Living on the Border: Psychotic Processes in the Individual, the Couple, and the Group

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This book centres on the problem of psychosis, understood from a psychoanalytic perspective, as it manifests itself in different contexts and different levels of organisation: from the individual psychoanalytic session, through work with couples, groups and institutions and wider levels of social organisation. Beginning with a discussion of the psychoanalytic approach to psychosis centring on the work of Freud, Klein and the Post-Kleinians, it goes on to cover individual, couple and group therapy with psychotic patients. It draws on clinical material and theoretical discussion to explore the links between psychotic processes on different levels. This work is aimed at different professionals working within the psychodynamic frame of reference: individual psychotherapists, couple and family and group psychotherapists; organisational consultants and trainees in different therapies. As well as this it will be a useful resource to nurses, doctors and social workers who work with very disturbed patients and wish to learn about psychotic processes.

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Foreword

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1 - The psychoanalytic Approach to the Treatment of Psychotic Patients

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CHAPTER ONE

The psychoanalytic approach to the treatment of psychotic patients

Hanna Segal

The psychoanalytic approach to the treatment of psychotic patients is based on the general assumption underlying all psychoanalytic thinking that psychological phenomena are amenable to understanding. The beginnings of psychoanalysis are in a way very modest. It starts with Freud listening to the communication of his neurotic patients. Up to that time, the patient was classified, manipulated, maybe treated, but his communications were listened to in a cursory manner only and were not considered material for examination. Psychoanalysis starts with Freud's conviction that the verbal and non-verbal communications of his patient could be understood and should be examined with the intention of understanding. The pre-Freudian attitude to mental illness partly continues in many psychiatric approaches to psychosis. That is, they can be classified, diagnosed as schizophrenic or manic depressive, given treatment, and so forth, but their communications are considered either as not understandable or as only marginally relevant to the understanding of the patient. In fact, it is often considered to be a diagnostic point that the content of the schizophrenic patient's psychotic communication is not understandable.

 

2 - Reflections on “Meaning” and “Meaninglessness” in Post-Kleinian Thought

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CHAPTER TWO

Reflections on “meaning” and “meaninglessness” in post-Kleinian thought

Margot Waddell

Although not a psychoanalytic concept as such, “meaning” has always been central to the theory and practice of psychoanalysis. But even those theoretical concepts that could be described as “traditional” or “classic” evolve, not only over the course of time but also in various frameworks for thinking, so that they acquire different resonances and significances and throw light on different areas of human thought and interaction, ones that may have previously fallen outside the compass of the original formulations (Sandler, 1983).

“Meaning”, and its psychologically equally significant correlate “meaninglessness”, are such concepts. In his “Short Account of Psycho-Analysis”, Freud (1924f [1923]) summarized his major findings, among which he included: a theory “which appeared to give a satisfactory account of the origin, meaning and purpose of neurotic symptoms” (p. 197) and which emphasized the fact that “even the apparently most obscure and arbitrary mental phenomena invariably have a meaning and a causation…” (p. 197).

 

3 - Rigidity and Stability in a Psychotic Patient: Some Thoughts about Obstacles to Facing Reality in Psychotherapy

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CHAPTER THREE

Rigidity and stability in a psychotic patient: some thoughts about obstacles to facing reality in psychotherapy

Margaret Rustin

This chapter is an attempt to think about a particular kind of rigidity in a post-autistic patient, Holly, who lives simultaneously in a psychotic private world and in the world of relationships and shared meanings. I worked with her for nine years, and I discuss here the material of a session some months prior to the end of her therapy. In considering the meaning of our interchange, I wish to distinguish between the changes that have been achieved and the ongoing obsessional ruminative power of the psychotic process. I shall try to consider these from two perspectives: the patient's continuing partial addiction to delusional defensive structures, which she experiences as protective, and the analyst's countertransference difficulties in facing the limitations of the work. Both of us needed to struggle with anxieties about facing reality; the reality of the approaching end of the treatment brought these into clearer focus.

 

4 - Forms of “Folie-à-deux” in the Couple Relationship

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CHAPTER FOUR

Forms of “folie-à-deux” in the couple relationship

James Fisher

In this chapter I want to consider some aspects of the theoretical structure underpinning my view of psychoanalytic therapy with couples, which I have described in terms of a struggle to emerge from narcissism and move towards marriage (Fisher, 1999). In working with couples, it may appear to be overstating the challenge we face as therapists to talk in terms of the psychiatric diagnosis of a folie-à-deux. The phenomenon of a shared psychosis is a well-known, although relatively rare, psychiatric condition. However, I want to suggest that, from a psychoanalytic perspective, getting to grips with pockets or extended moments of shared psychotic states constitutes the heart of the challenge in psycho-analytic therapy with couples. A couple's capacity to recognize and to find their way out of such extended moments is a mark of the developmental process I am describing as emerging from narcissism and moving towards marriage.

 

5 - Psychotic and Depressive Processes in Couple Functioning

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CHAPTER FIVE

Psychotic and depressive processes in couple functioning

Francis Grier

Much has been written about the differences between the psychological universes of the paranoid-schizoid and depressive positions for the individual. In this chapter I wish to explore how these differences affect couple relationships, especially when their shared paranoid-schizoid frame of mind is extreme, bordering on psychotic functioning. I wish to give special attention to the way these differences express themselves in their impact on couples' ideals, and the results of the betrayal of those ideals. I also wish to emphasize how couples' different experiences of the passage of time fundamentally affect their psychological functioning.

Ideals

Couples in trouble often themselves bring up in the initial consultation the centrality of ideals in their view of what should constitute the core of a relationship. They will often say how sad or angry they are that the hopes and ideals they cherished at the start of their relationship have now become so dim, or spoiled, or lacking. Although it may not be conscious, at the start of a relationship each partner tends to have an ideal, often absolute, of a specifically desired relationship to which he or she feels entitled. When a relationship with a real partner does not meet the requirements of the ideal, typically the partner is blamed for betraying the ideal relationship (and he or she is expected automatically to share an identical version of this relationship). An essential development in couple relationships entails the psychological separation and movement of the partners from a more or less fused, conglomerate unit towards a more flexible couple structure, consisting of two separate partners who can move in and out of combined and individual psychological functioning. The less this development can occur, the more the couple will remain in the orbit of narcissistic, paranoid-schizoid functioning, where the reality and the consequences of the difference and separateness of the partners will not be tolerated. A defensive clinging to the ideal that the couple should function as a single, almost undifferentiated unit can push the couple towards very disturbed modes of functioning.

 

6 - The Frozen Man: Further Reflections on Glacial Times

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CHAPTER SIX

The Frozen Man: further reflections on glacial times

Salomon Resnik

This chapter is a contribution based on my experience as a psychiatrist and psychoanalyst working with psychotic patients in different contexts, in both institutions and private practice. The patients I write of here have been treated in individual, group, or institutional settings. I have chosen the “Frozen Man”, whom I mention in my book Glacial Times (Resnik, 1999), because that case impressed me a great deal and I was able to follow the patient institutionally, individually, and then in a group. I shall try to express my personal approach to psychoanalytic psychotherapy with such a severely psychotic patient.

The Frozen Man

Mr V was referred to me by Dr R, a psychiatrist colleague who worked in the mental hospital where I was a consultant supervisor. My colleague had already started to treat him, but he found it very difficult to deal with such a complex case. I agreed to see Mr V for an extended assessment with a view to either seeing him on an individual basis or offering him a place in my group for psychotic patients. Here I will discuss my initial meetings with Mr V and his subsequent experience in a group. He participated in this group for two years. I shall try to describe my impressions of the patient and of the transference situation.

 

7 - Psychotic Processes: A Group Perspective

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CHAPTER SEVEN

Psychotic processes: a group perspective

Aleksandra Novakovic

In this chapter, I present some complex situations that arose when patients from a psychiatric rehabilitation inpatient unit went on outings in the community. In the incidents I describe, acting out by certain patients created upheavals in a transitory group composed of patients, nurses, and members of the public.

The chapter is divided into two sections. In the first section, “Disarray on patient outings”, I describe the incidents on the outings, as recounted by the nurses during the course of a staff group, and discuss the implications of the patients' acting out in psychiatric rehabilitation work with these patients. In the second part of the chapter, “Dynamics of psychotic experience”, I look at the parallels between the psychotic patients' experiences and experiences in the group and consider the impact of patients' acting out on others in the group, specifically the nurses. As I understand it, the nurses were forced to endure irreconcilable feelings, and this culminated in an experience akin to a kind of breakdown, characterized by the inability to think. This observation led me to think of the psychotic patients as concurrently experiencing and enacting different feeling states.

 

8 - Psychotic Processes in Large Groups

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CHAPTER EIGHT

Psychotic processes in large groups

Caroline Garland

In this chapter, I give two examples of instances in the wider world in which the group-as-a-whole functioned in the grip of a psychotic process. In the first brief instance, in which little therapeutic work was possible, the events took place in a girls' secondary school. The second, which involved much of London in the immediate aftermath of 9/11, is an attempt to show something of the way in which a traumatized group can begin to gather itself up to think and act coherently once more. Both instances concern an attack upon an existing belief-system: one from within the same system, which was unsuccessful; and one from an alternative system, which was devastatingly effective in the shorter term.

The little girl who said she was a witch

During a training as a child psychologist many years ago, I was asked to see an 11-year-old at an inner-city comprehensive school. The school was a devout Church of England establishment for girls only. The pupils wore a sober uniform, at odds with the lively gear sported by many other comprehensive schools of the day. The school lived within the shadow of the large parish church to which it was attached, and there were frequent and intimate contacts between the two establishments: morning prayers, for example, were held within the church. Many of the staff were members of the Christian Union and attended meetings regularly.

 

Ward Observation

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Ward observation

Upon entering the ward, I went to the nurses' office. The nurses were very busy with something and did not seem to notice my presence. After waiting for a short while, I said that I had come for the community meeting. One nurse then told me to go to the nearby large common room, where the community meeting group was about to start.

In the group room, five patients and one nurse were seated, in two circles. There was an inner circle composed of several chairs and one sofa, and an outer circle formed by several chairs scattered further away and one sofa near the wall of the room. After a short while, a second nurse entered and then a third nurse popped in just to ask for the TV to be switched off; she then went out, although she returned a little later. One patient said he did not want the TV to be switched off, and it remained switched on for a little while (I did not notice when it was switched off later on). One patient left the room, and then another patient also left and shouted very loudly just outside. One nurse then left, and the nurse remaining in the room at that time asked me if I wanted to introduce myself; I did so.

 

Commentary I

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Commentary I

David Kennard

My first reaction on reading this account was to identify with what I imagined was the experience of the observer, first on not being noticed when he went to the nurses' office, and then sitting in the room waiting for the meeting to start. It was the experience of being ignored, unrecognized, almost not existing. I was surprised at how these very disturbing ideas could be so easily aroused just by reading the opening lines of the account, which recalled some of my own experiences of ward meetings. It was a reminder of how powerful the effect can be simply of walking on to an acute psychiatric ward without a clearly defined role, of feeling excluded from the busy world of those with roles.

As the account went on, I found myself caught up in the interactions of the meeting, and my initial feelings subsided. I still experienced strong reactions, but now they were ones of interest, anxiety, irritation, or amusement at the unfolding drama of the meeting, until it came to its abrupt end. I share these initial reactions in the hope that they may be similar to some readers' reactions, and also because they may reflect some aspects of the experience of life on the ward.

 

Commentary II

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Commentary II

Julian Lousada

The poverty of relationships

The “observation” presents a vivid description of a community meeting in which the patients demonstrate their disturbance and frustration. For the most part it is only their voices that we hear. So, from the outset, I found myself wondering what was understood by the term “community”, and whether the patients or staff belonged to it in any meaningful sense. The theme of anonymity and the poverty of relatedness pervades the account from the very outset. For example, I was struck by the generic reference to “nurse”, as if the nurses could not in any way be differentiated, by gender, age, or ethnicity or indeed by name. The ward manager's absence from the community meeting seemed to express something powerful about the utility of this meeting in the manager's mind. What is revealed systemically is a repeated failure of connections or communications, and an absence of relatedness between those involved.

From the outset, both the task and the activity are sabotaged. The two circles made for a confusing “setting”, perhaps indicating an inner and outer state of mind or an atmosphere in which there was no expectation that the nurses and the patients might find a way of connecting such that a community could be experienced. Certainly the boundary and container of time was damaged by the nurses' inconsistent arrival; three were present and then, as the meeting began, two left. The coming and going of both nurses and patients has a restless pacing quality, as if checks are being made on whether or not the community has formed only to discover it hasn't, but nevertheless the meeting continues, with the nurses enquiring about the minutes from the previous meeting when no decisions or comments had been made.

 

Commentary III

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Commentary III

Mary Morgan

This observation of a community meeting in a psychiatric hospital might not immediately present us with material about couple relating—there is only one brief interchange between a patient and a nurse that might constitute a couple interaction. However, I think it is possible to take this interchange and also the general exchange between the staff and patients on the ward as examples of couple interaction. In particular, these illustrations show us some of the psychotic elements that occur in poorly functioning relationships.

Before describing these processes, I will put this in the context of the idea of creative couple relating (Morgan, 2005), in which a genuine and creative intercourse takes place. The capacity for “creative couple relating” comes about as part of psychic development and contributes to a belief that by allowing different thoughts and feelings to come together in one's mind, something new and potentially creative can develop out of them. As well as being an internal capacity, relationships with external others are affected. The different, or sometimes opposing, perspective of the other is not felt to obliterate one's own view but can be taken in to one's psyche and allowed to reside there and mate with one's own thought. In this way, the individual's own psychic development can be enhanced through engaging with another person. There develops a state of mind in which two minds can come together and create a third, a new thought. When this state of mind is possible, there is a genuine curiosity about the other and what is in his or her mind, and how what is in the other's mind may not only be valuable in itself but may transform something in one's own mind.

 

Commentary IV

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Commentary IV

Wilhelm Skogstad

This ward observation is both interesting and disturbing. The reader is given the raw observation material of a moment in the life of a psychiatric ward, with acutely psychotic patients and their ward staff. One hears nothing of the observer's emotional response or of the wider context, and one has no way of gaining answers to the questions one would like to ask. It is a disconcerting glimpse into a world of madness.

What are we to make of this? The kind of institutional observations Hinshelwood and I proposed (Hinshelwood & Skogstad, 2000a) would take place over a considerable period of time. In trying to make sense of an institution, such as a psychiatric ward, one would take account of the particularities of negotiating entry into the organization, of what is directly observable in the sessions, the observer's emotional responses to the observation, as well as the processing of all of these together in a seminar, with the minds of others as sounding boards. Even with such wider material, any hypotheses coming out of the process would need to be treated as tentative. They might be confirmed or disconfirmed by further observations, but they would never have the same validity as in psychoanalysis, where the patient's responses to interpretations provide important and often illuminating additional material. With one observation alone, as in this case, and no chance to check things out further, one is limited to speculative thoughts and might easily be drawn to false conclusions.

 

10 - Asylum and Society

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CHAPTER TEN

Asylum and society

Elizabeth Bott Spillius

Since first publishing the paper on which this chapter is based (Bott, 1976),1 1 have changed my view of what its central theme should be. The original research was a study of a typical large British mental hospital carried out somewhat intermittently between 1957 and 1972. Originally the paper had two main themes: the persistence of chronic hospitalization and the presence of endemic conflicts in the hospital. I devoted a great deal of discussion to the first theme because it was assumed in the 1960s that the number of long-stay “chronic” patients was rapidly declining. The big old hospitals in the country were to be closed down and replaced by psychiatric wards in general hospitals for short-stay “acute” patients. The remaining chronically psychotic patients would be housed in a reduced number of the old country hospitals or, better, in some sort of facility provided by local government authorities. “Community care” was a fashionable idea, though little real effort was made either by the National Health Service or by local government authorities to make concrete plans for it.

 

11 - Schizophrenia, Meaninglessness, and Professional Stress

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CHAPTER ELEVEN

Schizophrenia, meaninglessness, and professional stress

R. D. Hinshelwood

Professional men, they have no cares Whatever happens, they get theirs.

Ogden Nash

The central contention of this chapter is that, in fact, professionals do care, in contrast to Ogden Nash's popular conception. However, caring for psychotic persons is problematic. It takes its toll on both families and professional carers, and the retention problem among psychiatrists and psychiatric nurses suggests that insufficient attention is paid to the low job satisfaction in our work. Demotivation and demoralization seem to be endemic.

I want to examine more precisely the nature of this stress and its consequences for the individual carers. In addition, given that stress is the business of mental health organizations, we can examine which features of the services themselves, although arising from the collective ways individuals try to cope with stress, obstruct the organization in its work.

Joe Berke, co-founder of the Arbours Association, once quipped that “Schizophrenia is an expertise in producing disquiet in others” (Berke, 1979, p. 33). Berke was well aware of the stress of his therapists and carers and of what they had to withstand. There is a specific kind of stress in confronting psychosis which, not surprisingly, has deleterious effects on the individuals involved, on their job satisfaction, and on the organization as a whole. Freud noted the difficult feelings these patients evoke:

 

12 - Brilliant Stupidity: Madness in Organizational Life—a Perspective from Organizational Consultancy

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CHAPTER TWELVE

Brilliant stupidity: madness in organizational life—a perspective from organizational consultancy

Tim Dartington

In the play Enron, by Lucy Prebble (2009), the main protagonist Jeffrey Skilling (neither hero nor anti-hero) describes life in a bubble:

Every dip, every crash, every bubble that's burst. That's you. Your brilliant stupidity. This one gave us the railroads. This one the internet. This one the slave trade. And if you wanna do anything about saving the environment or getting to other worlds, you'll need a bubble for that too. Everything I've ever done in my life worth anything has been done in a bubble; in a state of extreme hope and trust and stupidity. [p. 114]

This chapter explores the way that concepts derived from psychoanalytic practice with individuals and groups can contribute to the understanding of disturbed organizational processes. I draw on examples from group relations consultancy and work with human service organizations in the public sector.

A psychoanalytic perspective is helpful in thinking about the context in which leadership is expressed in ways that can promote or sabotage the task of a group or organization. There is much to support the view that there has been a change in the prevailing ethos of our modern world towards one that is hostile to human dependency. As a consequence, the narcissism of leaders tends to go unchecked and may even be idealized. Like individuals, social organizations construct defences against anxiety, particularly the anxieties that are specific to the task at hand. These defences can result in serious dysfunction of the organization as a whole. For public services—and here the NHS is a prime example—struggling to respond to the unmanageable pressures external to the organization, the management can come to act as if it is under siege.

 

13 - The Dynamics of Containment

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CHAPTER THIRTEEN

The dynamics of containment

David Bell

The title of this chapter serves to capture a dimension of mental health care that I think we all know about at some level, albeit implicitly rather than explicitly. It refers to both the inner world and external reality and, crucially, the relationship between them. Transactions across this boundary generate the most primitive anxieties even in the relatively well, as we all know from the experience of moving house, moving country, or major changes in role. But what for others is a tremor is, for those who are mentally ill, more akin to the feeling of an impending earthquake, a psychic catastrophe that reawakens all the terrors of breakdown.

A supervisee brought the following material. A not very ill patient was late for her session. She described her journey. On the way she had a lovely walk; she met a friend, they talked; it was a beautiful day, wonderful scenery. And so she went on. The analyst thought of her as involved in a happy world, excluding him; he experienced himself as looking on at this happy scene, feeling that he had been kept waiting because, in comparison, he was rather uninteresting. He felt a pressure to make a comment conveying this to the patient. But instead he stayed with his uncomfortable feeling and refrained from making what he thought of as the expected interpretation. He remembered that this patient was socially isolated, and very inhibited, dominated by a cruel superego that made her feel uninteresting and worthless. The analyst could now see that she had projected this superego into him and was trying to nudge him into an enactment that would serve to attack the pleasure she had experienced on her walk. Understanding this enabled him to contain the pressure and think about it, and this provided the possibility of development. For, as it turned out, the capacity to enjoy the countryside and her conversation with her friend rested upon important developments in the analysis.

 

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