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19. Conclusions

Jackson, Murray Karnac Books ePub

I have presented a wide range of examples of the thinking and behaviour typical of severe psychotic illness and have offered commentaries based on the application of Kleinian concepts. I wished to demonstrate the value of these concepts as guidelines, or navigational aids, to learning and treatment by psychotherapists, psychiatrists, and others working in the field who have different perspectives and different but related special skills.

At the beginning, I pointed out that the perspective of this book is that however much later experience may promote or obstruct normal development, it is in the mother-baby relationship that the seeds of psychosis are to be found. I quoted Winnicott’s maxim that the place to study psychosis is in the nursery and Segal’s assertion that the roots of psychosis lie in the pathology of early infancy which structures the budding inner world and influences later developmental levels in an epigenetic fashion. I also remarked that it was not going to be easy to write a text that would be intelligible and do justice to both psychiatric and psychoanalytic thinking.

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4. Paranoid schizophrenia— command hallucinations: “Brian”

Jackson, Murray Karnac Books ePub

Some psychotic patients who have lived in a chronic state for long periods of time have never had the opportunity of a psy-chodynamic exploration which might have led to a better understanding of their situation. With others, an attempt has been made but, for various reasons, has failed. The following case illustrates both some of the complex factors that may be involved in such a situation and how a psychotherapeutic approach in the appropriate setting with the right psychotherapist can help the patient.

Brian

The case of Brian, aged 43 years, was brought to a large discussion group after he had had three years of weekly psychotherapy. Only a single session of discussion was possible, at which time a prognostic formulation was agreed in the group and recorded. Three years later, the therapist provided a follow-up report.

Brian had been disabled for more than twenty years by an illness diagnosed as chronic paranoid schizophrenia, and he was maintained on a moderate dose of neuroleptic medication. Attempts at rehabilitation had failed, and two attempts to engage him in psychotherapy some years earlier had been quickly abandoned because of his completely uncooperative attitude. At the age of 37, he had been admitted to a day hospital that specialized in the rehabilitation of chronic schizophrenic patients, and he had been allocated to a rehabilitation programme that required him to live in the ward during the week.

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APPENDIX c: The future—-winds of change

Jackson, Murray Karnac Books ePub

In the last few years, important collaboration has grown among psycho-analytically informed professionals devoted to developing and integrating the application of psychoanalytic and other psychological methods of research and treatment in the psychoses and other severe mental illness (Johannsen, Larsen, McGlashan, & Vaglum, 2000; Martindale et al., 2000; McGorry, 1996).

An initiative begun several years ago in the United Kingdom, the Association for Psychoanalytic Psychotherapy in the Public Health Sector (APP), has grown dramatically. It has forged links with other European groups to form the European Federation for Psychoanalytic Psychotherapy (EFPP), with an active section devoted to psychosis and a membership of 12,000 in twenty-three countries.

The International Symposium for the Psychotherapy of Schizophrenia (ISPS), founded by Benedetti and Muller in Switzerland in 1954, has become a large and growing international organization. It has recently extended its boundaries to embrace new contemporary perspectives, with a new title, The International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses, while maintaining its acronym (ISPS) and its dedication to preserving its psychoanalytically based origins. Expanding from its original nucleus in Switzerland into the United States, the Scandinavian countries (TIPS), and recently Australia (EPPIC), it has taken root in the United Kingdom and promises to have increasing influence in the coming years. In these organizations, as well as in the International Psychoanalytic Association (IPA), special interest is developing in the relation of psychoanalysis to the psychotherapy of psychoses. An initiative aimed at building bridges between psychoanalysis, neuroscience, cognitive science, and psychology has recently been launched by the Anna Freud Centre, London.

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9 Paranoid violence: “Duncan”

Jackson, Murray Karnac Books ePub

The term “schizophrenia” has sometimes in the past been regarded in popular usage as “split personality”, and cases of sudden and dramatic shifts of identity are a phenomenon familiar to fiction writers. “Jekyll and Hyde”, the “Doppelganger”, the “alter ego”, and more complex variants such as “demonic possession” or “multiple personality disorder” (MPD) are a perennial source of fascination for the reading public. The term “split personality” is not used in psychiatric practice, where such cases are likely to be classified as hysterical disorders of dissociative type, or in the case of MPD as the expression of borderline personality disorder.

The psychoanalytic concepts of splitting and identification are helpful in understanding many psychotic and non-psychotic disorders. The following case, presented by a female social worker and discussed on a single occasion in a large group of hospital staff, illustrates the dynamics of one type of violent behaviour in a psychotic patient and leads to reflections about his possible future.

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14. Chronic schizophrenia— catatonic and spatial features: “George”

Jackson, Murray Karnac Books ePub

Catatonic schizophrenia was once common among the chronically institutionalized schizophrenic patients of many mental hospitals. In its classical form, it presented as grossly disturbed behaviour and dramatic motor phenomena. Stuporose or semi-stuporose states, often with the assumption of stereotyped postures, sometimes punctuated by sudden outbursts of panicky and at times violent agitation, were characteristic.

However, the advent of anti-psychotic drugs, advances in the practice of psychiatric nursing, and improvements in the organization of traditional mental hospitals have greatly reduced its incidence. Minor forms may still be encountered in which the differentiation from obsessional states may be difficult. In the following case, the psychodynamics and meaning of such symptoms could eventually be understood, and the underlying psychological conflicts resolved.

George

When presented to the seminar, George was 24 years old and had been in twice-weekly psychotherapy in a treatment home for young schizophrenic patients for four years. He had had his first psychotic attack at the age of 16, when long-standing symptoms of depression changed to an acute hallucinatory psychosis with catatonic features. He experienced auditory hallucinations in the form of voices commanding him to kill himself. He said that he was Hitler and the Devil and at other times that he was Jesus Christ. He had a vision, which he thought might have been a dream, of Christ on the cross, which terrified him. He believed that other people had access to his thoughts and could read his mind.

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