The terror that the seriously disturbed patient has of relationships with others defines the limit and at the same time the enormous resources that the therapist has to help the patient. I have learned at first hand, through my work with seriously disturbed patients, as G. Salonia says, the importance of coupling seriousness with lightness to construct the background (what the authors call “life security grounding”) in a slow, constant way. Quoting Salonia again: “... with neurotics you need to re-construct, with seriously disturbed patients construct, the confines between the outside world and the inside world, the confines between body-house-cosmos.”

The being there of the therapist, which is always fundamental in the therapeutic work experience in Gestalt, with seriously disturbed patients invests the deep, intense and confused levels that in the relationships of the-child-that-was were fertile ground for the insurgence of the psychosis. The Cure is really in the way in which the therapist “is” in the relationship; the therapeutic power of Gestalt is in this: to give support specific to the interruption of contact in the development of the relationship (quoting M. Spagnuolo).

I will present a case that I have been following for the past six years, individual psychotherapy through the Public Mental Health Care System. I will make a brief presentation of the patient’s clinical history and give some indication of the procedure of the case. Through the exact words taken from the sessions I will focus on the times and the ways I built the relationship, supporting the experience of interruption of contact that determined the pathology with an inverted path: from paranoid projection to healthy projection, from absorbed introjection to healthy, chewed introjection, from psychotic confluence to the healthy, nourishing confluence of the therapeutic relationship.

F. is the first born of two sons (4 years age difference), whose living parents come from a middle-class family.

In 1991 the parents asked the Public Mental Health Service of their town for help, as in a few months their son was to be released from a prison psychiatric unit where he was serving a sentence for attempted murder: in 1986 he had assaulted and knifed his mother, injuring her. The parents told the operators (my psychiatrist colleague and myself, a psychologist) that “the boy doesn’t want treatment, because he’s not conscious of his illness; he hates psychologists and psychiatrists. He was doing the first year of a psychology degree, so we’ll have to pretend to be friends” - continue the parents - “and treat him at home.”.

This was a clearly psychotic request confluent with an attempt to drag the operators into the family system.

As operators of the Service, we refused this way of taking on the case, but made ourselves available to support the parents, who were frightened and worried at the idea of their son’s return, and we also asked to involve the younger brother in family system therapy. The brother refused as he wanted to be left out; he refused the situation, he didn’t want to be involved “for and against” his brother. A clear modality of the system of expressing the two polarities - one son mad-rebel-bad and the other rigid-good-right.

After an apparently quiet period, the father got in touch, contacting me personally, saying that F. wanted to do psychotherapy with a female psychologist. I told him to let his son phone me and I’d give him an appointment; I stressed that if F. asked me if I know them, I will say yes. F. phoned, asked for an appointment, and didn’t ask anything about me knowing his parents. In any case how could he? Confluent with the system, confused and worried by the outside world, that which was normal, like talking to a person on the phone, became extremely difficult. Also for myself, details became “particularly important”: for example how to not tell lies and at the same time not to cheat him, how to not anticipate giving answers that he was not ready to hear.

We spoke about this beginning roughly four years later, during a session in which he asked me, finally “waking up” from the torpor of the Id Function:
P.: “But how did my parents know you? Did you ever see them or speak to them during the therapy?”

Then I told him what had happened years previously. He was upset and angrily said that his parents had tricked him; I brought him back to the here-and-now of the relationship with me, asking if he had felt tricked by me and was angry about that.-

First year of therapy

The first impact with F. was very violent: I had a great sense of anguish, and I imagined how much he must also have had, so I reduced the time of the therapy session, and this considerably reduced the stress for both of us. He told me he wanted to know why his leg shaked. He came for this problem In a few weeks he would be leaving for Africa for a month, and he didn’t want to have this disturbance. By the time of our second meeting he didn’t have this tremor and with extreme lucidity and precision he told of the episode of aggression towards his mother, which happened 5 years previously. As a result, he was put in the criminal asylum.-

P.: “I was exasperated, I didn’t want to kill her, I only wanted to stop her, I could have killed her, but I only want to stop her!”

P.: “As always, I feel my thoughts are being read” - he laughed- “since the Jesuits put videocameras in me, everyone reads in my thoughts, it’s terrible, and when I realise my mind’s being read, I’m forced to think things I’m ashamed of” (he was delirious during the session).-

Let’s analyse the sessions word for word considering the time dimension: why just now did he decide to go into therapy, or rather speak to a psychologist?- And let’s analyse the mode of contact: he went into therapy to find out the truth about one piece of behaviour, he did not in fact define himself as a patient, but wanted to find a solution as a cognitive itinerary. The time and way gave meaning to the figure that emerged: he needed an external anchor to his mother to be able to move away (journey to Africa). He took as a figure the need for answers to the symptoms that showrf themselves, a long way removed from the real suffering.

In the here-and-now of the session an extremely lucid individual figured, but unaware; with rigid confines, but very fragile, impenetrable but very permeable. He showed me his violence, his capacity for being dangerous, but was extremely afraid of my presence and the possibility that I could be dangerous to him.-

He returned to therapy after his trip to Africa and for the whole of the first year the relationship oscillated between the fear of meeting (P.: “I come because you need me”) and the refusal to introject (P.: “All psychologists are ignorant”).
My attitude, serious and light, clear and respectful, protected the space of the therapeutic relationship from outside invasion, keeping out other family members from the therapy (they could neither come nor ask on the phone without F. knowing beforehand), and from internal space, creating a really stable space, and thus less menacing: always the same room, time and day for the session.-

This background attitude helped me a lot even in the most difficult moments of the therapy as regards connecting his projections to my interior experiences. In the first year my feelings wavered between fear of his destructiveness and firmness in my non-destructive role; from hostility towards him being so disqualifying and omnipotent, to impotence-power of accepting the limits of my therapeutic possibilities. It was very important for me to feel the need of a “third-person,” my supervisor, who, from the background, with his presence that was always available and welcoming, made me firmly anchored and welcoming, whilst I was going through the evolving of this relationship.

Second year of therapy

My being there so constantly and definitely let my patient in the here-and-now of the session experiment different ways to find the right emotional distance from me. In the meantime, the physical distance had been defined, sitting in a position, chosen by him, at about three metres away from me, on a chair near another desk.

During the second year of therapy he tried to get closer with verbalisations such as: “When you get tired of me, tell me, because I’ll never finish having therapy”, and chase me away: “You are ignorant like all psychologists! I do therapy because you need me in order to work! You too can read my thoughts through the videocameras”.

My being there was still anchored in the here-and-now experience with him, I felt disgusted at his nastiness and taken with his tenderness and intelligence. I used this to build, through his relationship with me, the broken path, supported by healthy functions: the clear, well-defined, modifiable, respectful environment that had always been missing from around him.-

P.: “When I was little my mother used to say to me, 'You see you mustn’t stay in the big bed! There are spiders, see them walking on the sheets,' I couldn’t see anything, but I didn’t know if there really weren’t any there. I know now!”.

I thought: he had to go mad to separate from his mother’s madness. I remember talking about it with my supervisor, who had met the mother many years previously, and who said: “Seeing her, I understood why he had knifed her; I also had the same wish to stop her.”

My standing still and waiting for him to move, experimenting with me how close he could come, and how to do it, brought us to the third year of therapy.-

Third year of therapy

It’s in this period that F. tried to verbally attack me in a violent way. He asked me continuously for book-lists for Gestalt therapy. Strangely, but intuitively, I refused to give him the list of Gestalt books. After my refusal and his violent attack, I understood what had happened: I was risking doing the same thing as before psychotic decompensation. In fact, at that time he had immersed himself in “revolutionary” books for two years, without going out at all or seeing anybody, books that were incompatible with and opposite to the introjection he’d always absorbed from his mother. At that time he had read everything by Freud, Nietzche and Sade. At that time, it had been an attempt to find a way out of the confluence, but without the appropriate support, it just came about in the same dysfunctional way. He didn’t chew the new food but just swallowed new introjections.

F. was asking to swallow my therapy and consequently me too, it was difficult to maintain my diversity (I would never have read all the books he had read in two years! ).He refused the fact that I could bee different from him, that I could say “no” to him without abandoning him; he threatened to leave therapy and in the here-and-now of the session showed me his anger ( “I want to throw the desk in the air”).
I remember being frightened of him in those months, and it seemed a step back to the first months of therapy. Speaking with my supervisor at that time, I wavered between a sense of guilt (I could give him something to read, I could also read something myself. ) and my determination (I felt that I shouldn’t do that). My supervisor’s presence helped me a lot. I believe that the absence of a meaningful father figure in F.’s family history never allowed for what in theory is called the basic maturing process - from the We of confluence to the I-You of healthy contact.

This period of the therapy determined a significant turning point in the therapy relationship: not letting myself get swallowed up by him, he was less frightened that I could absorb him.

Fourth year of therapy

He got closer without being frightened: I became important for him.

P.: “Therapy has changed my life, I’ve learnt many things from you and this has helped me get on better with others. I’ve become tolerant; even if I’m different from them, I can stay with them”.-

Generalisations such as “All priests are power mad” or “Everyone is evil” stopped, and become “Priests are not all the same” and “In the world there is good and bad” or “People can be good and bad."

This greater capacity for discrimination made new, uncrystallised figures emerge from the chaos of the Id function. One day he said:
P.: “My friends didn’t wait for me, I’m sure the Jesuits told them, I won’t go there anymore”

T.: “Maybe you could ask them what happened?”

Saying this, I was asking him to do something that years before would have been impossible: risking going beyond the fear of being abandoned or refused, risking the humiliation of asking. Was the torture of delirium still more tolerable than the anguish of realty? No, in fact a short while after he told me he had asked them and I had been right, they had simply misunderstood each other.

Fifth year of therapy

F. asked me for the diagnosis: “Am I mentally ill?”

The Personality- function emerged, I felt that this was a very delicate moment, I couldn't avoid him suffering, but I felt that I must protect him. (I wanted to set this out word for word to show how, in my opinion, the Personality-Function started to emerge.)

T.: “The mentally ill person is one who suffers, and you, too, have suffered a lot.”

P.: “What type of mental illness?"

T.: “Narcissistic Personality Disorder with a Psychotic nucleus”

P.: “Does it mean I’m mad?”

T.: “When there’s that much suffering one goes mad.”

P.: “Do you know something you’re not telling me?”

T.: “Maybe something you haven’t asked me?” (Thinking: will he ever ask if the videocameras are a delirium?)

P.: “What more could you tell me - That I haven’t got videocameras? It would mean that I’m delirious.“

T.: “Every delirium is real suffering that’s so unbearable to make you lose contact with reality.”

P.: “No, that can’t be so” (He moves his chair away)

T.: “What is it?”

P.: “I feel invaded by you, because you look at me.”

T.: “Ok, you can tell me and I’ll stop.”

I understood that he no longer needed to put his delirium between us. He could tell me what he felt and keep his delirium in the background.

At this point in the therapy I was aware both of my fear of his fragility and of the possibility that only staying with a structured delirium, even if more confined and less invasive than at first, he could avoid going to pieces.

I thought, "After having been his own victim and persecutor for twelve years, will he ever be able to stand the earthquake of seeing his delirium fall to pieces?

In that period was the first time that I was frightened “for” him and not “of” him.

Sixth year of therapy

The need to change, to become normal, to feel less different, to be able to experience getting closer to me without experiencing violence in the relationship was a new world for him.

P.: “The other day at table my father said to me: look how violent you are. Even the plate is afraid of you. I wasn’t violent. I understood that it was “he” who was frightened of me.”

He has reached the rational competence of understanding who experiences belong to.

He moves towards the world of women, no longer disgusting or inferior as before:

P.: “I’m ashamed of telling you certain things because you are a woman, whereas before it would have been humiliating speaking to a male therapist, now I feel that not all women are like my mother.”

P.: “If I’m violent and treat my mother badly she gets close and, vice-versa, I need to be even more violent just because she is close. She invades me, and I can’t stop her. If I get closer in a normal way, she pushes me away.”

One day he tells me:

P.: “My first experience with a prostitute was traumatic for me, I couldn’t do it.”

T.: “It was traumatic because it started badly, you couldn’t have a sexual performance without excitement and desire.”

P.: “True, it disgusted me.”

My being there was like a silent careful presence, sometimes clarifying and supportive, a presence that had never existed in that anguishing emptiness of his existence (reconstructing with healthy introjections and deconstructing archaic introjections).

During this year he decided to tell me his story from the beginning; the retelling is very different. He began to talk about himself as an ill person.

P.: “Maybe I was ill from the beginning”

His account was precise, with stages, routes, experiences and strange behaviour that he wanted explained, attempts at a cure that all failed (the best therapists and psychiatrists), books that upset him, etc.

P.: “I read them in the wrong way”

One day a phrase of his touched me deeply:

P.: “Nature gave me everything, but life took everything away.”

And also:

P.: “What does to change mean?”

T.: “Giving a different meaning to everyday things.”

P.: “The Jesuits woke me up with noises.”

T.: “In a different way.” (I support his fear and wish to change)

P.: “I could say they are hallucinations.”

The confines of the delirium had become much more flexible. It was possible to go into and come out of the delirious thoughts. He talked about delirium but not in an impenetrable way. He used it in order to avoid feeling new things, but in the background the “new” emerged and he was supported by the relationship to look at it.

P.: “In theory, in delirium does anything real exist?”

T.: “Whoever is delirious understands and feels real things, but which are unbearable, and he projects them outside as though this were more bearable.”

P.: “I feel you are near, but at the same time intrusive, as though you entered inside me.”

T.: “How can I be close but not intrusive?”

P.: “By understanding me without feeling me touched inside.”

T.: “Ok, if I can’t manage to do it, tell me and I’ll stop”. In the here-and-now of the relationship he experienced the “new.”

The last six months

P.: “I think about illumination the whole time, it must be something that you can’t explain or know; take off the veil of Maya that will make me see true reality!”

I thought, "It seems like his metaphor to see beyond the veil of his delirium!"

T.: “One sees what one is ready to see.”

P.: “I’ve always been curious and flexible, unlike my parents who are rigid.”

T.: “In what way have you inherited their rigidity?”

P.: “By saying that you know the answer.”

T.: “I have a hypothesis.”

P.: “Then when I am ready, this will happen. I like it, that’s where Gestalt is different from Psychoanalysis, isn’t it?”

The last three months

He wanted to return to the first year of his psychology degree again. It’s like an unfinished situation. I think it’s good, but at the same time it’s necessary to support him.

The psychotic decompensation that determined the structured delirium of the patient was a non-supported projection in the world: he couldn’t get away from his mother, but he had to, and so he started university in a city far away, in a Jesuit's college , a rigid container that invaded him (in fact they became the persecutors of his delirium).-

P.: “I’m going to go to university in Palermo; I don’t know if I’ll be able to come anymore”

T.: “I think you should come, as you need support.”

P.: “Yes, true, but if I have to attend?”

T.: “You can even come once a fortnight.”

P.: “Very good.” His face relaxed. I’m did not stop him from going;, neither was I chasing him away.

From the last sessions

P.: “What does being cured mean?”

T.: “It lets the patient evolve, grow and bear this happening.”

P.: “I like this definition, and, for me, what does being cured mean?”

T.: “Being able to do that which wasn’t possible before.”

P.: “Will I get better?”

T.: “I think that in part you already are.”

P.: “What is still necessary in your opinion?”

T.: “Sometimes you say things I don’t understand.”

P.: “I want to continue until the priests leave me, until the persecutions finish.”

T.: “ That seems like a good idea; I understand this.”

He was saying that he would be ready to leave his delirium! I didn't know if this would ever be possible, and I don’t know if I’ll be ready to still let him rave, accepting the limits of my therapeutic power.

I thought, "He’s already different from before, and if he can 'get over the delirium,' he will be able to get back that which “nature gave me and life took away from me” -. to quote one of his phrases!