Unimaginable Storms: A Search for Meaning in Psychosis

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A distillation of many years' work on a therapeutic milieu ward of the Maudsley Hospital, in which psychotic patients were treated with an integral combination of psychiatric and psychological care anchored in the use of advanced psychoanalytic concepts of psychosis. Compelling clinical material is reproduced to help illuminate the meaning of illnesses such as paranoid schizophrenia, catatonia, psychotic anorexia and manic-depression. Several depth interviews by Murray Jackson, an authority on the application of psycho-analytic thought to the problems of psychosis are reproduced for the first time.

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CHAPTER ONE. Paranoid schizophrenia: ‘the radio loves me”

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SALLY

Sally, a very disturbed 30-year-old woman, is the second child and eldest daughter of a large Catholic family of eight children. The family lived in a council house in a small town in the Midlands. The parents’ marriage was unhappy, and the father left to live in another country when the patient was 12. Sally’s relationship with her mother seems to have been highly ambivalent: however, she made close relationships with several siblings. She survived well until adolescence, at which point her schoolwork disintegrated and paranoid ideation began to colonize her mind. By 21 she was convinced that when she masturbated, the whole of the town was watching her; subsequently, she believed she was being filmed. She suffered extreme persecutory guilt feelings, which seemed to be linked to her past sexual activity. After careful investigation, it became apparent (beyond reasonable doubt) that she had had an incestuous relationship with her father from the age of 11, before his departure. It seemed likely that several of the children had been sexually interfered with in one way or another. Sally felt that her mother had abandoned her and had handed her over to her father, and she hated her mother for it. These feelings may also have had their origin earlier in her life, when she was displaced by six siblings at close intervals. She felt her mother had forced her into the role of being a mother to her younger siblings, which had prompted her to turn to father for affection. She viewed him in many ways as a mother. At the same time, it seems that Sally’s father also viewed Sally to some extent as a maternal figure, thus adding to the confusion. Her longing for intimacy with her mother drew her into relationships with women, not overtly sexual but sufficient to make her feel sometimes that she was homosexual. At other times, she was afraid that she was masculine in her orientation. This was expressed concretely in moments of psychotic dread that she was turning into a man—a fear that may have partly been the expression of a wish to be in her father’s place in order to have possession of the mother for whom she longed. It was interesting to observe that, when the theme of her longing and despair in relation to her mother emerged openly during treatment, she became quite sane and coherent for the duration of the conversation about that theme.

 

CHAPTER TWO. Schizophrenic self-burning: which self?

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Self-destructiveness, a common feature of mental illness, may afflict the psychological self, the bodily self, or both. In psychological self-destructiveness, motivations of varying psychodynamic complexity are discernible, often involving guilt regarding internal objects and deriving from destructive and reparative desires. Bodily self-destructiveness takes various forms, of which the most common is self-poisoning with prescribed or other drugs. Of all forms of self-harm, burning by fire is the most dramatic and rare, and it is one of the most difficult to understand. An investigation undertaken with colleagues at the Maudsley Hospital approached the subject in the following way:

Acts of self-poisoning, cutting, jumping and hanging are often explicable in terms of depressive or destructive motivations, the choice of methods being determined by what is available, occasionally with imitative or symbolic significance. Minor self-mutilation, which includes self-cutting and less often small burns with cigarettes is encountered frequently, particularly in female adolescents and young adults with personality disorders or in association with anorexia nervosa. It is usually repetitive, causes little harm and is not a suicidal act. Although studies of self-cutting are highly informative regarding clinical and motivational correlates, they do not explain the psychopa-thology or clinical features of major self-mutilation (amputation, castration, blinding, tooth avulsion) which appears to be both a rare and more psychotic act. Fatal or potentially fatal self-burning is an extreme form of self-mutilation and needs to be distinguished in its clinical and psychosocial aspects from minor self-burning and from other violent self-harm. Although death may ensue, suicide may not necessarily be the conscious intent [Jacobson, Jackson, & Berelowitz, 1986]

 

CHAPTER THREE. Psychotic character: “a bit of an old rogue”

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A significant proportion of the clinician’s work is concerned with attempts to assist individuals whose behaviour and symptomatology are the expression of lifelong difficulties in forming and preserving close emotional relationships. Such patients are regarded as suffering from personality disorder. They present in many forms, often associated with diagnosable psychiatric illness such as hysteria (seen more often in women), schizoid states {seen more often in men), obsessive-compulsive disorder, or depression. They tend to lead chaotic, unhappy lives and often cause emotional damage to others. Psychoanalysts consider that such disturbances derive from failure in crucial phases of early emotional development, which leaves the individual without a coherent sense of self or a capacity to manage impulses realistically. They are often afflicted by feelings of futility, emptiness, and depression. Although at times they function psychotically, these occasions are usually responses to stress and last for no more than a few hours or days, rarely leading to a diagnosis of psychosis. Over extended periods, these patients may experience many phases of disorganization, but they do not deteriorate, hence they are designated as demonstrating “stable instability”. Since they inhabit the border between neurosis and psychosis but belong to neither, they are classified as borderline personalities, and it is widely acknowledged that they are extremely difficult to treat. In recent years a burgeoning literature, psychiatric and psychoanalytic, has accumulated about them.1

 

CHAPTER FOUR. Catatonia 1: psychotic anorexia

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Catatonia is the term used to describe a disorder, the main feature of which is a recurrence of episodes of catalepsy. The actual term was first used in a psychiatric context by Kahlbaum in 1874 in a classic monograph entitled “The Tension Insanity” (Johnson, 1993). Catalepsy is a state of extreme physical immobility and mutism, lasting for minutes or hours at a time. A characteristic of catalepsy is the spontaneous adoption of postures, perhaps statuesque or stereotyped, and the automatic maintenance of bodily positions imposed by the examiner. Cataleptic phenomena may also include trance or stupor. The origin of catalepsy can be psychogenic (as in hypnotic suggestion), pharmacogenic (induced by certain drugs, including neuroleptics), or organic (neurological disease such as encephalitis lethargica).

The association of catalepsy with schizophrenic features led to the diagnostic category of catatonic schizophrenia (Bleuler, 1950) and later to hopes that such patients might respond to psychoanalytic psychotherapy (Rosen, 1953). Initial optimism proved unjustified, and it was found that most attacks could be cut short by electro-shock treatment, although recurrence was usual. Catatonic schizophrenia was once commonly encountered in psychiatric practice and is now relatively rare. This is probably due to the powerful symptom-reducing capability of neuroleptic drugs and an increasing preference by clinicians for more sophisticated diagnoses. Nevertheless, catatonia remains a common presenting problem and challenges the psychiatrist’s skills in evaluating organic and psychogenic factors in each individual case.

 

CHAPTER FIVE. Catatonia 2: imitation of Christ

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DAVID

David, a trainee priest, was 25 when the exploratory interview to be described was conducted. He had broken down two years earlier with a schizophrenic illness and was treated with ECT and a maintenance dose of anti-psychotic medication, which his mother supervised. Some months after his discharge from hospital, his mother went away for a fortnight, and David failed to take his medication. As a result, he relapsed into an acute catatonic state. Mute, immobile, refusing food, and demonstrating automatic obedience, maintenance of imposed position of limbs, and the “waxy flexibility” typical of catatonia, he was admitted to his local hospital as an emergency. After observation and intra-gastric feeding, he was again treated with ECT and eventually emerged somewhat from his state of withdrawal. Attempts were then made to encourage him to talk about his experiences, but they were unsuccessful. He showed no emotion apart from smiling in what seemed to be a quite inappropriate way and demonstrated many characteristic symptoms of schizophrenia, including listening to hallucinatory voices. When questioned. he would say he was quite happy, but his train of speech was regularly interrupted by thought-blocking. He disclosed a fear that his thoughts were being broadcast and that they could be heard by others.

 

CHAPTER SIX. Manic-depressive psychosis

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Manic-depressive psychosis is an affective disorder producing periodic disruption of apparently normal moods by pathological depression or elation. Although a single manic state in a lifetime is not uncommon, manic-depressive illness is usually seriously disabling, hard to understand, and often difficult to treat. Before the advent of mood-stabilizing drugs, the most effective treatment was ECT, which is still occasionally used in dangerous crises as a life-saving strategy. Impressive anti-depressive and anti-manic medication, and compelling evidence for a genetic component in the illness, have focussed attention on biological aspects of the disorder. Even when allowing for such genetic influences as a necessary causal factor, there exists an equally compelling case for the parallel study of developmental psychology if a sufficient causal explanation is to be found.

Psychoanalysts have long contributed to the understanding of factors involved in the predisposition to manic-depression, to the precipitation of episodes, and to its psychodynamics. Abraham (1911, 1924) and Freud (1917e [1915]) laid the foundations for the understanding of the nature of pathological happiness and unhappiness. Recognizing the extreme abnormality of the affections manifest during attacks, Abraham began with the simple statement that in such states hatred paralyses love. The hatred is unconscious and, like the love it paralyses, has infantile origins. It represents a severe developmental failure in the normal process of individuation. In particular, emotional attachment is dreaded because of extreme sensitivity to the loss that may follow. Jealousy and its precursor, envy, may be present in highly destructive form, often very difficult to detect. Immature processes of identification that are normally left behind persist and are regressively reactivated under external stress or internal fears of loss of the loved object. The prototypical object is obviously the mother and, in later life, “security figures” who are invested with maternal significance.

 

CHAPTER SEVEN. The treatment setting

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The clinical vignettes presented in the first six chapters refer to work that took place on a small, experimental unit of 11 beds, which shared a ward with a general unit of a similar size. The units together made up an acute admission ward known within the Maudsley as Ward 6. The experimental unit made use of a psychoanalytic perspective in its treatment plans, whilst its partner functioned on more general psychiatric lines. The two units dealt with a wide range of disturbances, and since most of the nursing staff served both units, a beneficial mutual influence evolved. An increasing psychodynamic attitude developed on the ward as a whole, whilst the provision of a firm psychiatric base for work of a psychotherapeutic nature came to be appreciated.

Contexts and credos

The psychodynamic philosophy of the unit regarding the nature of functional (as opposed to provenly organic) psychoses and their treatment could be summarized using a number of theoretical and clinical observations repeatedly confirmed over time. For example, psychotic conditions and severe disorders of character with psychotic features often called “schizoid” or, more recently, “borderline” conditions, affect individuals who are predisposed by reasons of constitutional vulnerability or adverse environmental conditions in infancy and childhood, or both. Many psychotic symptoms and delusions reveal meaningful content and are an expression of profound intra-psychic conflict. An acute psychotic attack may often be understood as the final stage in a struggle—perhaps lifelong—of a vulnerable individual to adjust to the world of external reality in the face of overwhelming and unresolved emotional problems of relating to the self and to others. This struggle has its roots in infancy and early childhood and in a failure, in varying degrees and for differing reasons, to experience a sufficiently stable relationship with the mother or primary object. The development of a normal core to the structure of the personality and a capacity for making and sustaining emotional attachments have been impaired, and it is frequently the demands on the adolescent to change and grow that precipitate the first overt breakdown.

 

CHAPTER EIGHT. Integration

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Our aim in this book has been to demonstrate the value of a psychoanalytic perspective in the understanding and treatment of psychotic disorders, and of the importance of making emotional contact with afflicted individuals from the first opportunity. We have illustrated the significance of a psychodynamic evaluation when breakdown occurs or appears imminent. The greater the sensitivity of the assessor to the patient’s emotional reality and the better his understanding of psychodynamics, the more profound and accurate will be the evaluation. A treatment plan may then be formulated and implemented in accordance with the patient’s needs and capacities, which may vary at different times. Such a plan coordinates psychodynamic, psychosocial, neurobiological, and pharmacological methods so that each occupies its appropriate place within a comprehensive, fluid grasp of the patients problems. An attempt to reach a patient emotionally from the earliest moment involves: exercising empathy, discerning the non-psychotic part of his personality, attempting to understand his life (external and internal, present and past), searching out the meanings of his disturbance in relation to his history and prevailing phantasies, considering his experience of the interviewer and of providing him with the experience of being understood. Such a formidable list indicates a specialized activity in which competence can only come with training and experience. However, even in inexperienced but supervised hands, a basic knowledge of psychodynamic principles coupled with an attitude of respectful curiosity and a belief in the patients resources and reparative capacities can prove to be of great benefit. If this attitude is carried over into long-term individual psychotherapy with an experienced therapist, impressive results can follow (see Levander & Cullberg, 1993). By comprehending the psychotic person’s experiences in his terms, we discover an existential coherence and emotional logic to his communications. These may be confused or hard to follow, but they are his own ways of expressing his crisis. If we succeed enough in understanding him, we reach levels of meaning that offer significant explanations of the phenomena under observation. “Understanding” in the way we describe takes many forms, not least, for example, acceptance, tolerance, and the withstanding of the patient’s communications. It is shorthand for the practitioner’s progressive recognition of the patient’s experience, its relation to his life story, and the way he has needed to control his severe underlying anxieties. Control requires the use of unconscious mental defence mechanisms to deal with otherwise unmanageable feelings arising particularly when he tries to achieve emotional closeness to others. In severe psychotic conditions these mechanisms have been active since infancy and may have led to structural changes within the personality. These can appear obvious when the onset of psychosis is early, or they may be slow and insidious, or present as limitations of personality that may not be obvious. Any improved awareness of his life problems and the causes of his limitations will help the patient integrate the meaning of his psychosis. The search for meaning and understanding may be thought of as an attempt to help a sane and cooperative part of the patient’s mind to acquire an interest in how his mind works. We must try to find out why a part of his mind has become psychotic and why he maintains a preference for the psychotic world, with all its confusion and sometimes terror, to the pains of the world of dependent relationships. Important contact can sometimes be achieved at the first encounter, as we have demonstrated, depending upon the evolutionary stage of the psychosis. If a high degree of integration is subsequently acquired as the result of long-term individual psychotherapy or psychoanalysis, the quest for self-knowledge can become an enduring motive for the patient and an unswerving ally of sanity.

 

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