Psychosis: The problem of a specific technique
I use the term psychosis to indicate that form of severe mental disorder that manifests chiefly in young adults but which is not rare in childhood, adolescence or middle age either. In the past, the consequences of the illness were so severe that psychiatrists treating the condition named it dementia praecox (Kraepelin 1883) and schizophrenia (Bleuler 1911). Besides its alarming symptoms, psychosis was dreaded because of its course, as it saw a gradual deterioration of the patient’s mental and relational abilities, his fate inevitably being an asylum, at times for the rest of his life. Instances of spontaneous recovery from psychosis were also reported, Kraepelin himself having related cases that developed in this manner, and in 1838 the English nobleman John Perceval wrote in one of his books about his fall into psychosis, his confinement in an asylum and his subsequent recovery.1
Today the clinical picture of psychosis has greatly changed on account of the availability of medication. The disorder no longer necessarily takes an inevitable chronic course but consists of recurring critical episodes. Although this does not mean recovery, a balance can be reached whereby the individual may lead a life that is not particularly satisfying but is at least not institutionalised. Mental health professionals will inteivene at the first sign of the illness nowadays, and when hospitalisation cannot be avoided, it is short term only; in addition, psychotropic dings can be used to stop the disease process at least temporarily. Thanks to a trained medical team, the condition can be prevented from worsening and developing into chronic forms of mental deterioration. As just mentioned, the current course of psychosis is that of an intermittent illness, critical episodes alternating with periods of well-being in which social contact and relational skills are limited. The more severe and lifelong clinical manifestations described in past psychiatric treatises, which clearly manifested during extremely long periods of hospitalisation, are rare today, practically having disappeared altogether.
In the past, the patient’s regression was certainly due in part to prolonged institutionalisation: lengthy periods of isolation from the healthy population, coupled with unsuccessful therapeutic care, meant that the destructive device which is specific to psychosis was given free rein to unfold. At times regression was aided by transferring patients on a regular basis to hospitals with less effective care: whereas first admissions were to an environment that could provide intensive psychiatric care, in the case of relapses, the patient would be transferred to less specialised hospitals where prolonged isolation favoured the patient’s regression.
Today, not only does a psychotic patient receive care early on, but his care plan goes beyond the clinical manifestations: one specialised team takes care of the symptomatology together with environmental and family factors that may contribute to the illness. In Italy, especially over the past few decades since the closure of psychiatric hospitals, huge individual and group efforts have been made to stop the illness from progressing and to reintegrate the patient into the community.
Psychotherapeutic treatment is indispensable in the course of the illness. From the first episode, the patient’s fate will be shaped by the orientation of the psychiatrist and care team. If the psychiatrist’s orientation is biological, psychotropic drugs will be the cornerstone of treatment. Psychotropic drags are certainly extremely helpful to alleviate or suppress the more evident symptoms - that is, hallucinations and delusions - but they are confined to treating the symptoms and not the causes of the illness. At times, on the strength of persecutory anxieties, the patient categorically refuses to take medication, and when he does agree to take it, he tends to experience passivity; as with any medical therapy, the patient expects to ‘be cured’ without necessarily understanding how.
Should the patient be under the care of a team whose orientation is psychodynamic, initial care goes beyond prescribing psychotropic drags: the doctor, who in this case is more open to dialogue, whenever possible, will suggest a psychotherapeutic course and refer the patient to a colleague trained for this task through personal analysis and therapeutic work that enables him to understand and communicate with the psychotic patient.
A specific technique
Freud formulated a theory and a technique for treating neurosis but did not believe that the same technique, based on the analysis of transference, could be applied to therapy for the psychotic patient. According to his line of thought, a complex -that is, an idea or a wish in conflict with other needs of the psyche, usually of a moral nature - is at work in the neurotic patient and ends up being repressed in the unconscious, manifesting as symptoms of suffering. Over the course of treatment, the patient relives this conflict in the transference with the analyst and discovers the childhood origins of his complex; this results in greater awareness of his unconscious functioning, the neurosis thus being got rid of.
Freud’s idea was that psychotic patients could not be analysed as they were unable to develop transference; despite returning to the problem of psychosis many times, without, however, studying it systematically, during the last part of his life, Freud described several defence mechanisms, such as denial and splitting, that paved the way for subsequent developments in understanding psychotic and perverse mechanisms. At the same time, he encouraged and supported pupils of his who worked with psychotic patients, such as Abraham and Ferenczi, in the hope that a theory to effectively deepen understanding and treatment of psychosis could be developed.
The first analysts to undertake analytic therapy for psychosis could not but refer to Freud’s model for neurosis, even though it would have been preferable to move beyond this framework of reference: no easy feat, though, considering that not even today do we have a thorough understanding of the origins of the illness (biological, environmental, psychological) or its development.
If we examine psychoanalytic literature, we can see that the outcomes of analytic therapies for psychotic patients regarding recovery are not so clear. For example, we do not know whether these so-called recoveries are effectively that or simply temporary remissions. It seems, however, that cases of full recovery are but a few (Mariotti 2000).
As previously mentioned, psychoanalytic technique, the foundations of clinical work, consists in the analyst’s ability to understand the patient’s mental state so as to describe his experiences and thus activate his understanding of psychic processes. Freud, in order to reach this objective, worked to reduce defences, in particular censorship and repression, and he tried to make the patient more aware of that nucleus of hidden truth at the root of his suffering.
Our mental functioning is based on our ability to make many of our emotional perceptions unconscious; for example, dream work allows us to carry out complex operations in order to understand and assign meaning to what we have experienced outside awareness. Analogously, in analytic work, repression is resolved, enabling us to trace back the experienced emotional reality via associations.
Unfortunately, this work cannot be done with the psychotic patient, as his emotions and conflicts are not dealt with using repression, his very instruments of perception and knowledge having been distorted and wiped out. This is why a technique and an orientation are needed that differ from those applied in the treatment of neurotic patients.
Analytic theory of the psychotic state has both continuous and discontinuous explanatory models of the disorder. The continuous hypotheses present psychotic development as the result of mechanisms at work in normal development and neuroses, whereas in the discontinuous hypotheses, psychosis represents a radical break with normal thought functions and emotionality, which are replaced by completely different mental processes, about which we still know relatively little (London 1988).
The continuous or unitary hypotheses seek to keep analytic theory of psychosis and neurosis linked and tend to inteipret psychotic behaviour as originating unconsciously in intrapsychic conflicts similar in nature to those of neurotic patients. Discontinuous theories instead are specific, resting on the assumption that psychosis is a distinct disorder that does not concern the repressed unconscious, this being my orientation.
For the continuous models, the delusional experience derives from a psychic conflict, occurring therefore at a level of unconscious functioning that governs the mental life of the normal person and the neurotic patient. Caper (1998), for example, claims that the unconscious delusional fantasy can be gradually transformed into a normal unconscious fantasy.2
Conversely, by postulating a clear divide between neurosis and psychosis, discontinuous theories sustain that withdrawal is a dissociated experience that is neither integrable nor transformable in the psychic world. Even when a degree of awareness seems present in the patient, it makes no contact with the delusional belief.
A clear example of judgement dissociation to save the delusion can be found in the memoirs of President Schreber (1903). Although Schreber was capable of understanding the mental state of other patients, he was not with regard to himself. He expressed this as follows: ‘I am fully aware that other people may be tempted to think that I am pathologically conceited; I know very well that this very tendency to relate everything to oneself, to bring everything that happens into connection with one’s person, is a common phenomenon among mental patients’.
This explained, he added: ‘But in my case the very reverse obtains. Since God entered into nerve-contact with me exclusively, I became in a way for God the only human being, or simply the human being around whom everything turns, to whom everything that happens must be related’ (p. 276).
As stated previously, in psychosis the patient is largely unaware of the dangerous mental state related to this pathological process; once set in motion, the process produces changes that are difficult to reverse and which paralyse or destroy the recognition of psychic truth. The complexity of the problem of analytic technique regards the fact that psychosis does not concern the dynamic unconscious but a more basic form of mental functioning that leads to the patient distorting his thought function outside awareness. The psychotic patient destroys the very tools that would allow his unconscious to understand psychic experience; he is unable to unconsciously repress and process experiential content (he cannot ‘dream’) and is therefore unable to benefit from work done by the unconscious.
Consequently, the analyst cannot use with the psychotic patient the same approach that he does with the neurotic patient; he must ‘forget’ what he has learnt from his personal analysis, from clinical practice with other patients and from discussions with colleagues.
The analyst must be aware of the fact that these patients do not have symbolic thought; they are unable to understand psychic reality via the use of emotions, be they conscious or unconscious and their minds are saturated with sensory elements that will then underpin the development of delusions and hallucinations. These concrete sensorial elements cancel out the inner psychic world by invading and dominating mental processes and sensorially ‘permeating’ the mind. Psychotic dreams fall outside symbolic processing, acquiring instead a quality of concrete sensory facts.
I would like to state here several reasons why I believe psychoanalysis has encountered great difficulty in treating psychosis:
- • Psychoanalytic therapy was built around problems related to neuroses, and for a long time, psychoanalysts tried to treat psychosis using the same methods employed for neurosis.
- • Psychotics are not very rewarding patients: they have frequent relapses and tend to discourage the therapist, who expects improvements to be stable, as in the case of neurotic disorders.
- • Frequently, it is not possible to treat psychotic patients in therapy with a dual setting only. Collaborating with a psychiatrist is needed for the prescription of medication, should this be necessary, and with support figures such as family members for the patient's extra-analytic life.
- • Analytic technique for psychotic patients is very particular. On this subject, Rosenfeld (1987) maintained that analysts should learn from scratch how to treat psychotic patients, since what was learnt for the therapy of ‘normal’ patients cannot be applied with psychotic patients. Analysts should even consider acquiring new therapeutic skills through specific training.
- • The analyst should have a certain familiarity with psychotic patients before taking them into therapy; naturally, this knowledge is more easily acquired after having had this kind of patient in one’s charge in a healthcare institution.
Borderline states and psychosis
I shall not discuss the clinical differences between the two syndromes but just mention several psychopathological structures common to borderline states and psychosis that are due to a deterioration in unconscious functions, in particular those of emotional awareness.
Whereas neurosis is the result of discordant functioning of the dynamic unconscious, borderline structures stem from an alteration to the emotional-receptive unconscious: that is, the mental apparatus that symbolizes affects and understanding and modulates emotions. A similar distortion but with a different outcome is observed in psychosis, in which the communicative function of the unconscious is continually weakened or completely wiped out by the invasiveness of a solipsistic and grandiose world that closes itself off from the perception of external reality.
All manifestations of borderline symptomatology, such as constantly oscillating between moments of extreme dependence and flight from relations, brings to mind a total lack during childhood and adolescence of those processes that favour the development of Symbolisation and the containment of affective states. Patients are dominated by violent emotions that they are incapable of describing or understanding, let alone processing: in other words, the unconscious based on repression did not get structured. Frequently, it may be ascertained that the disorder developed following continual childhood traumas, whereas in psychotic conditions, it is not always possible to trace evidence of such. In psychosis, for various reasons, a process of detachment and isolation from one’s emotional-relational world is performed, and a psychic structure (the psychotic part of the personality) that replaces contact with the real world is created.
In the course of the analytic process of borderline and psychotic patients, the problem is not so much to make the unconscious conscious, but to develop the patients’ originally wanting intuitive abilities. This is difficult work, as these patients are unable to use associative thought that would permit psychic facts to be understood intuitively.
The unconscious emotional-receptive function is similar to implicit knowledge: it functions as does procedural memory, which is indispensable for relational and emotional experiences. In the case of patients destined to develop a borderline state, this ability is damaged from the beginning, whereas in psychotic patients, it undergoes gradual deterioration by psychopathological structures such as delusions, which develop during the course of the illness; another difference is that the distinction between ill and healthy parts in psychosis is sharper, and the course of the illness depends on the power the psychotic part has to invade and colonise the healthy part. In the borderline patient, impulsiveness, self-destructive acting out and alternating emotional and dazed states predominate. Delusion development is highly probable in the psychotic patient, but rare in the borderline patient.
The patient who is destined to become psychotic has lived since childhood in a withdrawal dissociated from reality, a secret place where he builds a world of concrete fantasies and images, wiping out emotional functions that would enable him to understand psychic reality. Mental operations performed in the psychic withdrawal do not observe the rules of normal psychic processing; for example, they cannot be repressed or ‘dreamt' so as to be transformed into thoughts. One problem in therapy is that the patient does not usually communicate the operations that occur in the withdrawal because he idealises them and is unaware of their pathogenic power; he therefore cannot foresee their consequences, among which is the likelihood of delusion development.
In the beginning, these psychotic procedures produce pleasant and exciting mental states, but then, when the process gets out of control, they create distorted and distressing perceptions, such as hostile hallucinations that the patient feels he is the target of.
This kind of experience in which sensorial excitement replaces thought is also present in borderline patients, but to a lesser degree; while the latter oscillate in and out of various mental states, psychotic patients go down a road that is often irreversible.
Borderline patients are unable to control their emotions, which they cannot even understand and must expel in order to reduce their anxiety; psychotic patients, on the other hand, tend to isolate themselves, use their bodies as a source of stimuli and treat the world of grandiose fantasies as a real world.
As previously mentioned, one objective of analytic treatment is to develop the patient’s functions of self-awareness and his emotions. It is therefore important to prepare a specific setting that allows for the development of these experiences that the patient has never lived; in other words, the analysand must be helped to build a real identity through the relation with a new object, the analyst.
- 1 This book was republished by Gregory Bateson in 1961.
- 2 Incidentally, this also seems to be Winnicott’s point of view (1971).