beyond doubt that our thinking
mostly proceeds without the use of signs and, furthermore, in large measure, unconsciously.
The fact that an intuition seems to arrive unexpectedly by chance implies an unconscious
process preceding it. The invention or discovery occurs through a combination of ideas:
there are an extremely high number of these combinations and only a very few are useful, the
majority being of no use at all. This activity occurs unconsciously and these combinations
occur more readily if one’s attention is kept uctuating: to invent, it is necessary to think
sideways. Naturally this recalls Freud’s ‘free- oating attention’ and Bion’s being ‘without
memory or desire’. Creating consists in not making useless combinations and in examining
only the useful ones: invention is discerning and choosing.
Poincaré (1908) underlines that the unconscious ego is not merely automatic; it is
also capable of discerning; it has tact and subtlety. It knows how to choose; it knows how
to guess better than the conscious ego because it succeeds where the other fails.
A feeling of intuitive pleasure arises when the magmatic eld of phenomena and
perceptions is organised around a gure that emerges from a background: this gure
includes and organises all the elements present in a superior and meaningful order. This
is the moment of ‘illumination’, a small or big triumph that accompanies the scienti c
discovery and, to a greater or lesser degree, exalts every birth of ideas.
We can therefore reach the conclusion that it becomes impossible to think if one’s
attention is too dispersed, while, on the other hand, forcing it too much in one direction
is equally damaging to intuition.
Intuition, the insight which leads to new discoveries, enlightens us and gives
an order and meaning to data that previously did not have them. The psychoanalytic
4
Merit must go to Freud for sensing that the ow of conscious thought must lack direction and attention must
uctuate if new ideas are to emerge: in this way he was a pioneer of modern ideas about unconscious cognitive
processes. Freud’s recommendation that the analyst should be like a blank screen, or Bion’s take on being without
memory and desire, suggests that the analytical interpretation springs from the unconscious when all mnemonic
images or conscious desires are absent.
interpretation and understanding that occur in analysis are part of these ‘lucky’ events
that happen in the speci cally emotional eld of psychoanalysis. But this moment of
intuition is temporary because immediately afterwards the horizon widens and there is
something else to be sensed or a new problem to be resolved. Consequently, man cannot
experience knowledge as an attainable objective forever but rather as an open horizon
that allows oscillation in creative doubting.
The point I would like to develop in this paper regards the system that changes in
psychosis. This system allows intuitive thought to develop in a dynamically selective
way and to carry out its function of internal communication.
A series of observations leads us to believe that the intuitive and perceptive
functions of the self and of emotional awareness that allow psychic life are involved in
serious disorders like the psychosis.
Fonagy and Target (1996) maintain that patients with serious personality disorders
inhibit a particular aspect of the normal development of their mental processes—the
re ective function—and so do not manage to respond exibly and suitably to the
symbolic and signi cant qualities of other people’s behaviour and communication, as
well as not being able to represent themselves and be aware of their own emotions.
I have already said (De Masi, 2000) that, in my opinion, the psychotic state blinds
the ‘unconscious emotional-intuitive functions’ and so the patient totally lacks any capacity
for self-observation and awareness of his/her own mental and emotional processes.5
I would like to differentiate here between consciousness and awareness, two
concepts that are often considered equivalent. ‘Consciousness’ is the capacity to register
a psychic event, to memorise it and to remember it. ‘Awareness’, instead, has to do with
the meaning and understanding of that event, and is linked to the presence or absence of
the intuitive function and to the capacity for self-observation.
The state of unawareness, deriving from the impossibility of using the unconscious
intuitive function usefully, reaches an extremely high degree during the psychotic process.
In the psychotic state, conditions are therefore created that contradict the analytic method
itself, based on the possibility of insight by means of associative work originating from
the unconscious intuitive processes.
The system that is then altered in psychosis is the one that normally allows the person
to learn in a dynamically selective way from his/her intuitive experiences: consequently,
the psychotic person denies his/her dependence on reality, if for dependence on reality
we mean the constant doubting exploration of our intuitions.
To demonstrate how a failure in intuitive thinking makes our usual analytic work
dif cult, I will try to describe, and comment on, part of an analysis with A, a patient
who functions in a psychotic way. In this material I will focus on the analysis of the
delusional construction.
The patient in analysis

A, who is 26 years old, had a psychotic episode of a delusional nature while abroad.
His symptoms were dulled by pharmacological treatment. His persecutory delusion,
5
Modern ideas of infant development (I am alluding to work by Emde, Stern and Infant Research, as well as to
Fonagy’s and Target’s theories on the re ective function) highlight the importance of the child’s original emotional
capacities, which can be strenghtened or distorted by the maternal response. It is possible these early distortions of
the intuitive and emotional functions are the precursors of a person’s vulnerability to the psychotic solution.
1154 FRANCO DE MASI
following a period of megalomanic expansion, was triggered by a quarrel with a work

colleague of Iranian origin, who became head of the conspirators that were making
attempts on his life. I met A after he had been in hospital and had had a short period of
meetings with the psychiatrist who’d had him in care.
In our rst encounters, A told me he felt reassured by his return home and thought
he could regain the ‘affects’ he had moved away from. The rst months with this patient,
who I saw once a week, helped me form a clearer picture of the psychotic episode and
assess whether a desire to tackle an analysis might develop within him or not. Our
sessions gradually increased to two a week and at a certain point he agreed to lie down
on the couch. Subsequently our sessions increased to three and then four, despite his
dif culty in admitting that he needed help.
However, I felt a considerable emotional coldness in the analytic relationship. I
perceived that I was considered a potential intruder who should be held at bay. I also
noticed that with his impersonal way of speaking the patient was slowly reproducing that
suspicious, questioning atmosphere that could easily lead him back into delusion.
Although he had certainly improved and had started working again as a part-time
consultant (leaving home and meeting people), he in fact functioned as though suspended
between two adjacent psychic realities, one of which could unexpectedly take the other’s
place. He was, in fact, afraid of being poisoned in the café where he ate his lunch; he
regarded the casual glance of a passer-by or a banal nose bleed as a threatening sign,
proof of a conspiracy against him. When a girl who went to the same gym as he did
injured herself slightly by chance, the instructor said, ‘Go and disinfect yourself’. For A,
this phrase con rmed that there were toxic substances in the place, used by his enemy
to damage him. Although relatively improved and not openly psychotic, A felt like a
threatened person, forced to live a totally clandestine existence: whenever the veil of total
anonymity was violated, this produced violent persecutory anxieties in him.
At times he told me that his persecutors continued to operate by means of diabolic
instruments and sophisticated devices (microphones, cameras) that lmed him or recorded
his words so that he could be pointed out to whomever was responsible for killing him.
I had the feeling that even the analytic room was secretly scrutinised to exclude the
presence of microphones or transmitters. I soon realised that the delusional atmosphere of
the psychotic episode had been re-established, recreated by the power of the imagination.
To show how the delusion is created and how its powers of attraction are developed,
I will relate an episode that illustrates a sequence of this type.
While the patient was attending a conference of an organisation for defending
the rights of the Third World, he joined in the ovation which accompanied the speech
of a particularly vehement speaker against powerful international monopolies. He
immediately felt danger in the air, concretely realised in his perception of the intentions
to poison him on the part of the owner of a restaurant where he had gone to eat with his
companions in the interval (he saw strange manoeuvres in the preparation of his food
and the restaurant owner busy poisoning his dishes).
The patient believed that his being the object of murderous attempts depended on
his joining in the enthusiasm for the speech, and thus revealing his emotions and turning
himself over to the mercy of persecutors who now wanted to poison him. He was, in fact,
quite convinced that when he is ‘emotional’ he becomes the target for terrifying retaliation.
During the session, I put forward the idea that the vehement speaker might also
represent a part of himself, aggressive and polemical towards powerful organisations that
he is idealistically against. I pointed out to him that his ‘emotivity’ is a mental state of
anger and subversive violence against people perceived as violent and tyrannical.6
It was clear that his improvement had taken him back into the same aggressive
con guration his delusion had originated from. I believe this patient is the bearer of
a con ict focusing on power (the Ma a, the clan of Iranians), capable of evoking in
his imagination evil, destructive and persecutory gures. He is not, in fact, capable
of differentiating between his desire to realise himself assertively and aggressive
competition with a powerful person whose place he secretly wants to take.7
The problem posed in analysis is that of helping the patient disentangle himself
from this melting pot of explosive passions, though avoiding the suggestion that he gives
up his vital aggressiveness.
The psychotic transference8

I have already mentioned the unusual feeling of non-involvement that, for a long time,
this patient transmitted to me. From the very beginning I was aware that he did not
want to be involved in the relationship, even though verbal communication owed
easily between us, and that at times he was only physically present in the room. I was
relieved, though, that for the whole of this period the analytic space appeared to remain a
suf ciently neutral place, protected from persecution. This ‘neutral’ position was always
on a knife-edge, however.
For example, when the patient spoke to me in this period of his doubts about leaving
his parents’ at, as his mother suggested, I sensed that my eventual stance on this would
be subjected to special scrutiny. If I were to express doubts about him immediately leaving
home (where, among other things, the patient was more protected from persecution), it
would be as though I was declaring my anxiety, con rming in some way that enemies
did exist who wanted to make an attempt on his life. If I was aware of the danger, then it
was also possible that I was one of them. His mother’s position, pushing him out of the
house, is more reassuring for him.
If a friend told him that he ‘knew’ where his country house was because it was near
his own, then he might feel that he had been discovered by the ‘organisation’ persecuting
him and that his friend was a spy.
6
On this occasion we succeeded in making some connections with previous psychotic instances that the patient had
not informed me of. During a holiday break to a village in southern Italy he had felt persecuted by the Ma a. At
that time, idealising himself, he had begun to think that he could defeat the Ma a. But after a while this resulted
in his fear of persecution. During the ensuing psychotic crisis, he imagined being the chief of a powerful global
organization that fought against injustice throughout the world. However, he gradually identi ed himself with an
avid character, ambitious and power hungry.
7
In my opinion, this delusional constellation originates from an early infantile con ict with his father who, on the
one hand, encouraged the boy’s ‘superiority’ yet, on the other, humiliated him during their confrontations. It must
be noted, though, that the patient had never been aware of this con ict: he always identi ed completely with his
father—the ‘winner’. I believe that it is this pathological identi cation that has interfered with the development of a
separate identity and true self.
8
Some authors (Kernberg, 1975; Rosenfeld, 1978; De Masi, 1992) distinguish between ‘transference psychosis’
and ‘psychotic transference’. While transference psychosis lies in psychotic manifestations emerging exclusively
in the transference, psychotic transference crosses over to include the analyst in the psychotic delusion that is
developed outside the analytic relationship. Rosenfeld (1997) emphasises the importance of recognising quickly the
development of a psychotic transference. Failure to do so can often result in the development of an acute psychotic
situation. In this case, hidden and split psychotic parts escape control and overwhelm the non-psychotic elements of
the patient’s personality.
1156 FRANCO DE MASI
In analysis, if I spoke about him making connections on the basis of information

that he had given me and using simple intuitions, I discovered that the patient thought I
was endowed with telepathic powers and that I belonged to the organisation spying on
him and wanting to eliminate him.
Once, I passed him as he was sitting in a café near my of ce but, as I did not
see him, I did not stop and say hello. The next session, after a great deal of effort and
considerable anxiety, he confessed to having seen me. It seemed to him as though I was
running in the direction of a nearby small shop of Persian carpets, which was supposedly
a den of persecutors who wanted him dead.
At rst, I was greatly worried by this sort of communication. With hopes wavering
that the analytic setting could remain free from persecution, I began to fear that I, too,
was included in his delusion and would lose my analytic function.
However, I must point out that my fears did not correspond to the nature of the
therapeutic process, which instead followed its course. Although worried, I thought that
it would be possible to probe further, by means of the psychotic transference, into the
secret scheming that engulfed and transformed the patient’s psychic reality, as well as
the gure of the analyst.
So I asked the patient how he thought that I, the person looking after him, could
ever think of betraying him by joining forces with whomever was persecuting him.9 He
said that he knew nothing about me, that I was a stranger and that I could betray him.
For example, he added, I could be frightened by his omnipotent persecutors or I might
be attracted by the vast sums of money they could offer me. At this point I understood
that the patient considered me to be someone so easily in uenced by terror or fascinated
by money that I could wipe out every affective bond that I must have had with him. A
explained to me that he did not trust anyone outside his family circle.
In subsequent sessions he repeated that he did not know me, knew nothing about
me. Everyone, except his parents, could be bought by enemy power or be brainwashed
into destroying him. He admitted he had been reticent precisely because, not knowing
anything about me, he did not trust me.
This admission of dif dence allowed me to realise better the signi cance of the
emotional distance and feeling of non-involvement between us that I had felt right from
the beginning. I could also understand his dif culty in asking me questions or nding
out about me, and his apparent lack of curiosity about me. The next sessions furthered
an initial working out of this point.
The patient began to think that, if he was courageous enough to nd out a bit
about me, he might be able to think of me as a human being and rid himself of the
image suggested to him by an inner voice of me as a puppet without affections easily
transformable by enemies. This acquisition could help him build a good relationship
with me and could become a stable element in his internal world.10 I understood that
the construction of the psychotic transference contained, in a condensed form, the same
9
I asked myself afterwards why I had not interpreted to the patient in that session that I had been transformed into
a persecutor on account of his projections. Evidently I had sensed that he was not able to understand or accept this
type of interpretation (the description of his projective identi cation) because of his matter-of-fact way of thinking.
For this reason I had replied in my turn with a question that I hoped might help him to re ect on the psychotic
transformation that had just occurred.
10
In my opinion, when working with psychotic or severely disturbed patients, it is necessary to keep in mind their
lack of curiosity regarding the analyst as a person. In these kinds of patients, the curiosity is inhibited and is
sometimes felt as a guilty, dangerous intrusion.
mechanism as the creation of the delusional system. When he felt me to be at the service
of his powerful enemies, I am quite certain that the patient was projecting on to me his
positions or past anxieties (his being won over by power and richness or his submission
to powerful people).
I was struck, though, by his lack of empathy and his incapacity to understand the
feelings of others, and mine in the analytic relationship.
In this way, it really seemed as though he could obliterate the presence of every
human relationship and all positive feelings in the outside world, and automatically
transform all objects other than himself into negative and dangerous ones.
Terror and imagination

Thomas Freeman (2000) emphasises that even when the patient has emerged from a
psychotic episode, the ‘crisis’ continues to remain as a powerful destabilising element.
Terri ed of having to relive it and of becoming psychotic once again, the patient is
frightened even of remembering the circumstances, let alone the evolution, of the
psychotic crisis. 11 Freeman believes that this fear constitutes a dif cult obstacle to
overcome due to the regressive power of the analytic treatment, which tends in itself to
destabilise psychic structures.
While agreeing with Freeman about patients’ terror in returning to the psychotic
episode, I do not believe that the hypothesis of analytic regression is helpful in explaining
their dif culty to work through the ‘crisis’. In my opinion, the reasons are many and are
partly independent from the fact of being in analysis.
When you work analytically with a person who has suffered a psychotic breakdown
you see the proof of the profound devastation the episode has left in his/her psyche. Even
when it has been overcome, the psychotic episode, with all its vicissitudes, remains in
the psychic world as a terrible trauma experienced alone, destined never to be forgotten
because it is unthinkable.
The patient’s state of mind regarding the past psychotic crisis, even after years,
is dominated by the terror that the same delusional reality will be reproduced. Even a
few words, said casually during the analytic dialogue, but which can be connected by
association to the traumatic event, arouse the patient’s terror, due to the unexpected and
invasive feeling that he/she is not remembering the event but reliving it in the present
and so is still trapped in the psychosis.
The past psychotic crisis is like a catastrophic traumatic event.
In this situation, every connection that leads back to the psychotic trauma is
immediately abolished because, through association, it reproposes the catastrophic
anxiety and rebuilds the delusion. This is why the analyst nds it extremely dif cult to
get to the point at which the past psychotic episode can be examined with the patient.12
11
But this is not always true. At times, the psychosis leaves such a pleasant memory of freedom and omnipotence
that it is feared for its irresistible attraction. In both cases, the psychotic episode is like a mine eld that appears too
dangerous to clear.
12
Terror prevents the trauma being worked through. Psychoanalytic studies on trauma tell us that the memories and
feelings linked to traumatic experiences are separated from the rest of the psyche because they are unbearable.
By inhibiting perception of the event, the dissociative defence prevents any working through of the trauma and
perpetuates it. Recent neuroscienti c discoveries have shown how panic remains enclosed in the primitive circuit
of fear, referring to the amygdala, instead of following the rational circuit that includes the cortex. LeDoux (1996)
says that the unconscious memories of fear, de ned by means of the amygdala, seem to be branded on the brain.—
1158 FRANCO DE MASI
The delusion remains like an indelibly xed trauma that can never be ‘forgotten’,
forever smouldering, ready to be awakened by any association, memory or allusion.
The psychotic crisis is not ‘forgotten’; it does not become a memory but remains
hanging imminent: for this reason it cannot be understood or worked through. To be
understood and ‘thought about’ an event must be ‘forgotten’; it must become ‘past’ and
placed in the memory, where it can become thinkable because it is part of us but not
confused with us; it must be felt as separate from the perceiving ego because it is sited
in memory.
My impression is that the psychotic experience escapes this transformation and
cannot be placed in the memory, as happens with the other types of experience, because
of its special traumatic qualities that prevent any distancing from it and its ‘being
forgotten’ in memory.13 Even when the crisis has been overcome, the psychotic nucleus,
neither worked through nor transformed, remains ‘encysted’ in the psyche in such a
way as to produce instability and possible returns.14 This seems to be one of the reasons
why improvement, even spontaneous, in the psychotic state occurs through ‘defective
recovery’, with a limited integration of personality.
Since the danger area is speci c for each individual patient, my suggestion is to
carefully explore the nucleus around which the delusional ideation and traumatic anxiety
are organised. The strategy I chose to follow with A was to share his perceptions of terror
and make connections with past and present events so that the psychotic episode could
become an object for reconstruction, re ection and possible insight.
For example, as a defence against the panic anxiety emanating from the psychotic
nucleus, this patient has to believe he has everything under control. Consequently, any
unexpected event becomes an occasion for persecution.15
After two years of analysis, my impression is that the analytic work done on the
reasons that led him (and lead him) towards persecutory terror has weakened the power of
the psychotic nucleus to a certain extent. The past now seems relatively cleared up and it
is possible to talk about it together with a view to understanding it better. In my opinion,
his present anxiety has aspects that are more similar to panic or to a hypochondriac
ideation, rather than to a true delusional structuring. Let me give an example.
Recently, A has had to attend a refresher course in order to nd a job. This time,
while no longer denying the impact that every new experience has on him, A expressed
the fear that, on meeting people he did not know, his psychosis would be reproduced
in the same manner as in the past.16 In order to avoid the anxieties that would be able
[contd] This might be one of the reasons why traumatic delusional experiences, including delusional ones, are
extremely dif cult to work through.
13
Bion (1965, 1967) theorises that the unconscious provides symbolic and imaginative functions which permit the
transformation of sensory experiences into thoughts. Traumatic and psychotic experiences, due to the anxieties they
produce, do not therefore enter the unconscious for possible transformation; consequently, they cannot be repressed
or ‘forgotten’.
14
In one of her last works, Melanie Klein (1958) conjectured that psychotic experiences (that seem to belong to the most
cruel and primitive aspects of the mind) are pushed down into such deep layers of the unconscious that any working
through is quite impossible. Here they remain as dangerous, split-off entities. I believe that, in this way, with her spatial
model of the unconscious, Klein was attempting to explain the problem of relapses in psychotic patients.
15
I believe that having unexpectedly seen me outside analysis stimulated his anxiety because it dispelled the
spatial separation between persecutory thought and uncontaminated analytic gure. My impression was that every
unexpected event added strength to the delusional construction.
16
During our rst summer break, totally denying his anxiety, the patient had gone to a holiday club on an island in
the Mediterranean, where he collapsed in a near-delusional breakdown.
to invade him too much, he imagined himself keeping away from potentially ‘phobic’
places, like the canteen, and bringing his own food from home so that he would not be
persecuted by the idea of being poisoned. While exploring this hypothesis, he was struck
by the thought that his precautions could be guessed by possible persecutors, who might
then think up further ways for poisoning him. At a certain point, he said that I, his analyst,
could point him out to the alleged enemies, thus rendering all his protection useless.
As I showed him how his imagination constantly develops catastrophic thoughts
that expose him to panic, I also concentrated on the ‘psychotic contamination’ of the
transference.17 ‘Why’, I asked him, ‘should I, your analyst, be in the service of your
persecutors?’ ‘Because everything is possible’, he replied.
Even though I was aware that my answer would collide against the omnipotent
thinking he uses to construct every reality, I replied that there are possible things,
improbable things and impossible things. Everything is possible only in the world of his
imagination: there he can uproot every rule and have absolute freedom of imagination.
A answered, ‘When I came in here I looked at you and asked myself if you were good
or if you were an emissary of the Iranians. Now I am really sorry to have thought that’.
The patient’s ‘everything is possible’ announces mental chaos where everything
is possible. In the imagination leading towards psychosis, multiple realities in fact exist
that never contradict each other. Every new hypothesis is superimposed on the preceding
one in a perceptive constellation in constant movement..18
The patient’s persecutor can also do exactly what he wants, not only because he is
persecuting him and wants to kill him (there is no limit, no representative of justice), but
also because he has all the possible means, all the possible equipment, an enormously
powerful apparatus. The ‘everything is possible’ thought re ects the exaltation of the
successful delusional period. But now the prospects are overturned: before, every exalting
thing was realised; now everything that A fears occurs.
The small but signi cant analytic sequence described above sheds light on the
development of the delusional experience that leads to the creation of the psychotic
transference, which can be used for beginning to understand together how the patient
builds up his delusion, making me become the persecutor.
In this patient, the state of delusional terror amounts to the creation of a dehumanised
world where dangerous affects such as revenge, avidity and a desire to kill are perceived
as real and omnipresent, while the affective relations that link people together are quite
absent: obliterated.
The persecutory development and the omnipotence with which the persecutors
relentlessly harass A are credible for the patient because he himself has experienced as
real the desire to dominate the world by destroying in himself every perception of bonds
of solidarity and friendship.
During the same session as that related above, A successively went into, and
subsequently came out of, his delusion through understanding the human relationship
that exists between him and me.
17
In this sense, the psychotic terror is similar to the panic attack. Having suffered the attack, far from being
reassured at having survived it, he becomes increasingly frightened by the original situation that gave rise to it.
Having escaped from the danger only serves to strengthen the alarm. Despite A’s fear of poisoning being refuted,
his imagination continues to create fresh danger on every new occasion.
18
The falsi cation principle and the spatial and temporal a priori are lacking in psychotic thought. For the patient, I
may be the analyst, but also the person who betrays him. The persecutors are abroad, in Italy, everywhere. For these
reasons, according to Popper, psychotic thinking is not falsi able.
1160 FRANCO DE MASI
Dream-thought and dream-delusion

I am going to try to describe the impressions of a long illness which took place quite entirely
within the mysteries of my soul: I don’t know why I use the word ‘illness’ for as far as my
physical self was concerned, I never felt better. Sometimes I thought my strength and energy
were doubled. I seemed to know everything, understand everything. My imagination gave
me in nite delights. In recovering what men call reason, do I have to regret the loss of these
joys? (Nerval, 1996, p. 4).
Here began what I shall call the over owing of the dream into real life. From that moment
on, everything took on at times a double aspect—and did so, too, without my powers of
reasoning ever losing their logic or my memory blurring least details of what happened to
me. Only my actions were apparently insensate, subject to what is called illusion, according
to human reason? (p. 8).
With these words Gèrard de Nerval announced and described in Aurélia, one of his
most evocative works and a faithful account of his psychotic crisis, the appearance and
progressive forming of the dream-delusion that would enthral him in the fascinating
sway of madness.
I quote his words because I believe they describe with unusual effectiveness two
aspects of the psychotic experience: the lack of awareness and the lure exerted by the
psychotic world for those attracted by it. These two points ask important questions to our
notice about the quality of the psychotic ‘dream’ and about the nature of the delusional
intuition, to which I would like to add further re ections.
One of Bion’s original contributions was to have put forward the idea that thought
originates from forerunners and that, among these, dream-work generated in the
unconscious is closely linked to waking thinking: ‘The dream-work we know is only a
small aspect of dreaming proper—dreaming proper being a continuous process belonging
to the waking life’ (1992, p. 19).
According to Bion, it is the dream-work-alpha (distinct from dream-work) that
elaborates reality and gives meaning to experience by means of unconscious activity that
is always active, testi ed to by the construction of the dream. This constant elaboration,
which occurs subliminally not consciously, allows us to sense what happens inside us,
to perceive the continuity of our existence and our personal identity, and to have future
prospects. Waking-thought and dream-thought are therefore closely linked and mutually
dependent in their working.
So that they can be used to make dreams, the perceptions of an emotional experience
have to be transformed by the alpha function and have to acquire dream characteristics.
Contrary to what happens in the psychotic state, the non-psychotic person ‘makes
perceptive reality a dream’ and, thus, establishes the subjective experience.19
The capacity for understanding ourselves and the links we have with objects derive
from the continuity and reciprocal permeability of waking-thought and dream-thought.
But the way by which we know ourselves and become aware of our psychic reality
escapes our conscious perception.
I would like to refer here to the contribution of another particularly intuitive
psychoanalyst, Bollas (1987, 1992), who speaks of the ‘unthought known’. With this
In this sense, the capacity to ‘dream’ is fundamental for the development of the imaginative function that allows
19
perception of one’s own emotions and those of others. Bion calls this function ‘reverie’, that is, the spontaneous
capacity to use the intuitive imagination in order to understand the emotions.
‘unthought known’, Bollas alludes to the connection that escapes representation, an

unconscious dream that works in everyone’s being and expresses the need to recognise
the part of the psyche that lives in a world without words.
In other words, we do not recognise certain areas and functions of our mind
that contribute to the formation of the subjective experience. This is the area that both
realistic and delusional intuition draw from. A mysterious watershed line separates the
two attitudes: dreaming in order to intuit or dreaming in order to enter into delusion.
Apropos of the use of visual images in dreams, Chianese writes,
What distinguishes dreams from other formations of the unconscious is the visual element,
which has a singular constitution. What is seen in dreams cannot be confused with what is
seen in the waking state. The visual element in a dream is both near and far, intense and
evasive, within reach yet untouchable. The image is never a simple copy or reproduction of
reality; it combines gures far apart in time and space. The visible in a dream is close to the
invisible that an artist renders ‘visible’ (2000, p. 326).
In ‘dream-thought’ (dreaming for intuiting), the dream corresponds to a symbolic

transcription of an emotional experience and the images of the dream refer to the
thoughts of a language that tries to integrate the dreamer’s emotional story, defences or
unconscious fantasies.
In ‘dream-delusion’ the visual element does not refer to the invisible made visible
by the artist or to the invisible that the intuitive function of the analyst and the analysand
would allow to be understood and revealed. The psychotic state, instead, announced in
the dream, confers a concretely hallucinatory character to the dream, allows no room for
intuition (insight) and interferes with the dream-thought function. In ‘dream-delusion’
(as in hallucinations) the visual perception annihilates the intuitive imagination and takes
the place of representation.
In our analysis with psychotic patients, we must be careful to distinguish ‘dream-
thought’, the expression of the normal function of dreams, from ‘dream-delusion’, which
alerts us of the way the patient’s perceptive experience is being transformed and which
will lead him/her to clinically evident psychosis (Capozzi and De Masi, 2001).
Bion would say that the psychotic individual cannot talk to us of the difference
between dreaming and waking, between the dream and the non-dream, and that we,
in turn, cannot distinguish between his/her dreaming and his/her sleeping (Grotstein,
personal communication 2001).
While resembling a sensory production similar to the dream, the ‘dream-delusion’
remains xed in the waking memory and, in the waking state, continues to give life to
its characters that impose themselves on the ‘dreamer’.
I will describe a fragment from the supervision of a young patient in analysis, whom
I will call B, in order to show how the power of the delusional imagination is constantly
at work during the psychotic process: ‘A thought came to me yesterday evening when I
was half-awake, a fantasy perhaps, but I don’t know to what extent it was … I remember
that after I had begun analysis with you I came here one day when you were not working
but just seeing various people. You arrived shortly afterwards and were surprised to nd
the door open: you asked yourself if you had left it open by mistake or if someone else had
come in. I thought it might have been children looking for documents: you asked me to go
and have a look and … I thought perhaps there was a room at the end in a terrible mess
but I didn’t/hadn’t even realised … I thought I might have seen two young boys escaping
1162 FRANCO DE MASI
as I came in, but I hadn’t paid any attention and would not be able to recognise them … I
felt totally useless, as though you had asked me for help and I had not been up to it …’
B has been in analysis for two years at four sessions a week for a previous delusional
episode. The patient’s psychotic episode was focused on persecution by criminals who
had threatened him in a discotheque and on the repeated perception that he had killed
someone in a car without realising. 20
I will not dwell on the signi cance of the patient’s delusional fantasy, the emergence
of the gure of a parent–analyst as a mother incapable of defending herself and who asks
him for heroic performance, or his world populated with bad people, young delinquents
from infancy now wrongdoers to be feared, all important elements in the delusional
construction and taken up in the analyst’s interpretation. Instead, let us listen to the
patient’s comment after the analyst’s intervention, who can only remember having
received him on a half-holiday and who believes that the subsequent sequence of events
was constructed by the patient: ‘I realise that before I had real things under my nose that
I did not see, while other things that I invented seemed real … Now I am less obsessed
with the idea of having caused crashes, I am pretty much convinced that these were
fantasies, but I still keep on creating others …’
In other words, B is beginning to realise that his imagination is ceaselessly at work
falsifying the memory of events and that this happens quite out of his conscious control.
Something paradoxical happens in delusions compared to dreams: while dreams
are mysterious since their signi cance awaits discovery, delusions are frightening since
their signi cance is manifest. They are ‘dreams’ that never end, unlike real dreams that
disappear when their communicative function is over. Delusion constantly searches for
con rmation in order to maintain its whole assertive force intact.
For example, if I try and show patient A how his persecution might have originated
from megalomania, and hypothesise that he was perhaps unable to accept that he was
of no importance to his Iranian colleague (who destroyed his megalomanic sense of
existing by stealing his girlfriend) and that, to defend himself from this humiliating
perception, he has fantasised an epic struggle without end against his rival, the patient
says that he understands this hypothesis of mine, which goes in one ear, and nds it
useful. However, as soon as he leaves the session, it comes out of the other and he
forgets all about it.
In other words, the delusional memory is not liable to working through until the
patient can remove himself from the highly imaginative power of his grandiose self and
his true personal identity is suf ciently developed.
In the therapy of these patients, it is important to understand the strength of
attraction and the power of the delusional imagination, by identifying the underlying
anxieties or omnipotent desires stimulating it, and to try to ‘deconstruct’ it.
I use the term ‘deconstruction’ because the word ‘interpretation’, which we use for
indicating our therapeutic tool, does not seem suitable for the clinical problems posed
by the power of the delusional imagination.
Thus, I would like to emphasise the fact that the analysand and analyst must be
able to examine and recognise gradually and in detail how the delusional experience
is built up and how it develops, by accurately examining the emotional conditions and
the delusion’s far-off preparatory roots, and linking up the various scattered fragments,
The patient, who had never thought of asking for police protection against his persecutors, was delusionally
20
convinced of being guilty, therefore wanting to give himself up and be charged.

which have appeared and continue to emerge during the analysis. This work must be
done constantly, session by session, over a long time.
In my case, I gradually realised how important it was to return to the rst delusional
episode that had signalled the start of the patient’s psychotic state and to try and hold this
reference point stable for a possible working through of the delusion.21 In fact, only by
containing the energy of the delusional fantasy and constantly seeking its reasons in the
present and in the past can mental spaces be usefully liberated for a possible development
of thought and personal identity.
A special aspect of our analytic work dealt with reconstructing A’s infancy. My
opinion was that a delusional idealisation of his father and an omnipotent identi cation
with him was an essential factor in his delusional construction, which had his roots in his
childhood. As a child, A admired his father and wanted to be like him. Just as his father
imposed his supremacy over his mother or over the patient himself, so A continually
demanded acts of submission from his younger sister. He was fascinated by games of skill
and was fanatical about records, with which he often claimed exceptional con rmation from
his mother, who, in the patient’s memory, watched him with ecstatic admiration. The game
of being like his father was not a ‘game’ for the patient but reality (he was his father), a
pathological and omnipotent identi cation with a grandiose gure. In adolescence, he was
so entrapped in fantasies in which he performed heroic deeds that his companions had to
bring him back to earth to get him to re-emerge from his exciting withdrawal.
My clinical experience in this case was that the ‘deconstruction’, or the dismantling
of the delusion’s construction of the patient, allowed the acquisition of the functions of
awareness that gradually permitted A to begin to ‘see’.
Maintaining this capacity over time guarantees that the delusional experience,
where it reappears, is recognised and made potentially transformable, thus preventing
its automatic conquest of the mind.22
As an example of this possible passage, I will relate A’s analytic experience
when we were trying to understand better the dynamics of the passage from the state
of grandiosity to the persecutory delusion. On this occasion, the patient sensed that he
had projected his own omnipotent mental state into the Iranian colleague, when he did
not refrain from courting the girl and nally seduced her. In his mind, the colleague
became his persecutor who wanted to take revenge upon him because A had dared to
bar the way to his omnipotent power. I think that the clash with his Iranian colleague
was so catastrophic because it had killed not only the patient’s omnipotent self, but also
his potential self connected with it. The projected grandiose self was now perceived as
threatening and capable of doing what it wanted with him.
In reality, the competitive aspects of his colleague had served the patient as a
means for making this person a suitable object for the projection of his own omnipotent,
avid parts that were full of a desire for domination and narcissistic triumph. In this way,
the mad part of the patient, sited in his colleague, had begun to live an independent life
that was, though, indissolubly bound to him as the effect of an omnipotent projective
identi cation in the sense described by Klein (1946).
21
‘An important point that must be considered is the signi cance of the very rst episode. It is not only the stirring
outbreak but also a dynamic fact of enormous importance, without which the patient would have been able to stop,
or even compensate, his disposition to the psychosis’ (Arieti, 1974, p. 909).
22
Similar considerations, although less dynamically complex, must be made regarding the construction of perverse
systems, panic attacks or hypochondriac states.
1164 FRANCO DE MASI
I have described this passage because it seems to me to represent one of the moments
that initiated the ‘deconstruction’ of A’s delusional experience. Through this process,
the delusion ceased to be a concrete mental state imprisoning the patient and became a
psychic fact in which the delusional experience began to be ‘digested’ and transformed
since the patient himself became able to think about and understand his contribution to the
delusional construction.
This analytical material has become more and more frequent in A’s analysis as the
patient has strengthened his intuitive thinking, which was almost absent in the beginning
of this therapy.23
Conclusions
I have expounded part of the material of a patient’s analytic treatment in order to show
the dif culties that are encountered in analysis when intuitive thought gives way to the
development of delusional thought. I have also pointed out the need to relive with the
patient the psychotic episode, which can return and make its presence felt even during
the analysis, in order to work through it bit by bit as intuitive thought develops. This
operation is anything but easy on account of the traumatic anxiety, which tends to keep
the psychotic episode split from awareness and is therefore a potential generator of
further psychotic crises.
The ‘assertive energy’ (Searles, 1979) that sustains this patient’s psychosis seems
to lie in the development of an ideational system where the grandiose imagination has
taken the place of the ordinary capacity to evaluate his own, and other people’s, mental
processes. From this point of view, we can understand A’s grandiose evolution as a
defence against the anxiety of annihilation (‘being nothing’), an illusional defence that
further destroys every possible recovery of personal identity.
If, in order to exist, the psychotic person has to transform his/her identity by
altering his/her perceptive functions, he/she will contemporaneously annul the system of
emotional truth (the emotive-intuitive unconscious) that allows him to grow mentally and
to understand emotional reality. For this reason, he/she is destined to plunge into chaos.
The unceasing role of the solitary imagination, which is like a lm projected in
the mind with characters living their own lives, becomes all-important in the psychotic
system. Projected in the mind, this lm blocks the channels of the patient’s intuitive
imagination and exerts a powerful attraction over him/her.
The theoretical references peculiar to psychoanalysis for understanding the
delusional construction, such as projective identi cation, omnipotent unconscious fantasy
or the hallucinatory realisation of desire, although working in the psychotic state, do not
seem to be suf cient for understanding a complex transformative process that tends to be
unstoppable and constantly changing, like that sustained by the delusional imagination.
I believe, therefore, that we must contextualise the statute and role of the delusional
imagination better, in order to distinguish it from other forms of imagination such as day-
23
In working with psychotic patients, the analyst must be alert to the moments when, through dreams or particular
associations, the intuitive imagination, or the capacity to understand one’s own mental processes, begins to
manifest itself.
24
This topic has been thoroughly debated in the Internet discussion, co-ordinated by Paul Williams (1998), of
‘Psychopathology and primitive mental states’ by Robert Caper (1998). The discussion highlights how dif cult it is to
theoretically classify delusional thinking.
dreaming, withdrawing into fantasy worlds and childish games, up to religious or artistic
imagination, in which the defensive, explorative or constructive aspect appears evident.24
In other words, what are the positive imaginations necessary for keeping the future
open or for building new shared realities (‘dream-thought’) and what, on the other hand,
are the falsi cations of a delusional nature (‘dream-delusion’)?
Though produced by the imagination, delusion is a construction at odds with the
development of thought.
The paradoxical element is that thought, like delusion, is sustained by the
imaginative capacity; it originates and is maintained by this.25 In order to think, one
must be able to imagine. The imagination or the capacity to dream, which are the means
allowing the birth of thought, must never be extinguished if we want psychic life to
remain as a potential space open to the future.26
A characteristic of the psychotic state is not so much projection towards the world
or indeed curiosity—qualities peculiar to intuitive imagination—but a psychic retreat
and a use of the perceptive organs to build an arti cial sensory state of mind.
The constant production of newly created realities, projected outside him/herself,
means that the psychotic person reaches the mental state attributed by man to God, who
created the world out of nothing as a projection of his own imagination.
To assert itself, delusional reality must, therefore, annul the hypothetical or
explorative nature of thought, removing every metaphorical value from it. 27
Arising from a speci c intention to transform psychic reality, delusion blocks the
potential space for thought and, while being produced in individual fantasy, kills the
intuitive imagination and takes its place. The delusion is like a fetish, a closed system
that engulfs the in nite potential of thought.28
An equally important issue is how to handle the transference (and what should be
intended by psychotic transference), which, in the case of psychotic patients, is certainly
not a revival of past con icts. Personally, I believe that the profound alterations of the
perceptive function in the psychotic state prevent the neurotic transference being likened
to that of the psychotic state.
The importance of the transference analysis, which constitutes the basic element of
the analytic technique, in fact, derives from a genetic hypothesis of the mental disorder.
Simplifying this greatly, one might refer to the Freudian model hypothesises that,
during the childhood, an idea or an instinctual complex is subjected to repression since
it is a generator of a con ict. In parallel, the Kleinian model proposes that parts of the
25
As Freud (1911) set out in ‘Formulations on the two principles of mental functioning’, the pleasure principle,
which pre-exists the reality principle, continues to work even after the latter asserts itself. Fantasies and dreams are
expressions of the pleasure principle that form a thought activity parallel to the one inspired by the reality principle.
26
Through his imagination the child is able to create, but in his play he is aware of exploring new realities. Imagination
permits him to discover an as yet experienced reality; a reality lived by the others. ‘Pretending to be’ is the area of
the fantasy necessary for psychic development and for the identi cation with parents. In his childhood games, A did
not pretend to be the father, he was the father. Even religion belongs to the realm of imagination, creating a shared
imaginative area, a psychic reality, in which it is possible to believe.
27
Artistic creations ll the potential possibilities of the imagination, creating new imaginative worlds and broadening
psychic reality. For this reason, these new worlds become new shared realities, potentially usable by all. On the
contrary, the perverse imagination creates a fetishist world with xed, psychotic-like qualities, in which the potential
space is destroyed.
28
Melanie Klein (1930) states that the psychotic patient is imprisoned in his madness by the power of his sadistic
cruelty, experienced as a terrifying, persecutory presence. Consequently, the capacity of symbolic thinking is lost,
resulting in an arrest of the psychic development.
1166 FRANCO DE MASI
personality are split off and projected into the analyst who becomes the container of the
patient’s unwanted and unconscious parts.
The transference, therefore, is the indicator of the permanence of the con ict or of
the action of an unconscious pathological fantasy. It is possible to work through the con ict
or integrate the split-off part of personality only through analysis of the transference.
From this point of view, the psychotic transference does not have much in common
with transference as a revival of the past or as projections of unconscious parts of the self;
the psychotic transference has its own speci c character linked to the nature of the psychotic
state. I believe that Freud, who thought of transference as a revival of the past, meant this
when he maintained that psychotic patients are incapable of forming a transference.
My impression is that childhood con icts certainly exist but, not having been
mentalised due to the precocity of the traumatic experience and the absence of unconscious
intuitive thought, they are not part of the transference formation as normally happens.
In this work I have considered the psychotic transference as a ‘psychotic
contamination of the analytic relationship’, a new creation of the constant omnipotent
imaginative activity that transforms the gure of the analyst in the same way as the
patient’s psychic reality and that must be adequately analysed and made explicit.
This paper, which attempts to examine in greater depth an aspect of the analytic
encounter with psychosis, stems from my overall experience in the treatment of this type
of patient, going beyond the cases described above. I have endeavoured to point out some
constants that must guide our therapeutic approach and help us to have a speci c mental
setting during the analysis of a psychotic state.
I am profoundly convinced that the more we introduce psychotic patients to our
analytical rooms, the more elements we will have to further our knowledge about this
mental condition and the ways to make it liable for working through.
Translations of summary
Über das Wesen intuitiven und wahnhaften Denkens und seine Implikationen in der klinischen Arbeit
mit psychotischen Patienten. Der Autor versucht, die intuitive Vorstellung von der Wahnvorstellung zu
unterscheiden, und vertritt die These, dass die Psychose das System des intuitiven Denkens so verändert,
dass es sich nicht auf eine dynamische und selektive Weise entwickeln kann. Wissenschaftler aus
verschiedenen Disziplinen, die mit der Psychoanalyse nichts zu tun hatten — beispielsweise Einstein,
Hadamard oder Poincaré —, waren der Ansicht, dass sich intuitives Denken im Unbewussten vollziehe,
und zwar durch verborgene Prozesse, die ein kreatives Aufeinandertreffen von Ideen ermöglichen. Dank
Bions Arbeit beginnen Psychoanalytiker nun zu verstehen, dass das Denken im Wachzustand unbewusst mit
der Traumarbeit ver ochten ist. Die wahnhafte Konstruktion ähnelt einer traumgleichen Sinnesproduktion,
bleibt aber anders als ein tatsächlicher Traum im Wachgedächtnis erhalten und erzeugt Charaktere, die ein
vom Gewahrsein des „Träumers“ unabhängiges Leben führen. Die Psychose ist ein Traum, der nie endet.
Der reale Traum hingegen löst sich auf, sobald er seine Kommunikationsaufgabe erfüllt hat. In der Analyse
psychotischer Patienten ist es sehr wichtig, die Wahnvorstellung zu analysieren, von der die Persönlichkeit
beherrscht wird und die den mentalen Zustand unaufhörlich verändert, wobei sie die emotionale Wahrheit
verdreht. Die Wahnvorstellung ist so tief im psychischen Funktionieren des Patienten verwurzelt, dass
die wahnhafte Welt, die scheinbar verschwunden war, selbst nach systematischer Analyse unter neuen
Kon gurationen wiederauftaucht. Der psychotische Kern bleibt eingekapselt; er ist für die Unstetigkeit
des Patienten verantwortlich und ruft unter Umständen weitere psychotische Zustände hervor. Der Autor
beschreibt Ausschnitte aus dem Analysematerial eines Patienten, der im Anschluss an eine medikamentös
behandelte psychotische Episode ein intensives psychotisches Funktionieren zeigte. Er erläutert den
Charakter des psychotischen Zustands sowie den therapeutischen Ansatz, der benutzt wurde, um die
Wahnstruktur zu modi zieren. Der Beitrag setzt sich insbesondere mit der auf die panische Angst des
Patienten zurückgehenden Schwierigkeit auseinander, die psychotische Episode durchzuarbeiten und das
wahnhafte Erleben zu „dekonstruieren“. In dem geschilderten Fall konnte die Wahnkonstruktion durch die
analytische Arbeit in weniger bedrohliche, durch phobische Eigenschaften charakterisierte Vorstellungen
transformiert werden. Die Analyse der psychotischen Übertragung ermöglichte es, die verborgene Arbeit zu
fokussieren, die das Übertragungsbild des Analytikers und die psychische Realität des Patienten unaufhörlich
beein usst hatte.
Acerca la naturaleza del pensamiento intuitivo y delirante: Sus implicaciones en el trabajo clínico
con pacientes psicóticos. El autor intenta diferenciar la imaginación intuitiva de la imaginación delirante
y plantea la hipótesis de que la psicosis altera el sistema del pensamiento intuitivo, el cual en consecuencia
no puede desarrollarse de una manera dinámica y selectiva. Académicos de diferentes disciplinas, bastante
lejanos del psicoanálisis, como Einstein, Hadamard, o Poincaré, creen que el pensamiento intuitivo trabaja
en el inconsciente por medio de procesos ocultos, que permiten la con uencia creativa de ideas. Gracias
al trabajo de Bion, los psicoanalistas hemos empezado a comprender que el pensamiento de la vigilia
está entretejido inconscientemente con la elaboración onírica. La construcción delirante es similar a una
producción sensorial como la del sueño pero, a diferencia del sueño real, permanece en la memoria de la
vigilia y crea personajes que viven de manera independiente de la conciencia del ‘soñador’. Es un sueño que
nunca acaba. Por el contrario, el sueño real desaparece una vez que ha cumplido con su tarea comunicativa.
En el análisis de pacientes psicóticos es muy importante analizar la imaginación delirante que domina
la personalidad y que transforma continuamente el estado mental, deformando la verdad emocional. La
imaginación delirante está tan profundamente enraizada en el funcionamiento mental del paciente que, incluso
luego de un análisis sistemático, el mundo delirante, que parecía haber desaparecido, vuelve a emerger bajo
nuevas con guraciones. El núcleo psicótico permanece encapsulado; produce inestabilidad y puede inducir
posteriores estados psicóticos en el paciente. El autor presenta material analítico de un paciente, el cual luego
de un episodio delirante tratado con fármacos, demuestra un intenso funcionamiento psicótico. Se añaden
algunas consideraciones sobre la naturaleza del estado psicótico y sobre el enfoque terapéutico empleado
para transformar la estructura delirante. Este trabajo aborda en particular la di cultad para cruzar el episodio
psicótico y para ‘deconstruir’ la experiencia delirante debido al terror concomitante. En el caso reportado,
el trabajo analítico transformó la construcción delirante en una más benigna caracterizada por cualidades
fóbicas. El análisis de la transferencia psicótica permitió enfocar el trabajo oculto que había estado in uyendo
de manera continua en la imagen transferencial del analista y en la realidad psíquica del paciente.
Sur la nature de la pensée intuitive et délirante et sur ses implications dans le travail clinique avec les
patients psychotiques. L’auteur essaie de différencier l’imagination intuitive de l’imagination délirante et
émet l’hypothèse que la psychose altère le système de la pensée intuitive, qui de ce fait ne peut se développer
de façon dynamique et sélective. Les savants de disciplines différentes, aussi éloignés de la psychanalyse
que Einstein, Hadamard ou Poincaré, pensent que la pensée intuitive travaille au niveau de l’inconscient au
moyen de processus cachés, qui permettent la rencontre créative entre les idées. Grâce à l’œuvre de Bion, les
psychanalystes ont commencé à comprendre que la pensée à l’état de veille est inconsciemment entremêlée
avec le travail du rêve. La construction délirante est similaire à la production sensorielle du rêve mais,
contrairement au rêve réel, elle se maintient dans la mémoire de veille et crée des personnages qui vivent de
façon indépendante de la vie éveillée du rêveur. C’est un rêve qui ne prend jamais n. En revanche, le vrai
rêve disparaît lorsqu’il a rempli son rôle de communication. Lors de l’analyse de patients psychotiques, il est
fondamental d’analyser l’imagination délirante qui domine la personnalité et transforme de façon continue
l’état mental, déformant la vérité émotionnelle. L’imagination délirante a des racines si profondes dans le
fonctionnement mental du patient que, même après une analyse systématique, le monde délirant, qui avait
paru disparaître, re-émerge sous de nouvelles con gurations. Le noyau psychotique reste encapsulé ; il
provoque de l’instabilité et peut induire de nouveaux états psychotiques chez le patient. L’auteur rapporte
du matériel analytique concernant un patient qui, après un épisode délirant traité par des médicaments, a
présenté un fonctionnement psychotique prévalent. Quelques ré exions sont avancées sur la nature de l’état
psychotique et sur l’approche thérapeutique utilisée pour transformer la structure délirante. L’article insiste
en particulier sur la dif culté à travailler à travers l’épisode psychotique et à « déconstruire » l’expérience
1168 FRANCO DE MASI
délirante, du fait de la terreur qu’elle entraîne. Dans le cas rapporté ici, le travail analytique a transformé la
construction délirante en une forme plus bénigne caractérisée par des traits phobiques. L’analyse du transfert
psychotique a permis de se focaliser sur l’activité secrète, qui in uençait de façon continue aussi bien la
gure transférentielle de l’analyste que la réalité psychique du patient.
Alcune considerazioni sulla natura del pensiero intuitivo e del pensiero delirante e le sue implicazioni
nel lavoro clinico con pazienti psicotici. L’Autore cerca di distinguere l’immaginazione intuitiva
dall’immaginazione delirante avanzando l’ipotesi che la psicosi alteri il sistema del pensiero intuitivo, che
quindi non può svilupparsi in maniera dinamica e selettiva. Studiosi di discipline diverse molto lontani dalla
psicoanalisi, come Einstein, Hadamard o Poincaré, ritengono che il pensiero intuitivo operi nell’inconscio
mediante un lavorio inconsapevole, che permette l’incontro creativo delle idee. Grazie al lavoro di Bion,
gli psicoanalisti hanno incominciato a capire che il pensiero della veglia è inconsciamente intrecciato al
lavoro del sogno. La costruzione delirante è simile alla produzione sensoriale del sogno ma, diversamente
da un vero sogno, resta nella memoria della veglia e crea personaggi che vivono indipendentemente dalla
consapevolezza del «sognatore». È un sogno che non nisce mai, mentre il vero sogno scompare quando
il suo compito comunicativo è terminato. Nella terapia analitica dei pazienti psicotici è estremamente
importante fare un’analisi dell’immaginazione delirante che domina la personalità e trasforma continuamente
lo stato mentale distorcendo la verità emotiva. L’immaginazione delirante è così profondamente radicata nel
funzionamento mentale del paziente che, anche dopo un’analisi sistematica, il mondo delirante, che sembrava
scomparso, riemerge sotto nuove con gurazioni. Il nucleo psicotico resta incapsulato, crea instabilità e
può indurre nel paziente ulteriori stati psicotici. L’Autore presenta parte del materiale di un trattamento
analitico di un paziente che, dopo un episodio psicotico trattato con farmaci, mostra un vivace funzionamento
psicotico, e aggiunge alcune considerazioni sulla natura dello stato psicotico e sull’approccio terapeutico
utilizzato per la trasfomazione della struttura delirante. L’articolo affronta in particolare le dif coltà
dell’elaborazione dell’episodio psicotico e della «decostruzione» dell’esperienza delirante a causa del
terrore a essa connesso. Nel caso riferito, il trattamento analitico ha trasformato la costruzione delirante in
una più benigna, caratterizzata da qualità fobiche. L’analisi del transfert psicotico ha consentito di mettere
a fuoco il lavorio nascosto che ha continuamente in uenzato il quadro transferale dello psicoanalista e la
realtà psichica del paziente.
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Int J Psychoanal 2003; 84:1149–1169

On the nature of intuitive and delusional thought:

Its implications in clinical work with psychotic patients

Keywords: delusional imagination, intuitive thinking, psychotic transference, terror,

©2003 Institute of Psychoanalysis

Intuitive imagination and delusional imagination

The patient in analysis

following a period of megalomanic expansion, was triggered by a quarrel with a work

The psychotic transference8

In analysis, if I spoke about him making connections on the basis of information

Terror and imagination

Dream-thought and dream-delusion

‘unthought known’, Bollas alludes to the connection that escapes representation, an

In ‘dream-thought’ (dreaming for intuiting), the dream corresponds to a symbolic

convinced of being guilty, therefore wanting to give himself up and be charged.

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