Self Psychology and Psychosis: The Development of the Self during Intensive Psychotherapy of Schizophrenia and other Psychoses

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In this groundbreaking volume, David Garfield and Ira Steinman bring us into the immediacy of the analyst's consulting room in direct confrontation with the thought disorder, delusions and hallucinations of their patients grappling with psychosis. From the early days of psychoanalysis when Freud explicated the famous Schreber case, analysts of all persuasions have brought a variety of theories to bear on the problem of schizophrenia and the other psychoses. Here, as William Butler Yeats notes, "the centre cannot hold" and any sense of self-esteem - positive feelings about oneself, a continuous sense of self in time and a functional coherence and cohesion of self - is shattered or stands in imminent danger.What makes psychoanalytic self psychology so compelling as a framework for understanding psychosis is how it links together the early recognition of narcissistic impairment in these disorders to the "experience-near" focus which is the hallmark of self psychology. Now, with Garfield and Steinman's descriptions of healing in the mirroring, idealizing and twinship experiences of treatment, the theory of self psychology, in a comprehensive fashion, is brought to bear on the psychoses for the very first time.Join Garfield and Steinman as they bring the reader into these analytic journeys, inspired by Kohut and his followers and crafted with their own original insights as patients find their way back to a meaningful and functional existence.

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Chapter One: The Opening Phase—The Case of Judith

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Judith was a lithe, petite, blue eyed blonde woman in her early twenties when Dr. Steinman first met her in a psychiatry emergency room; blood oozed from four deep self inflicted cuts on her left forearm. She was sitting demurely in an uncomfortable wooden chair, her face bland and remote. Dr. Steinman began….

“What happened?” Dr. Steinman asked her.

“Nothing.”

He persisted: “Surely something happened.”

“I don't know” She remained impassive.

“Did something bother you?”

“Uh huh,” she responded in a meek, barely perceptible voice.

“What was it?”

“I didn't feel good.”

“Where?”

“Here,” and she pointed to her abdomen.

Dr. Steinman wanted to continue this developing line of exploration. Why, he wondered, would she cut herself? There must be a lot bothering this very young looking woman; even though her voice was calm and timorous, cutting herself was an emotion filled act—or one intended to stop emotions.

But the blood was seeping onto the floor of the shabby emergency room Dr. Steinman had begun to work at three weeks earlier at the end of his psychiatry residency. He had trained at a hospital that had a rather large staff for the psychiatry emergency room. But now, trying to support his young family, he was working with only a nurse's aide on duty with him. Before the blood became a problem, Dr. Steinman walked Judith across the street to a fully operational hospital emergency room where her wounds were sutured and butterflies applied.

 

Chapter Two: Judith—The Middle Phase

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From Dr. Steinman:

“During that first year of treatment, I hospitalized Judith for a few short hospitalizations to protect her from her self-destructive carrying out of the ‘Good Angel's’ edicts. This was done for her own good and also served the function of reality testing; the wishes of the ‘good angel’ were bad and would be dealt with accordingly. I became the powerful figure who entered her psychic life, not just as the ‘bad devil’, but as a new protector to protect her from the previous ‘protector’, the good angel, who actually harmed her.

Little by little Judith's confusion clarified and she reintegrated during this first year of therapy. Good and evil, right and wrong became her own issues, no longer placed outside of herself in the form of imagined and concretized beings. Both ‘Good Angel’ and ‘Bad Devil’ disappeared and were no longer in her consciousness.”

Taking a step back

When trying to identify whether Judith is developing a mirroring versus an idealizing selfobject transference to Dr. Steinman, one might be tempted to conclude that since he is acting in the role of a “protector,” that this means that Judith is mobilizing an idealizing type of needed transference to her therapist. He takes her to the hospital when she is bleeding, he gets angry with her when she is listening to the “good angel” and is hurting herself and at times, he scolds her “for her own good.” We get a glimpse, as noted before, as to what is important to Judith in all of this. When at the hospital, she tells the staff with a certain amount of pride that her doctor cares about her, she “comes into being” with being noticed, seen, and valued. We can hear Kohut's remarks as we think about her body dissociations:

 

Chapter Three: Repair of the Self—Judith

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Forward and trailing edge transferences

As mentioned earlier, Marion Tolpin's groundbreaking (2002) elaboration of a transference continuum involved the idea that Kohut's mirroring, idealizing and twinship selfobject experiences lay at the forward edge of growth and development whereas the classic repetition compulsion transferences could be seen to be the re-enactment of the unconscious conflicts of childhood. The understanding of the emergence of symptoms in the course of an established treatment may point to the breakdown or shift in forward edge growth facilitative experiences. This then leads to classical transference phenomena.

After Judith's “delivery” of the dead four-year-old and her announcement of “integration” into “one” self, there followed a period of some six months of “regression.” Judith spent much of her waking hours in fantasies of nursing and sucking. At first it would be a bottle, then a nipple, then a whole breast. Gradually, there were images of penises, penises to suck on, penises to cut off, penises to bite off. These images were accompanied by great fear and apprehension.

 

Chapter Four: The Infrastructure of the Vertical Split

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As we saw in the case of Judith, disavowed action can be seen as the patient's way of trying to hold on to a threatened sense of self agency. Behaviors, actions and a variety of different split off states contain vital elements of an unintegrated self. For Judith, the mirroring selfobject experience, as it deepened, allowed for the reintegration of these various psychotic behavioral states. The key concept here is “threatened.” Given Judith's experience with her grandfather, her very psychological existence was at stake.

This chapter, through two clinical vignettes, explores in greater depth Kohut's (1971) concept of the vertical split. Interestingly, Sullivan's (1953) identification of “selective inattention” as a security operation within a self system can be seen to foreshadow Kohut's concept of the vertical split. Stern's (1985) research on the development of agency within the infant and the important role of caretaker attunement to the felt consequences of intended action add to the clinical understanding of disavowed motor acts. Here, faulty selfobject experiences result in the development of an in-depth sector of the psyche that remains conscious, yet disavowed. We clearly saw this in Judith's psychopathology.

 

Chapter Five: Rachel—In Need of an Internal Safe Haven

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Rachel was a short, wan, twenty-year-old young woman with blonde hair over her face, when Dr. Steinman first saw her on the psychiatry ward, after her third hospitalization in eight months for serious suicide attempts, self mutilation and psychotic behavior. As she had been after the other suicide attempts, she was withdrawn and hallucinating; she looked blank, her attention on inward preoccupations.

On two previous occasions, she had overdosed; this time she had been found, dazed and confused, wandering on the Golden Gate Bridge. There were reddish lines on her forearms from cutting at herself with a safety pin.

Dr. Steinman:

Rachel didn't particularly want to talk to me, but I had been called in to see her since she was on such a downhill, negative course. Her family was concerned that they might lose their daughter during one of these psychotic and suicidal episodes.

Initially, Rachel was mute as I sat quietly with her. Gradually, she talked reluctantly, still immersed in whatever she was seeing and hearing. In response to questions, I learned that she was the eldest of two in a business family, her brother sixteen months younger and twin brothers five years younger. Her father was seen as authoritarian and rigid, her mother as inhibited and too tolerant of her father's “tyrannical behaviour.”

 

Chapter Six: Three Rats and the Extraterrestrial

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Lois was a depressed, withdrawn, woman in her mid thirties, when she consulted Dr. Steinman. She had a previous diagnosis of chronic paranoid schizophrenia, had been hospitalized several times and had been treated for the previous seven years with antipsychotics. She had lived in a half-way house for the better part of a year and now lived alone in a rooming house. She was unkempt, disheveled, clearly preoccupied, and hallucinating.

She had been married, but was now divorced. She had given up custody of her children, and had had a persistent delusion for years that three rats were gnawing away at her. She had little contact with anyone except for an old friend of hers who sent her to Dr. Steinman. By everyone's account, previous friends, family, psychiatrists, and ancillary staff, she was a burnt out case.

The diagnosis of chronic schizophrenia had been made during one of her first hospitalizations, when she told a psychiatrist about the three rats gnawing at her.

Living without a net

 

Chapter Seven: Jonathan and the Twinship Transference

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Jonathan would have been noticeable in any crowd. His full red beard swept below his knees; his unkempt, knotted hair reached his ankles, snaking through curious tortured curls, as it drooped toward the ground. His eyes were glazed and other-worldly, as he sat in Dr. Steinman's waiting room.

Jonathan had been psychotic for nearly twenty-five years, and had not benefited from the various psychiatrists and antipsychotic medicines he had taken over that time. Thus, his family figured they had nothing to lose by dragging him in to see the new psychiatrist they had heard about though a friend.

Dragging him in is what they had to do, for Jonathan's mind was elsewhere. His gaunt, spare frame and seer visage belied an inner preoccupation with something unseen by the rest of us. When his elder brother tried to get Jonathan to come in to the office, Jonathan barely moved. Slowly, with much urging and pulling from his brother and exhortations from his mother, he stood up. After five minutes, he haltingly walked, slow, hesitating step by slow hesitating step, through the doorway; in another five minutes, he had moved about eight feet.

 

Chapter Eight: Selfobjects in Psychosis—The Twinship Compensation

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Concepts from psychoanalytic self psychology may be valuable in explaining confusing clinical experiences in psychotherapy with psychotic patients. In this article, we describe three clinical cases in which the patient believed that one of the therapist's body parts was actually the patient's. This body part “mixing up” has traditionally been understood in terms of part objects or transitional objects. We propose that the twinship selfobject experience provides a better understanding and guide to clinical intervention in these circumstances.

Introduction

Therapists who work with patients suffering from the psychoses often go through periods when they feel confused. Sometimes, particular kinds of confusion, such as when patients psychologically “borrow” body parts of their therapists, can be specifically identified; these confusions may have diagnostic or therapeutic implications.

For some time, psychodynamic psychiatrists have understood delusions, hallucinations, and bizarre behaviors as having a communicative function. Some authors (Garfield, 1987; Havens, 1986; Searles, 1979; Stolorow, Brandchaft, & Atwood, 1987; Sullivan, 1953) emphasize a “decoding” process that may be helpful in clarifying certain kinds of confusion. This represents a search for Shakespeare's time-honored “method to madness.” Symbolization, dramatization, and thematic structuring are the common tools of this navigation.

 

Chapter Nine: The Widening Scope of Psychoanalysis: Self Psychology and Psychosis

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We hope we have illustrated, the principles and practices of self psychology in the intensive psychotherapy of psychosis, providing a useful way to conceptualize and implement how we work with patients suffering from schizophrenia and related psychotic disturbances. All of the patients presented in depth in this book have had previous diagnoses of schizophrenia, yet all gradually worked through difficult and painful problems that underlay their delusional or hallucinatory experiences.

Concepts such as the vertical split, cross modal empathic attunement, fear of re-traumatization, the “forward edge,” disruption and repair all help the self psychology therapist address the various deficits patients have and need to work through during the course of psychoanalytic psychotherapy. The three sections of the book—mirroring, idealizing, and twinship, have, of course, framed the foundation of this approach. It is important to note that with these foundational understandings of self psychology, people who were previously viewed as hopelessly mired in a psychotic process have been able to recover and some have been able to eventually come off antipsychotic medication.

 

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