I should like to begin by saying that I do not believe psychoanalytic thought has as yet managed to formulate hypotheses that can explain the origins and development of the psychotic process. Freud, despite having reflected on the nature of this morbid process, was to leave us a complex theoretical and clinical system that is particularly useful for neuroses but not for psychoses, the psychotic patient operating very differently from the neurotic patient.
Pioneers of psychoanalysis tried to address therapy for psychotic patients using the technique that was effective for neurosis, which was also the method they had been trained in and were well acquainted with. I, too, after many years of analytic practice, when I began to take into my care patients who had come out of a psychotic break, would listen to them as I did neurotic patients. Although there were at times improvements, relapses were also a frequent occurrence. One psychotic patient in particular, in my care for seven years, who had shown considerable progress to the point of making me believe he had overcome his illness once and for all, had an irreversible relapse after an analytic break during the summer holidays. From that moment on, I reflected at length on the reasons behind his relapse and on what I had neglected during the analysis.
Clinical psychoanalytic technique is based on the analyst’s ability to understand the patient's mental state and describe the patient's psychic experiences to him so that he may be helped to understand his own mind. For Freud this goal could be reached by studying unconscious processes, thereby overcoming resistance to censorship and repression. He believed that in every individual anxiety and suffering were produced by a part of his thoughts and beliefs that had become unconscious: hence the patient’s inability to understand what lay behind his malaise.
The unconscious is not, however, confined to this dynamic functioning that Freud described; alongside it are processes outside awareness that concern emotions and thought, which are implicit and not directly known to the subject experiencing them. Processes that become altered in psychosis principally concern the unconscious that operates to produce awareness of ourselves and our relationship with the world and, to a lesser extent, the Freudian dynamic unconscious, which is of secondary importance here. Everyone has reflexive consciousness based on symbolic abilities, language and a type of autobiographical memory that allows us to live in the present, reflect on the past and anticipate the future; these functions are, however, severely impaired in psychosis.
Analysts who work with psychotic patients need to understand how they can restore mental functioning within the analytic relationship in order to repair damage done by the psychotic invasion; frequently, this is a new and complex situation in that what has been learnt during personal analysis or during the treatment of other patients cannot be relied on. Given that the psychotic patient does not associate, we cannot work with associations, nor can we use dreams, which, when actually produced, are not symbolic but equivalent to concrete sensorial experiences. In addition, it is not easy to identify with a patient who lives in a psychotic state, since we have never experienced anything similar. This is all the more reason why we need to examine from a new angle how delusional activity becomes established in the mind. Furthermore, with regard to the first break, it cannot be viewed as a single and limited episode; the process of the disorder needs to be understood, and we must expect new psychotic manifestations to occur in the course of therapy.
The approach to use with the delusional psychotic patient is to describe his mental state in order to help him distinguish between his healthy and his delusional psychotic parts. The latter is not recognised by the patient as a sick part, but one that is good and healthy.
The omnipotent psychotic mental state appeals to the patient’s vanity and narcissism, making him believe he is superior and endowed with special powers. The analyst therefore needs to have experience in working with these mental states and describe to the patient the continuous transformations that the psychotic part operates on him, in particular the propaganda it exercises on his mind when it offers a pleasant world, one that is, however, dissociated and far from reality. I am of the opinion that the psychotic patient has lived most of his life in a fantasy withdrawal, which is why the delusional experience constitutes nothing other than the development of an old inclination that is no longer containable.
I should now like to briefly mention my reasons for writing this book. Part of my reflections on the psychotic illness and my way of analytically dealing with it can be found in my book entitled Vulnerability to Psychosis (2006). In this second volume, written more than ten years after the first, are further reflections that centre more on the patient’s therapy and on providing additional contributions to the genesis and psychopathology of the psychotic process.
Over the years, I have not ceased to wonder at the fact that such a sparse audience has been found for psychoanalytic input on psychosis among psychiatrists, psychologists and psychoanalysts alike. Intuitions of great past analysts on this illness thus risk being left aside and rendered obsolete, their clinical and therapeutic significance fading well into the background. And yet, if psychoanalysis were to consult with other disciplines, first and foremost psychiatiy and neuroscience, methodological wealth and depth that other disciplines inevitably camiot acquire would emerge. Contemporary psychiatry, in particular, which seems to have altogether abandoned the psychodynamic and phenomenological orientation of the past, has undertaken to identify, as the latest edition of DSM shows (DSM-5 2013), a series of symtomatologies for which suitable pharmacological solutions can readily be found. Naturally, I do not wish to underestimate the benefit and effectiveness of psychotropic drags, but despite being a necessary part of treatment for psychosis, when effective, they are not resolving, confined solely to limiting visible symptoms; moreover, they tend to be taken for extremely long periods, if not for the remainder of the patient’s life.
A variety of experiences has fashioned my conception of the psychotic illness and its treatment. For fifteen years, I worked as a psychiatrist in a public hospital with prevention, diagnostic and treatment services, where many psychotic patients were under my care. Still today, more than thirty years on, I can perfectly remember a number of them and reflect on their more-or-less unfortunate state of affairs. After leaving the hospital, I kept up my interest in psychosis through psychoanalytic literature but only began to take some psychotic patients into my care once I felt that my analytic identity had been consolidated.
In the beginning, I tried to listen to the psychotic patient in the same way I did the neurotic patient, and in spite of my surprise at the patient’s unpredictable course, I employed the usual set of tools for neurosis to deal with his anxieties and defences. I expected associations and tried to understand dreams, but over time this way of working proved inadequate: that is, of little help in preventing regression and relapses into psychosis. Indeed, treating the psychotic patient in the same way as the neurotic patient carries the risk of not highlighting in time how the psychotic part functions, all the while it stealthily colonises the mind towards an acute break. After much reflection on the reasons behind this lack of success, I gradually sharpened my listening until I had built up a specific vision of the origin of and analytic treatment for the illness.
My clinical work was further developed in my role as supervisor. For twenty years now, I have discussed clinical cases of individual colleagues with adult psychotic patients in their care and held monthly supervision sessions with them as a group. Yet another equally important experience is my supervisory work of therapies with severe children, which I discuss either individually or in a group context with child analysts and psychotherapists. I have under-stood how psychosis begins in childhood and that it often goes undetected by tire environment. Parents tend to underestimate what has already become a psychotic withdrawal, seeing it as some kind of game or childhood fantasy. The child’s isolation and sensorial withdrawal are frequently considered normal and not the expression of his capture by the psychotic construction.
The psychoanalyst’s field of observation is rich in heuristic potential in a way that no other clinician's is; we work in direct contact with the patient’s inner self and so can see how he constructs his psychosis from within. Moreover, we can go back to re-examine his childhood, when the first seeds of psychosis were sown, and draw attention to the emotional traumas that hindered development, driving him to repudiate psychic reality.
Among the pathologies in which adequate knowledge on their origin and development escapes us today, psychosis certainly features prominently. This pathological process develops outside words and beyond the sufferer's awareness; as mentioned earlier, it is not an unconscious process as in neurosis, but a morbid state that transforms consciousness, the nature and danger of which the patient ignores. In the psychotic state, awareness of one’s individuality is lost, and perception of external reality as existing outside them is absorbed into the Ego, whose boundaries disappear. No longer can a distinction be made between what is dreamt, created or just imagined; everything that is constructed in the imagination presents itself to the patient beyond a shadow of a doubt as the only true reality.
Both past and present efforts to treat psychosis can provide useful information on the nature of the illness; recapitulating these efforts, I aim to show how, despite the phenomenological complexity of the symptomatology, the key nuclei of psychotic transformation and the reasons underlying it can be understood in order to frame an effective therapy.
Firstly, I have considered past psychoanalysts who have left a written record of their work; at that time, no adequate theoretical frame for them to work within existed, nor could use be made of others’ clinical experience, and so their work was carried forward on completely unknown terrain. Only later, particularly thanks to analysts who referred to Melanie Klein’s thought, was a wider and more structured theoretical body of knowledge built up. This theoretical enrichment gave momentum to the first systematic efforts to provide analytic treatment, which were not, however, accompanied by corresponding and documented results on a therapeutic level; I believe this could explain why, after a period of interest in psychosis therapy, psychoanalytic contributions steadily fell away. Psychoanalysts as a whole most likely acknowledged this illness’s mysterious origin and difficult therapeutic course silently, however, without clear scientific debate where light could have been shed on such difficulties.
In the book, I particularly seek to highlight the beginnings of the psychotic process in childhood. Some children, as many authors who have dealt with this subject have pointed out, are already carriers of specific signs of mental malaise (the psychic withdrawal), which can spill over into a clear psychotic manifestation in adulthood.
I hope to put across the complexity of psychosis starting from the clinical level. It is my belief that clinical work, not to be separated from theory, of course, can bring to light the underlying psychopathological structures through a better understanding of the difficulties, which include resistance to change. Nowadays, many are the complex approaches used by psychotherapists, psychiatrists and psychologists alongside psychoanalysts to treat psychotic patients. I do not make a radical difference between psychotherapeutic and psychoanalytic treatments, the number of sessions or couch versus face-to-face, but I do believe the main focus of attention in clinical work should be the specific features of the psychotic state and analysing with the patient his readiness to be conquered by the illness.
The psychotherapy of psychotic patients, despite being complex, produces results for the patient, who would tend to regress and increasingly isolate himself if left alone. Given that the psychotic patient develops a bond of absolute dependence with his family and social group, thus shrinking his world more and more to avoid anxieties he cannot brave, the purposes of therapy are to reinforce his jaded vitality, support the healthy part of his personality, and contain the action of the psychotic part. Although he can neither acknowledge nor express it, the patient is aware that he needs help: hence his development of a strong tie with the therapist; one need only consider the deterioration and relapses that frequently occur when therapy is temporarily suspended, during the analyst’s holiday time, for instance. This is because the therapist operates as the patient's healthy Ego, and when absent, the psychotic part has more opportunity to conquer, seduce or overpower the patient's healthy part.
Below are a few basic points that may be helpful to all therapists:
The book is in three parts. In the first part, I have summarised the great efforts made by pioneering analysts who treated psychosis, taking into consideration only those who undertook psychoanalytic therapy in its usual setting and therefore not including the numerous colleagues who worked within an institutional or group context.
For the sake of practicality, I have arranged analysts who worked in a traditional setting in two groups. In the first are the non systematic analysts: that is, those not working within a structured theory, but on the basis of their clinical intuition. In the interests of brevity, I have chosen to consider only a few: Fromm-Reichmann, Searles, Sechehaye, Rosen, Fedem, Benedetti and separately Lacan. And in the other group are analysts who drew their inspiration from Melanie Klein’s thought, working with a structured and coherent theoretical apparatus that permitted the psychotic patient to be systematically taken into one’s care.
In the second part of the book, I look at specific features of psychosis, such as delusions and hallucinations, whose dynamic meaning and resistance to change must be contextualised. Psychosis does not involve some functions of the mind only, but the entire psychic system, which is invaded by sensory elements.
In the third part is a detailed description of the therapy of a psychotic patient who began his analysis with me a number of years ago. When he started his therapy, he had already suffered a psychotic break and was being treated with psychotropic drugs. Over the course of his therapy, the delusion situation frequently recurred obstinately and dangerously. The delusion was changeable in that the characters or figures changed, but the structure of the core delusion stayed the same. I chose this case because my work with this patient enabled me to understand the different ways the patient obstinately clung to the delusion, and moreover, it gave me the opportunity to show the various and difficult passages towards stable improvement.