Dreams and delusions in psychosis
Earlier, I described how the preparation of a psychotic episode is dissociated from awareness, the ill part being considered healthy: it is as if the psychotic nucleus had the power to hypnotise the personality into being passive and yielding, thus creating the precondition for the delusional invasion.
This makes psychosis therapy particularly complex because the analyst is without those messages he needs in order to prevent, contain and transform the pathological course. In this respect, psychosis differs from other states of mental suffering: the depressed patient, for example, talks continuously of his malaise and projects his suffering onto the analyst. In psychosis, however, the analyst must resort to indirect signs: prolonged silences, skipped sessions or indecipherable speech that can alert to the danger of an imminent break.
One tool the analyst can use to prevent a possible break is the dream, which at times can show in advance the progression of the psychotic process as it moves forward. The dream can describe the break that is looming (or has already occurred), which is represented by the patient and therefore potentially becomes thinkable. The psychotic dream of this kind is helpful not only to contain and halt the psychotic course, but also to make the patient aware of how he yields to its charm.
Angela1 is a twenty-one-year-old patient who had her first psychotic episode at sixteen, characterised by excitement and a mystical delusion, during which she was convinced she had intercourse with Jesus. After approximately two years of therapy, a second episode occurred in which the patient, convinced that she was the devil, begged the therapist not to look her in the eye; otherwise, she would be contaminated. The breakdown was managed at home with the help of a psychiatrist, and the patient's state of extreme suffering meant that she missed several sessions out of her evident fear of leaving the house and being killed. The therapist questioned herself at length on why there had been a new break and discussed this with me in supervision.
The analytic sequence that I shall now describe follows Angela’s partial recovery of the psychotic episode and regular attendance at her sessions again. This, in my opinion, is the moment in which Angela may be helped to understand the
Dreams and delusions in psychosis 63 reasons behind her break and the charm that the psychosis exerts on her mind. In a session, she brought this dream:
I’m on a train with my father, it’s evening time. We have to go to a little town, and since it’s evening, I expect we shall stay out overnight. During the journey my father is very focused on his paperwork and I feel ill at ease, alone. Then I’m in a car, my dad and I, and Mrs Franzoni2 is driving. I recognise Mrs Franzoni and feel extremely uncomfortable in the car with her. I arrive at a boarding school surrounded by a high wall; it is a boarding school where they teach archery. In the evening I’m in my dormitory with other girls, and in the dark I can see a girl who is smiling strangely at me, and she has a phosphorescent bow. The next morning we all go to the swimming pool, and as I’m afraid that my bathrobe will be stolen, I swim the “dog paddle” and hold it in my hands above the water.
The patient's associations of the dream are that when she goes to the council swimming pool, she is always afraid that someone will steal something from her, so she puts her towel and locker keys near the edge of the pool. When the therapist suggests that the bathrobe is like skin, Angela confirms that what she is afraid of is losing her identity. Then she speaks about the bow and says that this girl’s smile stmck her; it was a smile that instilled fear in her really. Since her fear of being killed is also there, the good thing, of course, about the bow is that it is phosphorescent and can be seen and recognised. The session draws to an end, and the therapist says goodbye to the patient, giving a mutual commitment to think about this dream.
In the next session, perhaps for the first time since being in therapy, Angela brings what she herself has worked out:
P: Well, I thought quite a bit about what the bow in the dream might mean. I thought too that the girl who owned it might be me. I also remembered that as well as the strange smile that scared me, her lips were all moist. ..
A: So we can say that there was strong sensuality ...
P: Yes, I thought so too, a big part of it is sexual. It was the light that evoked the bow, and so angels and devils came to mind. I become the light through the arrow hitting me.
A: Yes, this in fact is the delusional part, it is the part that hurts you, that lights you up and seduces you, making you believe that it is the only path to being superior, an angel.
P: [she giggles] Oh yeah, you’re right, it’s really crazy, I’m a human being after all, not an angel or a devil. I turn into them ...
A: I wondered whether Mrs Franzoni too represented an omnipotent part, killing her son who fell short of her expectations. In fact, in the dream, she is the one driving.... Perhaps when you are isolated (your father is focused on his work) and far from the rest of the world, this exciting part conquers you more easily .. .
P: Yeah, that’s right. . . . And I feel like an angel. . . that can turn into a devil whenever.
A: Exactly, and therefore you are afraid that someone wants to kill you.
P: I still go to the dogs, you know [Angela has stopped school for the time being and regularly goes to a city dog pound to help with the dogs], and I think it’s really important that I do. I thought about what you said to me last time, it’s true that thanks to them I’m starting to learn about feelings, but not just by recognising them in the dogs, I realise that they also open up something in me, like a lung that fills with air.... I think it’s the relationship.
I have reported this sequence to show how the delusional withdrawal (becoming the girl with the bow in the dream) can be a protective measure against solitude, but also and above all, it is a flight into a state of sexualised pleasure that Angela creates in order to take advantage of her father’s mental distance (and that of the analyst).
The psychotic patient is taken with a kind of perversity that corresponds to a transgressive distortion of the mind; this practice, apparently pleasant and like a mental drug, will sooner or later turn out to be persecutory, (self-)destructive and catastrophic because it sets off a never-ending process that overwhelms the patient himself. The urge to coerce the mind with drugging pleasure-seeking reaches a critical threshold of no return, the psychotic anxiety then breaking through with all its might.
The patient needs to reach the point where he can see the psychotic construction, as in this patient’s case.
As stated previously, dreams that psychotic patients bring to their sessions are enlightening because they describe, often very accurately, psychotic functioning and the exciting and befuddling power that keeps mental health in its thrall. During therapy, those parts that remain outside the system must be given support, prevented from being attracted to the system and helped to see clearly, so that the power of the delusion can be broken. Hence, the importance of guiding analytic work towards awareness of what the psychotic organisation means: that is, its tendency to incorporate the self and destroy the sense of reality. This is why, as can be seen from the clinical extract, psychotic dreams are helpful as they provide the analyst with an important message.
Accounts of this kind of dream are almost always without associations and should be thought of as a description of the dynamics between the psychotic and the non-psychotic part of the personality and of the action that the former exerts upon the latter. These dreams do not connect back to symbolic content but convey a message that is indispensable to working on the psychotic nucleus and on the patient’s readiness to delusion.
In the dream, Angela describes in retrospect the episode she was hit by and what her involvement in it was. Usually, the psychotic dream discloses in advance the delusion that is brewing; when it follows the delusion, however, the dream is the patient’s attempt to understand what happened in his mind. Hence, its value to the therapy as it can help the patient consolidate his efforts to resist future seduction by the psychotic part and better understand how it operates.
Since there is an awareness deficit in psychosis, the psychotic dream comes to represent a process in which awareness is lacking. Work here is complex and needs to be carried forward for quite some time; whereas the neurotic patient, after a useful interpretation, can integrate the content, the psychotic patient will continue to deny psychic reality. Irrespective of immediate effectiveness, psychotic dreams grant access to the area where the delusion formed; the analyst must therefore have experience of psychosis functioning to clearly understand the description of the transformation dynamics.
With regard to Angela’s dream, the analyst needs to focus his interpretation on the description of the psychotic transformation that occurs when the dreamer finds herself in the car driven by an infanticide mother, who represents her psychotic part. The delusional reality (the swimming pool and the phosphorescent bow) is clearly represented here, and it appears when Angela's father leaves her alone because he is too busy working (which may also allude to insufficient analytic care). The analyst can assign meaning to actions in the dream, carefully describing the psychotic functioning and its exciting and befuddling power. It is clear in Angela's case that the psychotic part has seduced her vanity (and will seek to do so again), making her believe she is special, with the reappearance of the excited sexual part that she had delusions about hi the past in her sexual encounters with Jesus.3
Themes that appear in the psychotic state are not many: the most common are those that describe the allure of the surreal and imaginary, sexualisation, omnipotence, megalomania, perverse excitement and drugging psychic experience. Without any form of disguise, these themes are described in declarative psychotic dreams. It is of utmost importance that analysts who accept a psychotic patient into care have a good knowledge of these dreams, which, when recognised and given back to the patient, can provide him with the opportunity to think and to begin to free himself from the psychotic ensnarement; should the analyst not understand the dream and trivialise it, he will not be in a position to stop the patient from proceeding towards psychotic colonisation.
I shall now try to clarify the nature of the delusion and distinguish it from daydreams, myths and dreams.
In psychoanalysis, the term psychic reality means an individual’s conscious and unconscious subjective psychic experience, and it includes fantasies, conscious and unconscious beliefs and positive and negative feelings that connect us to people and to all the knowledge gained from our life experience. Freud (1900) used this term also for the beliefs of hysterical patients who were convinced they had been subjected to sexual abuse in childhood: despite being untrue, their memories of abuse are real to them. Freud thus established that psychic reality or, rather, personal beliefs and actual reality do not coincide.
Generally speaking, people can distinguish between what is subjective and personal, such as ideas, thoughts and emotions, and what comes from external reality and interacting with others. With regard to psychosis, the inability to distinguish between inner and outer reality has rightly been highlighted, and the mechanism of projective identification described by Melanie Klein (1946) is certainly what creates this confusion between what is internal and what is external.
So what kind of psychic reality does the delusion represent?
How the delusional experience is conceptualised is fundamental to the success of therapy. If we consider the delusion a message, we should tiy to decipher its implicit meaning, as we do, for example, with dreams; if instead we consider it a construction built from scratch - in other words, essentially an obstacle to communication - our approach in the therapeutic relationship should be that of deconstructing it to enable the patient to free himself from its control, recover his intuitive thinking and establish contact with emotional reality.
Following on from Freud’s (1910) comments on Schreber’s memoirs, many analysts have considered the delusion something similar to the dream, a sort of truth that can be unveiled. Freud (1938a) himself, in Constructions in Analysis, confirmed the idea that the patient can disclose some of his history in the delusion.
From this viewpoint, the delusion may be considered to contain a hidden truth that was distorted by the defences and conflicts that govern the patient’s mind. Indeed, Freud wrote that Schreber’s complex delusion production as well as his sense of being persecuted by Professor Flechsig, his psychiatrist, both concealed a nuclear point of repressed homosexuality. Schreber’s illness was the product of a homosexual conflict with his father, the libido remaining fixated at a primitive stage and anxiety projected outwards.
Many other authors, too, believe that in the delusion there is a kernel of truth. According to Niederland (1951), for example, what Schreber feared most was having to follow in his father’s footsteps as he felt unable to live up to being a member of the Reichstag.
In his relation with Flechsig and in his delusion (God-Sun-Father), Schreber withdrew into the female position since taking on a male role would have been unbearable. Similar observations were made by other authors - Israels (1989), for instance, who considers one of Schreber’s complaints, that of his chest being compressed by ‘divine miracles’, as the consequence of orthopaedic apparatuses devised by his father to rehabilitate children; the introj ection of paternal authoritarian and coercive methods returned as hallucinations and delusions.
As stated earlier, Freud (1938a) likened the delusion to the dream, and they do in fact bear many resemblances: both are nourished by a narrative plot comprising sensorial elements, visual images and auditory perceptions that lend a feeling of reality, but upon awakening, the dreamer, unlike the delusional patient, can compare the dream and reality and understand that the dream corresponds to an emotional narrative that is his, but which is not real.
For a psychotic patient, it is very difficult to distinguish a dreamed fact from a real one that has actually happened; when he dreams, he is uncertain whether it is a dream or reality, and when he is delusional, he is unable to think of the delusion as a dream in the awake state. That a ‘voice’ or an ‘intuition’ unveils a new irrefutable reality in the delusion makes the psychotic patient consider the dream a revelation of ‘another’ reality.
Freud (1910) recalled that President Schreber, at the time of his second psychotic episode, had dreamed that his nervous illness had returned and he had fantasized being a woman on one occasion during intercourse. According to Freud, in these cases the patient discloses in advance the same material that will then enter the psychosis, and in fact, Schreber was to communicate in his delusion that he had turned into a woman and been impregnated by divine rays.
Therefore, there are dreams and dream fantasies that announce the delusional reality in the making; such dreams have no symbolic meaning but describe the delusion structure that is preparing to conquer the mind (Capozzi and de Masi 2001). As previously stated, these dreams must be treated with descriptive interpretations that help the patient see that what is presenting itself as an unquestionable external reality is in fact his own creation.
Freud (1924a) also assigned a reconstructive value to the delusion that sees an attempt at recovery and the reorganisation of reality after the catastrophe; when the Id overrules the reality principle, as occurs in the psychotic episode, the Ego must find an alternative in a bid to replace the lost reality.
A first critique, although indirect, of the conceptualisation of the delusion as an announcement and an attempt at reconstruction comes from Federn (1952), who instead considered it a falsification of reality following the loss of the Ego boundary. One of his most important propositions was that whereas ‘in neurosis we want to eliminate repression, in psychosis we want to restore it’ (1952, p. 136). It is not a matter of ‘making the unconscious conscious, but [of] making the unconscious unconscious again' (p. 178); therefore he recommended not giving symbolic interpretations of the meaning of the delusional experience because the patient, instead of understanding them, might think that the analyst is revealing the existence of a new reality.
A second way of understanding the delusion, based on the belief that there is a radical difference between neurosis and psychosis, is that of a totally new construction in an alternative, dissociated reality, which is my way of seeing delusional experience. The delusion is not the product of intuitive thought or unconscious activity, but the configuration of a new perceptive reality that is the exact antithesis of creative thought and self-awareness; that is, it is a separate mental experience, created by the mind’s sensory activity, which cannot be understood using traditional psychoanalytic concepts of defence, repression, denial and so forth.
The imagination that creates the delusion does not take us back to an emotional reality or a repressed wish, but it ’unveils’ a new world that tends to take root in psychic reality. The patient constructs his delusion content with the same sensory processes he uses to perceive external reality: the sensory imagination that produced the delusion gets engraved in his mind, and it becomes a real experience that can be reproduced. Processing the reality of a past delusional experience so that it may be considered a memory that is distinct from the present is what proves to be difficult; it is always brooding and potentially capable of recapturing the healthy part of the personality.
Using the imagination intuitively is a process that develops late on. Very young children are unable to represent their experiences: hence their inability to mentalise psychic experience; when they begin to play, they enter the ’make believe’ stage where play and reality coexist simultaneously, and then at a subsequent stage, they form a theory of mind (Fonagy and Target 1996).
I use the term imagination to denote a mental activity that can make use of sensory images and that conveys wishes, curiosity and seeking experience and openness towards the world. Play and dreaming are both sensorially built experiences (visual and auditory images) that convey meanings, wishes and symbols that originate in the subject’s emotional reality; the dream, in particular, has a communicative function that generates emotional experiences, comparable to that of artistic narration.
That psychic reality contains conflictual thoughts means that the same thought activity contains ambivalent impulses; however conflictual or egodystonic it may be, a thought remains a thought - it does not turn into a concrete perception, as unfortunately occurs in the delusion.
When the illness gives rise to delusional dissociated experience, it is not easy to foresee whether the patient will be able to recover the unity of his mind. Despite there being evidence of cases of spontaneous recovery, the psychotic delusion, even when it seems to have faded away, leaves traces that facilitate relapses.
Hanna Segal (1957) formulated the concept of the symbolic equation to explain the nature of psychotic thought, pinpointing one of the most serious complaints of schizophrenic thought, which is the inability to symbolise or, rather, to distinguish symbols from concrete objects. Segal discussed the case of a schizophrenic patient, a talented musician, for whom stroking the bow on the violin strings meant masturbating. He therefore refused to play in public because for him playing meant masturbating in front of strangers: the symbolic equation of psychotic thought.
For Hanna Segal, the symbolic equation, where no difference exists between the symbol and the original object, is used to deny the absence of the object. Symbolic activity, instead, originates when depressive feelings dominate paranoid-schizoid feelings: that is, when separation from the object, ambivalence, guilt and loss can be experienced and tolerated. The symbol is used not to deny but to overcome the loss. According to Segal, differentiation between self and object is necessary to maintain normal symbolic ability based on the introjection of objects experienced as separate from the self. With regard to the psychotic patient, one part of the Ego is confused with the object, and the symbol is confused with the object that is symbolised: an excess of projective identification is what erases the difference between the self and objects and creates confusion between reality and fantasy.
Segal (1974) was also interested in the artist’s creative imagination and in how it differs from that of the delusional patient. In her opinion, the artist creates through reparation, allowing the birth of a new object; the delusional patient, on the other hand, is one with his creation. The moment the artist has finished a piece of work, he lets the created object be separate from him and can thus see his work from the right distance and with a critical attitude; he feels distinct from the parental couple, even though he identifies partially with them. The delusional patient places himself in his parents’ stead, not acknowledging any of their functions. Lastly, the artist seeks to recreate an inner truth without mistaking his desires and fantasies for reality, whereas the delusional patient is unaware of the omnipotence the delusion produces.
In a piece of work published in 1971, Herbert Rosenfeld examined in depth the importance of projective identification and the splitting of the Ego in psychosis. In particular, he made a distinction between two types of projective identification: the first is used to communicate and the second to rid the mind of unwanted parts. This second form of projective identification is what the psychotic patient uses to transform psychic reality.
Edith Jacobson (1954) connected the delusional patient's identifications to the earliest infantile mechanisms of magical identification that make the child feel he is one single thing with the object or that he is the actual object regardless of reality. The link is clear between these forms of identification and the concept of projective identification proposed by Melanie Klein.
According to O'Shaughnessy (1992), the mind ceases to think when it uses projective identification excessively or differently from the way it is habitually used. Besides its communicative purpose, when an infant cries in order to be understood by his mother, for example, the mind can also use violent projections to evacuate self-awareness and object awareness; in this distortion, internal and external perceptions are not transformed into conscious and unconscious psychic elements that can then be repressed in order to enter dream work.
O’Shaughnessy reconnects with Bion (1957) when she says that the psychotic personality has its origins in fragmentation, which follows the expulsion of the means through which the Ego knows reality: that is, the senses, consciousness and thinking. In other words, there is an uprooting of what Freud called the ‘reality principle’.
Several authors - Caper (1998), for example - think that the delusional construction can be worked through gradually until it transforms into a fantasy.
My clinical experience leads me to believe that there is a radical incompatibility between delusional imagination and fantasy and dream activity. As stated earlier, the delusion brings with it an anomalous transformation of psychic reality, and it is wrong to think of it as a defence: the defences, by changing emotional perception, create a mind-set that tends to be stable; psychopathological constructions such as the delusion, however, tend to deform psychic reality, transforming it continually.
I consider the delusion a psychopathological construction: that is, a belief that produces a falsification outside awareness, which acts at a conscious level via massive distorted investment in sensory reality.
The delusional experience avails itself of the psychotic mind’s ability to make imaginative thought sensory. In this mental state, the psyche is employed not as a means to understand reality but to produce sensations and perceptions; that is, it is used as a sensory organ. What fundamentally characterises the delusion, as mentioned earlier, is its ability to construct an imaginary sensory world. At a certain point, however, this new pathological functioning of the psyche escapes the patient’s control, and he is no longer able to distinguish between newly created reality and pre-existing reality: the patient is conscious of the delusional representation but is not aware of its falsified nature.
One of the most precise definitions of the difference between imagination and delusion is that provided in an interview conducted by Laurice McAfee with
Joanne Greenberg, Frieda Fromm-Reichmann’s patient and author of I Never Promised You a Rose Garden:
Perhaps the most powerful thing I would like to say is that creativity and mental illness are opposites, not complementary. Mental illness and creativity are terribly mixed up. Imagination is, includes, leaves, opens towards and learns from experience. Madness is the opposite: it is a fort that turns into a prison.
(Silver 1989, p. 527, author’s translation)
The radically concrete nature of the delusional experience poses very knotty therapeutic problems. Unlike the dream, which can be understood and transformed, the delusion cannot; due to its predominantly sensory nature, it is extremely risky to formulate interpretations of its content for the delusional patient as they can lead to misunderstandings and mix-ups.
Pleasure in the delusion
I shall now briefly describe a clinical case that clearly shows how the delusional part takes control of the healthy part, luring it to exciting pleasure; specifically, it can be seen from the clinical material how several dreams portend the advance and manifestation of the delusion. We can understand that, once the episode has been overcome, the psychotic nucleus does not wither and die despite its branches having been severed as its roots and trunk remain firmly planted in the ground, ready to sprout again.
Alberta was hospitalised in a psychiatric ward after a psychotic breakdown with auditory and visual hallucinations and delusional thinking several months before the beginning of psychoanalytic treatment. The medical history gathered when she was admitted did not provide anything particularly meaningful; Alberta was an only child and always led an isolated life away from her peers. Her stay in hospital was relatively short because she regained contact with reality quite quickly even though not completely and was then entrusted to an outpatient clinic where the psychiatrist prescribed psychotropic medication and suggested analytic therapy.
The fir st months of therapy were face-to-face. Alberta, who came to her sessions regularly, accompanied by her mother, seemed interested in the therapeutic relation; she was almost amimic, fearful, at times absentminded and still immersed in a delusional atmosphere that she was trying to hide. She seemed sad and jaded, as if she felt empty and disoriented after the psychotic breakdown; at times she would try to speak about her family and the difficult relationship with her mother. After a while, the number of sessions rose from two to three then to four per week, and at a certain point, the analyst suggested that she lie on the couch. Regular contact was kept with the psychiatrist who was to check her therapy and intervene in the event of a break.
After the first few sessions, Alberta was able to come to her therapy on her own. As for her difficulty with her mother, she remembered that when she was fourteen, her mother had slapped her and forcibly taken her back home after catching her holding hands with and giving a small kiss to a classmate. Alberta said that
Dreams and delusions in psychosis 71 since then she had always refrained from going out with boys because she was frightened of her parents' possible reaction. In fact, during her adolescence she had never sought to become independent of her parents, never went on holiday with her friends and never had a boyfriend.
This episode of kissing her classmate when she was a teenager could be considered the first manifestation of the patient’s love withdrawal, which then gradually took up more and more space. The delusion that had led to her admission to hospital had in fact been of an erotic nature, and concerned a schoolmate from early secondary school whom Alberta thought was in love with her; in fact, he belonged to a group that used to make fun of her. At this stage, Alberta no longer had any contact with this former schoolmate. In the delusion, however, his presence was everywhere; he would follow her and speak to her but never be visible, hiding from her. During Alberta’s stay in hospital, her mental state was characterised by frenzy with visual and auditory hallucinations: that is, a string of delusional signals in which the boy would declare his love for her.
What follows is material from a session in the fourth month of analysis. Alberta came into the room smiling and a little frivolous:
I’ll tell you about a dream. I was living inside a video game; the walls would open and close at my command, when I said “open or close”. When I opened them, some people wanted to come in, but they were dangerous. It was a constant opening and closing. I would have liked to go out but I was forced to close them to protect myself. I am always afraid. Even yesterday when I went to the city centre with my mother I was afraid, and when I got home I breathed a sigh of relief.
Through this dream, Alberta is describing her psychotic functioning: she can create a video game that replaces psychic reality, opening it and closing it at will. But then the psychotic system becomes threatening; Alberta can no longer control it and risks being locked up in a prison with no way out.
Several months later is this session just a short time before the summer holidays:
I’m happy today because I had a nice dream, not an anxious one. I was with my friends from secondary school. We were at a school on the coast. I had a computer test to do, and my friends had a maths test. At a certain point I confided in them about what had happened in September [her psychotic breakdown]. Then I asked them to get the medicine that I have to take. They were very kind and understood me, but at a certain point Marco [her lover in the delusion] appeared, which was absurd; he didn't make fun of me and he wasn’t unfriendly either, the opposite in fact; he told me that he would like to get along with me and go out with me as long as I stopped being standoffish. Then I woke up calm and peaceful.
In the first part, Alberta manages to talk to her schoolmates about her psychotic breakdown and even remembers the medication she has to take, but then Marco,
the protagonist of her love delusion, appears. It does seem to be a peaceful dream, but a closer look shows that there is something ambiguous about it. Why does Marco appear suddenly in the dream? Why is the school on the coast? One might wonder whether the patient is trying to convince her analyst (as she does with her schoolmates in the dream) that everything is all right, and that she has regained her mental health, while in fact another delusional meeting with Marco is being organised, on the brink of the summer holidays.
In the next session, Alberta still seems peaceful:
It’s a time in which I'm thinking about the future; simple little tilings make me euphoric. I’ll give you an example: I bought a cream for cellulite to use this summer, it’s a nagging thought. I do nothing but think about the holidays. I bought a new swimsuit and spend forever in front of the mirror. It’s a thought that makes me euphoric, it makes me feel really active. And I've been chatting online to Daniele [a peer] about everything, the cinema, theatre, sport.
The analyst says that her thoughts are pleasant but tend to be almost ill-like and uncontainable. Alberta replies:
Yes, and I can only wipe them out if I take a sedative. Every time I go to the seaside I dream of meeting someone who will turn my life around, and might be the one I’ll run away with.
The conclusion we can draw from these sessions is that a new psychotic episode is being prepared for the summer break when her analyst will not be there. The cellulite cream and the holiday at the seaside (the school on the coast) offer a glimpse of a new state of sexual euphoria. Within a short space of time, the same delusional atmosphere of the first psychotic episode is in fact recreated: Alberta begins to miss her sessions, preferring to wander about town while telling her parents she is going to her analyst. Early intervention by the psychiatrist and the resumption of regular sessions after the holidays, which in this case were short, were to prevent the patient’s readmission to hospital.
This clinical material helps show how the delusion, once it is installed in the mind, tends to reappear. In this case, the allure of the eroticizing and ecstatic state is appealing and, at the same time, the approaching analytic separation tends to strengthen the psychotic part that will no longer be contained by sessions.
Alberta, precisely because she has always led a mortified and isolated life, tends to mistake freedom for the propaganda spread by the delusional part that portrays itself as an experience of exciting independence. When the dream about school is described during the session, the delusional part is already on the verge of conquering the healthy part. The dream describes how Alberta is once again allowing herself to be conquered, and, since she has lost awareness of what is happening, she is really delighted by this dream material. Here, the delusion has presented itself as a condition that will lead to a state of ecstatic excitement; mortified and weak, the patient’s healthy part yields to the flattery.
In delusions, perception of reality is altered in such a way as to comply with the dominant theme: the persecutory patient sees enemies everywhere and interprets others' behaviour as threatening; the patient with delusional love themes interprets simple messages as being clearly erotic. The patient's alarmed reaction is rather typical when we try to cast doubt on the truthfulness of his delusional experience; it is as if we purposely wish to doubt his perceptions to make him look mad, given that he considers these experiences as real facts.
In the delusional state, the patient does not think: he ‘sees' or 'feels’ as if he were daydreaming. While dreaming, we consider the dream content as real, but when we wake up, we understand that it is an affective-emotive narration that is not real at all. The dream after all is a symbolic experience that connects back to the dreamer’s emotional meaning, his wish, conflict or anxiety. The delusional experience has no awakening, doubts or distancing since it is not a symbolic narration but a concrete perception.
Another substantial difference between the dream and the delusion experience is that the latter continues to be 'a real fact' even when the healthy part is gradually restored. The delusion is forever something that really existed, with all the exciting or terrifying emotions that accompanied it; in this sense, it bears much resemblance to trauma, which, by its very nature, is not at all easy to work through. As is the case with the traumatised individual, the psychotic patient will frequently not remember the delusional experience out of his fear of once more coming under its sway.
The defence employed to avoid relapses is circumscribing the delusion, like a foreign body, and dissociating it; given, however, that its nucleus remains potentially active, often the delusion will form again. In Alberta’s case, the love delusion is like an ecstatic state of excitement, a nucleus of pleasure, always there to capture her and rescue her from depressive feelings.
To explain better how two realities, psychotic and real, can coexist, I shall refer to some material from a colleague’s super-vision, that of James Telfer (2013),4 which concerns Capgras syndrome, the pathology in which the patient lives with the firm belief that the people close to him have been replaced by alien replicas or imposters that are identical to them.
Elisa was a twenty-five-year-old young woman, shy and introverted; over a period of a few years, she became increasingly isolated and would nm into problems at work, to the extent that her parents began to be worried about her. One night they found her in the garden, armed with a knife, ready to attack them if they came anywhere near her. Elisa confided in the doctor and nurse who had been called out from the Mental Health Service that her parents were, in fact, imposters who wanted to kill her. She gave her consent to be admitted to hospital and to take psychotropic medication. When discharged a fortnight later, Elisa seemed rid of the delusion but was unable to feel like a real, alive person, and so she accepted beginning psychotherapy. During her sessions, she spoke very little, was vague and disoriented and still convinced that her parents had been imposters even though they no longer were. The sessions were difficult because Elisa spoke monotonously, had no sense of time and gave the impression of living in her own private world like someone who was reared without parents. Gradually, over the following months, the live presence of the therapist seemed to shift Elisa from her passive state. At a certain point, Elisa spoke of her grandmother’s death, which had occurred one year before the beginning of the delusion, a grandmother who had loved her so much that the patient thought of her as a mother. The loss of her grandmother was, in retrospect, the real traumatic event that had triggered Capgras syndrome because Elisa had been unable to work through the loss and mourning. Instead of ‘dreaming her’ to keep her alive in her inner world, as occurs in normal mourning, Elisa took the path of the delusion, refusing to acknowledge the role of her parents and turning them into dangerous imposters.
Relapsing into delusion
Alvise5 came from a city a long way from Milan, and even though it was July, with the summer holidays in sight, he wanted to begin analysis immediately. His determination struck me, and perhaps this was what made me decide to see him. His analysis began in September at four sessions per week in an analytic setting, and Alvise moved to Milan. Alvise had been in a psychiatric ward for two months, followed by a short course of treatment with a psychotherapist who then sent him to me. He had had a severe psychotic break that culminated in attempted suicide: while on holiday, he hurled himself off a flyover, under the delusional conviction that he harboured a diabolical power that made him totally destructive. Other diabolical presences were at work, too, often in the shape of animals, such as black dogs, while, to the toll of bells or bursts of gunfire, the world proclaimed mass suicides. Alvise had felt that he could telepathically enter others’ minds and bring about their suicides, and, thinking he was in touch with God (divine and terrifying voices declared catastrophic truths), he was convinced that his condemnation was final.
After seven years of analysis with me, the patient’s condition had improved so much that his parents persuaded him to complete his university studies. (He only needed to pass one exam and do his thesis.)
Despite displaying discomfort with and intolerance to intellectual work, the patient accepted his parents’ suggestion. In order to work on his thesis, Alvise needed to cut his weekly sessions from four to two; his analysis halved and the tension of preparing his thesis difficult to bear, Alvise had a new psychotic breakdown during the summer holidays. This time the auditory hallucinations were not experienced as perturbing, though (which they had been in the first breakdown), but as a special quality that made him unique, to the extent that he believed the CIA were searching for him in order to abduct him, take him to the United States and make him work for the American government.
Due to the new psychotic breakdown and a series of adverse circumstances, it was not possible to analyse his idealisation of his madness. Alvise and I both ended up feeling discouraged, and he did not come to his sessions anymore. Several years after this, I received news from his father that he had gone back home, was living a narrow life and regularly took antipsychotic medication. Ten years on, I received a telephone call from Alvise asking to see me again. We met up, and he greeted me warmly, but I had the impression that he still considered auditory hallucinations (this time centred on neighbours) as real facts. In the meantime, he had graduated, was looking for work, continued to take psychotropic medication and had put on a lot of weight.
When this analysis was over, I reflected a great deal on the case, and asked myself what had been lacking in my therapeutic approach. I had focused much of my analytic work on analysing the psychotic Super-ego that underpinned the hallucinatory state. Alvise had, in fact, improved and could tolerate awareness of the psychotic catastrophe that had happened. It is likely that pressure for a premature ‘recovery’, mainly sustained by Alvise’s parents, had favoured a return to psychosis.
During the course of my reflections, I asked myself whether I had really understood the origin and dynamics of the delusion and if I had actually managed to get to the bottom of the original psychotic episode: that is, whether I had understood how Alvise had entered psychosis. In retrospect, I came to the conclusion that I had not done this; when I had tried to share and relive the sequences of the psychotic episode with the patient, I found he put up very strong resistance and tended to trivialize what had happened.
I understood that I had given up on carrying out a systematic analysis of the first psychotic episode because of the patient’s resistance and my uncertainty about it and had instead focused on his need to repair the psychic damage in order that his mental functioning could be restored. I understood late that the original psychotic episode had been there between us like a third wheel.
I would like to recall two important thoughts that, after Alvise’s case, have always stayed in my mind. The first is by Arieti, who stated in his book Interpretation of Schizophrenia (1955):
An important point to be considered is the relevance of the original episode. It is not just a precipitating event; it is a very important dynamic factor, without which the patient would have been able to check, or even compensate, his psychotic propensity.
The second is by Searles (1979):
Schizophrenia cannot be understood simply in terms of traumata and deprivation, no matter how grievous, inflicted by the outer world upon the helpless child. The patient himself, no matter how unwittingly, has an active part in the development and tenacious maintenance of the illness and only by making contact with this essentially assertive energy in him can one help him to become well.
If the first psychotic episode enhances a patient’s readiness to be delusional (and the structure of subsequent delusional episodes is similar to that of the first), the analyst, as best he can, must go back to the past and rebuild the way in which the patient entered the delusion construction for the first time. It must be borne in mind that the first psychotic breakdown leaves an indelible mark on the mind, and it is onto this matrix that subsequent delusional experiences will be built.
Delusion relapses may occur for various reasons. When the delusion produces an excited state of pleasure as, for example, in the love delusion, the state of ecstasy, like a drug, gets lodged in the individual’s memory as an experience of vitality, which is why it can recapture the patient. We have seen this condition in the case of the patient Alberta.
Something very different occurs in the persecutory delusion, in which the patient is in fear of his life; in this case the psychotic experience is tantamount to something traumatic that remains fixed in one’s memory, like anxiety that cannot be worked through. The sensory and concrete quality of the psychotic experience makes it a true traumatic event that is ready to reactivate when the same configuration that triggered it happens anew. It is an endogenous trauma in this case, produced by the delusion that reawakens; just as traumatic experiences suddenly re-emerge as sensory, acoustic or visual flashbacks, the delusion, apparently forgotten but never completely dispelled, tends to reproduce itself.
I have already mentioned that the patient is easily colonised by the delusion formation, which poses a complex problem for the therapist. Somewhere in the mind is a place, not easily accessible to the analyst, in which the psychosis is constructed. The delusion has an undeniable hold over the patient, who neither averts the danger it poses nor understands its pathogenic significance; I cannot stress enough how helpful the message contained in some dreams is, as the withdrawal and the colonisation of the psychotic part are clearly described there, without any form of disguise, helping the therapist to intervene before the delusion suddenly explodes.
I would now like to examine analytic material on a patient who seemed on the verge of repeating a psychotic episode.
This case6 regards a twenty-six-year-old male patient who had a psychotic episode that ‘illuminated’ him. The pope informed him that he, Gianni, had invented ‘morkema’, a language that would enable the deaf and dumb to communicate with each other and with the rest of the world. Immediately afterwards, though, this illumination turned into persecution: a ‘voice’ would tell him that he was not a genius after all and that the devil had lured him into a trap to kill him. Gianni said that this ‘voice’ incited him to kill himself because after his death, he would be able to achieve something extraordinary. After working for several months on the delusion, Gianni began to feel less distressed and understood that he had gone from a state of grandiose excitement to one of persecution, in which he felt like the devil, who had destroyed the order of the universe.
Gianni: I felt distressed when I woke up. I dreamt I had a big tummy because I was pregnant and it moved like a book that had a child inside it. I felt good in the dream.
Analyst: What is your opinion about the dream? It seems as if you have everything in this dream, a penis and a womb. You got pregnant all by
Dreams and delusions in psychosis 77 yourself, as if another's presence were unnecessary: 'I can do everything by myself’. I do not need my parents to feel grown up.
Gianni: Yes, I see now that I have good parents. My best friend, Chiara, a lesbian, asked me to have a baby with her. But I don’t know how to. I don’t like her as a female, and I don’t think she could arouse me.
Analyst: ‘I can do it without a female’ seems to be the message in your dream. ‘I have everything inside me’.
Gianni: (laughing) Yes, maybe. I’d really love to live as I did in the past. Maybe in Berlin [the city he idealised as a place of sexual pleasure]. But now I know it would just be me escaping, and I’m a bit scared to go.
Besides the delusional content in this clinical extract, I think it is important to highlight the contrast between the distressed state upon awakening and the merry and aroused condition that characterises the dream. (The pleasure of begetting a child corresponds to the omniscient individual Gianni thought he was during his delusional experience.) It is precisely this that differentiates the psychotic part from the non-psychotic part of the personality. Distress upon awakening is the perception of danger that the non-psychotic part senses when the psychotic functioning appears. By analysing the emotions that the dream content arouses (anxiety and pleasure), the analyst can show the patient that there is fascination with delusional omnipotence, but also alarm and distress coming from the healthy part. Dreams of this kind are cause for alarm for the analyst, who must interpret the seduction performed by the psychotic part.
Specific to the psychotic illness is its progressive and generally unstoppable nature: the delusion nucleus possesses such force that it can maintain lasting power over the patient’s mind.
That the clinical condition of psychosis has radically changed today does not mean that the illness is no longer progressive and dangerous. The numerous chronic psychotic patients who populated asylums and, because of institutionalisation, were destined to spend their whole lives hi these places, are no longer common, but the pathological force of psychosis means it still needs to be fought against tenaciously.
Thanks to psychotropic drugs, the most dangerous expressions of the illness can be limited and the most clamorous symptoms kept under control, but stopping the process once it is set in motion still requires great effort.
During the course of the illness, mental paths are activated that function as predetermined delusion routes, where thought gets directed and distorted. Even when there is visible progress, the therapist cannot delude himself that stable improvement has been achieved; if anything, in some cases, the perception of having made progress actually creates a state of triumph in the patient, pushing him towards grandiose and maniacal mental experiences. Generally speaking, it may be asserted that the delusion experience settles in the mind like a mark, ready to reactivate in circumstances that are difficult to foresee: it is like a hot ember under ash that never burns itself out.
Naturally, there are more benign forms, limited to a single episode without relapses, but psychosis is a danger to the mind as cancer is to the body. It wouldtherefore be fruitful to work with patients, especially children and adolescents who are predisposed to the pathology, before the illness visibly manifests with a breakdown.
What gets lost in the psychotic condition, as mentioned earlier, is the difference between the psychotic parts and the non-psychotic parts: that is, between the healthy and the ill parts. Often the delusion and hallucinations are not considered by the patient as dangerous distortions to thought; what he believes is that he has acquired special qualities that place him above the rest of humanity.
This is how the idealisation of madness is brought about: the ill parts are perceived as good and healthy and providers of power. In the perversions, too, a similar phenomenon occurs, which is circumscribed, however: the perverse patient coniines himself to glorifying perverse sexual pleasure and his superiority in relation to normal mankind.
Awareness of the illness, a diagnostic element in traditional psychiatry, is still a dividing line today between neurosis and psychosis for this reason.
When we have a psychotic patient under our care, before us is an individual who lives in a world of dissociated sensory perceptions that alter thought and prevent him from understanding psychic reality; we must intuit the innermost way he distorts thoughts and perceptions, altering his very instruments of knowledge in the process. If the patient's sessions are close together, we can monitor his progress and setbacks; whatever course the therapy takes, our participation, observation and reflections must be consistent. In particular, when we witness regression (an extremely frequent occurrence in the course of treatment), we must go back to understand why it has occurred.
The case of Philip Dick, the well-known American writer who fell victim to a psychotic episode late in life, shows us how the dissociation that regulates psychotic experience does not allow delusional reality to be easily integrated with psychic reality.
In this particular case, it is not easy to establish the extent to which his abuse of drugs, barbiturates and vitamins played a role in his psychosis.
Dick called psychosis anamnesis and spoke of it as a fact that could not be forgotten; in his subsequent literary work, he sought to understand and rationalise it, and in his writing, it is evident how his hallucinatory visions were indelibly fixed in his mind, going on to constitute a complex and protean mixture in which true and false, perceptions and hallucinations, continuously blend together.
Dick most likely pushed himself so far into unreality that there was no turning back.
Carrère (1993) provides this description of Philip Dick’s psychotic episode: the writer, aching for days after having a tooth out, rang his doctor to have a painkiller prescribed, which was delivered to his home by a woman wearing a necklace with a gold fish-shaped pendant. Dick was mesmerised by the sight of the golden fish, which for him represented a way of being saved from oblivion and a means with which to activate intuition that would unveil reality. The girl was a secret Christian who had been sent to him to make this revelation, wearing the symbol that could uncover secrets. Like many characters in his novels,
Dreams and delusions in psychosis 79 who believe they live in one life and then discover they belong to another era or a different civilisation, Dick sensed that the shroud keeping human beings in slavery was being lifted.
At this point, he knew that he was in 70 AD and should not back away from the revelation of the truth; above all, there was no need for him to protect himself with reassuring explanations, telling himself that what was happening to him was a hallucination. He was a Christian, persecuted by pagans. During the nights that followed, he dreamt profusely and was certain that he had dreamt these dreams to make his delusion intuitions complete. Open books often appeared, perhaps written in foreign alphabets, the pages of which turned over so quickly that it was impossible to read them. Dick understood, however, that all the information in there was being hidden from him for security reasons.
Several days later, as soon as his wife went out, he approached his young son Chr istopher, who was looking for his bottle, poured chocolate milk in the shape of a cross on his forehead while reciting a religious passage in Greek and gave him the new Christian name Paul.
Several nights later, his wife woke up terrified because Dick had hurled to the floor the radio that he loved to keep on even at night: a song entitled ‘You’re No Good’ had been playing, which he had understood as You ’re no good; you’re bad and must die. The anxiety of being killed took control of him. The enemies of Christians, recruited by the Romans, wanted him dead; he, a secret Christian, had been found out and would have to die. Again at night, the radio broadcast in a deep voice insults and obscenities against him, interspersed with death threats.
In the morning, Dick believed that his enemies had put the radio programme on the air to drive him to suicide, but he had managed to thwart their plan. He thought that his brain, activated by the golden fish, had become like a radio receiver bombarded by contradictory information in a continuous flow of signals.
From that moment on, Dick produced various delusional fantasies, such as that of being a Christian in a cage at the Coliseum, with giant lizards trying to get him. At times, he would see writing engraved on a vase dating back to the eighth century BC and would agonise over the thought of not being able to reconcile this date and the historical period in which he was forced to live. Fantasy led Dick not only to produce delusions but to seek to explain them too. He would spend whole nights looking with fright at coloured marks on the wall that were dangerously spilling over, as if they were an infinite series of Kandinsky’s or Picasso’s paintings blending together. He would wonder whether the messages he was receiving came from inside him or from some outside agency. An excess of medication and vitamins might have brought about a change to his neuroreceptors, or perhaps he had become the subject of a telepathy experiment by the Soviets, given that these paintings were on display at the Hermitage in Leningrad.
One can see how the writer pushed his mind in two directions: the first by continually conceiving other worlds from which he drew inspiration for his novels and the second by reaching new levels through substance use. It is possible that the mind, when pushed ‘beyond’, produces phenomena that we call psychotic, but which others may call mystical.
In order to understand what happened to his mind, Dick left us a series of notes that have been gathered together in an extremely interesting book, The Exegesis of Philip Dick (2011), published after his death. In his reflections, one can see that he was sometimes able to diagnose his own psychotic episode but would stick to his belief more often than not. Idealising his state of alienation, he wrote:
In Feb. of 1974 I momentarily withdrew assent to the reality of this world; a month later this world underwent visible changes, and its true nature became perceptible to me: it is, as the Gnostics said, a prison. . . . What each of us must do is repudiate the world, which is to say, deny it “while at the same time’’ affirming a sanctified alternate reality, which I did vis-à-vis the golden fish sign.
(2011, p. 400)