Illness can push people into the paranoid-schizoid position

There are two different ways of responding to anxiety; the paranoid-schizoid  (p-s) and depressive positions.

In the paranod-schizoid position, anxieties are about life and death.   There may be underlying panic and massive fears.

  • time stands still
  • we see things as ‘you OR me’ , ‘your life OR mine’, not ‘you AND me’.
  • selfishness may save our life
  • consideration for others is cut off and out
  • we split people and things into simple categories, depending on whether they will keep us alive or threaten us
  • the capacity for reasoned thought is lost
  • apology is impossible  – responsibility is so frightening it has to be disowned
  • huge, life-threatening self-blame is covered up by blaming someone else
  • people can be afraid they should pay for their sins with their lives – so in order to save their lives, they may deny their sins.
  • forgiveness is not an option
  • other people may be felt as dangerous, threatening, intrusive.
  • other people may be used or manipulated or threatened, as a way of getting rid of terrible anxieties into them and out of the self
  • other people may be seen as cartoon characters:  Perfect Angels or Monsters, Saviours or the Devil himself.

People aren’t always aware that this is how they feel, but it may be possible to deduce it from their behaviour and what they say.

In the paranoid-schizoid position, guilt and blame can become persecutory.

  • too much guilt cannot be felt; it can only be pushed into or onto someone else
  • blame (originally and secretly) directed at the self is redirected at other people
  • other people are then felt to be blaming and accusing
  • guilt increases, and is increasingly denied, pushed onto someone else

When someone is ill, their partner, their child or their parent may be terrified about what will happen to their own lives.

P-S mechanisms can then mean that the ill person is blamed for their own illness, and for ruining other people’s lives.

When things get better and their anxieties reduce, they can revert to ‘depressive position’ mechanisms.  In the depressive position:

  • there is a sense of time; of present, past and future being distinct.
  • a sense of concern for others returns
  • other people are experienced as more real, more whole, more human-sized and less cartoon-like
  • sorrow and apology become possible as guilt becomes more realistic and less frightening
  • people can reach out in a caring way
  • there can be hope for a more realistic outcome
  • other people do not seem so ideal
  • there is less idealisation of the self
  • fear is less powerful and more realistic

People can move from one position to the other, as their anxiety levels are raised or lowered.

Panicking is exhausting and frightening.

These ideas are based on the work of Melanie Klein:   Julia Segal writes about Melanie Klein’s work in Phantasy in Everyday Life (Karnac books, Aronson or Penguins) and Melanie Klein (Sage)

18 Responses to Illness can push people into the paranoid-schizoid position

  1. Estelle says:

    Thank you Julia for this blog it has been really helpful to read as I have began working with a child suffering with M.S.

  2. Great to see a blog about this. I’ve been working as a psychotherapist with disability for coming up to 4 years and, even when digging, it seems that the information on this topic is more sparse than other areas. Surprising considering the breadth of disability and illness in our culture – I think it’s further manifestation of our collective fear of the subject.

    I’m no Kleinien and don’t know the P-S and depressive positions in any real depth. Looking at what you have here, it appears that P-S is the height of anxiety and depressive is when the anxieties have calmed.

    How does this fit with the more existential understanding of anxiety and depression being at either ends of a spectrum through which we oscillate, with the optimum state of serenity and mental health being a consistent and gentle moving between the two?

    These ideas may not tessellate in any way, but I’d be interested to hear your thoughts on this.

    • Thanks for this, Ciaran. You make some good points. I do think people are frightened of illness, and this can stop them thinking about it.

      I don’t see anxiety and depression as opposites. I think there are different kinds of anxiety; paranoid anxiety (when you split, and see the world as ideally good vs ideally bad, for example) and depressive anxieties, where you see the world more realistically. Depressive anxieties arise when you know it’s you doing the splitting, doing the hating of the bad – and you realise that this means you’ve been attacking the good as well. ie that ‘the mother you hate is the same as the mother you love’ – and the you doing it is the same you too. The depressive anxiety/fear is of losing the good person (‘Object’ /not-me) in your life. The paranoid one is of being destroyed by the bad object/person/thing.

      I’m not sure about the image of a ‘consistent and gentle’ moving between anxiety and depression.

      Klein certainly thought we moved between paranoid-schizoid and depressive positions, in terms of how we deal with anxiety, but she also thought there were other states of mind; that we didn’t have to deal with anxiety of any kind all the time. (For example, she thought curiosity was an important motivation, which makes us explore the world, and we do this in a different way when we are not anxious.) I think it’s important to be affected by other people in a realistic way, which means you are bound to get anxious at times. And becoming aware that you’ve been misjudging someone or something is humbling and upsetting.

      There is a problem with the word depression. People use it in lots of different ways. I don’t like the way it has a static quality. I like the word ‘sad’. It’s reasonable and realistic and important to be sad sometimes, when sad things happen, and sadness generally passes – or is aroused in connection with sad things. Being in a state of mourning is often confused or conflated with ‘being depressed’, and I think that is wrong. Being depressed has one meaning of being completely overwhelmed by the black cloud; often with no understanding of why, and with a fear that it will never go away. It’s possible to be a bit sad, but with an awareness that this isn’t the sole emotion in the world.

      I would agree there is something healthy about being able to go into different emotional states and come out of them again.

      Just some thoughts.. Delighted someone is reading and responding!

  3. Thanks for such a wonderfully full response. I’m always curious to see how different modalities intertwine and, from what you’ve said here, there are some really different ideas from existential psychotherapy – particularly with the distinction between losing the good as opposed to being destroyed by the bad. I think it’s time for a trip to Amazon to get some good introductory material to this!

  4. this was incredibly helpful says:

    This was so enlighting. Thank-you. I was able to relate this to someone I can understand better.

  5. erica stewart says:

    I think my husband may have this could you offer any advice to me please, especially how to react to it and how to get him some help. Thank you.

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  12. Tricia3 says:

    For someone’s who is paranoid-schizoid, this is completely wrong.

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