Trauma and the Super-ego in psychosis
The relationship between trauma and psychosis is complex and controversial and understood from numerous perspectives. One perspective considers the beginning of the psychotic process to be a consequence of repeated infantile traumas, often accompanied by abandonment and neglect. In addition to the violent traumas, all problematic factors in the child’s earliest dependence relationships during emotional growth play a part.
On this subject, Paul Williams (2004) has described the experience of being invaded by external forces that some severely disturbed patients speak of in analysis, and he has hypothesised that this feeling stems from an early contaimnent failure of their projections, as well as from the forcible introjection of disturbing aspects of the person who is supposed to take care of them. Incorporating the invasive object hampers the development of self-regulation and pushes the child to expel into others his own mental states that are unbearable to him; the use of violent projection in the individual’s mental functioning thus gets its start, preventing normal identification and the construction of a cohesive sense of self.
A similar concept was expressed by Piera Aulagnier (1975), who connected the origin of the psychotic illness to maternal violence, that kind of violence which the mother normally uses on the child to structure his sense of reality. In the case of the psychotic patient, excessive violence acts in the same way as an intrusive object that establishes itself in the child’s mind, and in a bid to escape the chaos, he tries to violently construct a representation of the Self outside the relationship with the mother. This violence employed by one mind on another is relived within the psychotic process: the patient feels forced to believe in the delusions, and the analyst feels invaded by a distorted and alien way of thinking.
Considerations by Piera Aulagnier and Paul Williams have in common the numerous observations of the ways in which parents manipulate their children outside awareness, using them as parts of the self and in so doing violating the psyche. Parents’ intentionality, be it conscious or unconscious, which often does not correspond to open violence, influences the child’s growth and potential development. What can psychopathologically condition the infantile mind is the emotional trauma that stems from the pathogenic relation between parent and
Trauma and the Super-ego in psychosis 91 child as it favours the formation of psychopathological objects and structures that will continue to function as parts of the future patient’s Self.
Violent traumas suffered at a young age need to be considered separately. A large body of data exists on this subject, which confirms the relationship between early trauma and psychosis (Read and Ross 2003; Read et al. 2005; Schafer and Fisher 2011). The literature documents a high rate of trauma, including physical and sexual abuse, in individuals destined to become psychotic in their lifetime. Read et al., on the basis of the 180 cases studied, believe that many symptoms of psychosis, hallucinations in particular, could be connected to abuse and abandonment. Severe infantile traumas are at any rate an important risk factor for any type of adult pathology.
Extremely interesting accounts from this viewpoint are in the aforementioned Living with Voices (Romme et al. 2009), which contains approximately fifty cases of patients with hallucinations. Not only do the patients described present with hallucinatory symptomatology, but some are affected by the psychotic process proper, which not infrequently leads to their being hospitalised. The authors, whose intention was not that of providing therapy, saw these patients in group sessions to help them reflect on the nature of their hallucinations; the aim was to take the edge off their condition through sharing with others who suffer from the same disorder. According to the authors, this experience was helpful as many patients from the group came out of their distressful isolation, where they had chosen to stay in order to conceal their symptoms for fear of being hospitalised against their will. The ‘voices’ they heard were described as commentary on thoughts or actions and had in common that they were initially friendly and comforting, but then turned aggressive if not downright diabolical.
Of the fifty or so cases considered, eighteen had suffered sexual abuse, eleven emotional negligence (three also with sexual abuse) and six adolescence problems. Two were victims of bullying, two others suffered physical violence and sexual abuse and seven were without a clear cause. Naturally, these figures are insufficient to establish causal connections, but they are useful to hypothesise that many people who have suffered severe infantile traumas are more vulnerable to psychosis.
A very interesting case is described in the book (mentioned in Chapter 7), which presents hallucinations with crows. It is the case of the patient who had heard voices since she was a child; this was totally normal for her, given her conviction that she had an implant in her head which produced hallucinations: that is, until she was hospitalised at the age of twenty-four. After many life events, hospital admissions, psychotropic drugs and episodes of depression, she was able to establish that the voices that spoke to her were seven in number. One of these was the voice of the boy who had abused her when she was eight, which she had begun to hear when she was thirteen; it was a vulgar and aggressive voice. She had not spoken to anyone about her abuse, and when she began to hallucinate, she forgot all about it. Among the other voices was one, for example, that she named with her hypocorism and whose job it was to comfort her. After joining the group, the patient felt less terrified and began to accept the voices; then, thinking backto the hallucinations about crows, she remembered the sexual abuse, which had happened in a wood under a tree in which there were dozens of crows. The abuse had been forgotten, but the hallucinations about crows had contributed to making it re-emerge, like pieces of a jigsaw puzzle that all fit together.
In some cases of sexual abuse, the hallucinatory manifestation is directly linked to the perpetrator. I have supervised two cases of adolescent girls who had been abused and had interiorised the perpetrator as a voice that intimidated and dominated them, creating uncertainty and making them doubt their own free will.
A trauma that occurs in early infancy interferes with those functions outside awareness that allow mental and emotional life to be represented, and it prevents the development of a mental structure capable of understanding psychic reality. When the infantile trauma is severe, it is clear that emotional functions involved in personality integration will be weakened: the stress, anxiety and loss of faith in others and in oneself generate an oppressing sense of non-existence. In these cases, hallucinations present themselves as seducing or intimidating voices; many hallucinations are organised around a powerful psychotic Super-ego that instils terror and humiliation. In infantile trauma, we may say that the voices issuing orders and making scornful remarks are like parental blame that gets registered in procedural memory and remains dissociated from the whole personality.
Psychosis as a trauma
A second point in the relationship between trauma and psychosis is that of considering the psychotic breakdown as a real trauma for the psyche: the traumatic event of the psychotic episode produces nameless dread and annihilation anxiety that upset the mind, biologically even more so than psychologically. Van der Kolk (2014) has described the case of Marsha, a participant in a group study on the long-term effects of mental trauma. Marsha involuntarily caused the death of her young daughter in a car accident due to her absent-mindedness. Using neuroimaging. the researchers were interested in changes to her brain activity while she listened to an assistant read an account of the accident, which had occurred thirteen years earlier. At the end of the test, once out of the scanner, Marsha was worn out and frozen, with dyspnoea and eyes wide open, the epitome of vulnerability. The scan had recorded activation in the emotional brain (the limbic system, especially the amygdala). These data confirm that when the individual is exposed to images, sounds or thoughts connected to the traumatic experience, the amygdala activates a state of alarm, as occurs in panic attacks (intensified blood pressure, heartbeat and breathing), many years after the event. This case studied by Van der Kolk confirms my belief that the psychotic episode is like a trauma for the mind, similar to that of violent traumas, and as such it is dissociated and stored in the psyche, ready to re-emerge and reoccur.
In her book The Centre Cannot Hold: My Journey Through Madness (2007), Elyn Saks describes her psychotic illness in detail, and for her, a psychotic break is like being in a war zone or being involved in a dreadful car accident. In fact, when psychosis is produced, it generates nameless dread, and the traumatic effect
Trauma and the Super-ego in psychosis 93 continues even when the psychotic episode has been overcome. The split-off delusion nucleus, which cannot be forgotten or transformed, always remains active and threatening. This is why the psychotic patient finds the breakdown difficult to remember; just the memory of it triggers unbearable anxiety, as in the case of severe trauma victims.
The psychotic Super-ego
The Super-ego was defined by Freud as heir to the Oedipus complex, an introjection of paternal authority and prohibitions, but also as a destructive entity whose origins lie in sinister forces.
Overcoming infantile omnipotence and gradually accepting the paternal figure’s regulatory and protective function result in a normal or oedipal Super-ego. A melancholic Super-ego, whose origins are rooted in a traumatic relationship with the mother, is instead destined to become a strict internal object that the Self and the object are criticised and attacked by. It was Abraham (1924) who stated that a melancholic Super-ego, fraught with hatred towards the Self and the disappointing object, forms when early trauma encounters the primitiveness of objects.
When Melanie Klein equated pathology and primitive mental states, she connected the ruthlessness of the Super-ego with the degree of aggressiveness in the primitive Ego, claiming that the struggle against the Super-ego, or first bad object, happened very early on: afraid of punishment and reprisals, the infant fears and hates the mother, who is experienced as an extremely severe Super-ego. Only a stable introjection of a good object can tame the Super-ego’s implacability and harshness. Once, and only once, the persecutory primitive Super-ego has been worked through and transformed can the child reach the oedipal experience; this failing, the peculiar paternal regulatory function of the oedipal Super-ego described by Freud cannot be interiorised.
If we are to understand the nature of the Super-ego in psychosis, we must first set down what differentiates it from that in other forms of illness. Contradictory and befuddling in nature, the psychotic Super-ego totally dominates the mind, advancing as seducing and then threatening. When this is taken into account, it is no longer feasible to consider the psychotic Super-ego as a primitive agency of the mind, but a pathological structure with no link whatsoever to the primitive Superego, despite it bearing some resemblance to it.
Whilst the primitive Super-ego observes the law of an eye for an eye, a tooth for a tooth - that is, punishment for the sin committed - the psychotic Super-ego is perverse and deadly: what dominates the rest of the personality is not so much primitive ruthlessness but intimidatory propaganda that comes over as moral truth and justice. What this Super-ego is engaged in is distorting mental growth: manifesting as an internal voice that intimidates the individual, it stunts his sense of freedom and his curiosity to learn from experience.
Therefore, in place of the normal Super-ego, a similar structure develops, one that cannot evolve into more highly developed forms but which corresponds to a psychopathological construction similar to destructive narcissism (Rosenfeld
1971). The normal Super-ego, the primitive Super-ego, and the psychopatho-logical structure may frequently be encountered in the course of the psychotic patient’s analysis, all operating simultaneously in different areas and at different levels. Whereas the primitive Super-ego can be gradually transformed through the analyst’s work of containment and interpretation, the pathological organisation is resistant to transformation: on a par with the delusion formation, of which it comes to be a part, it needs deconstructing so that its power over the rest of the personality may be weakened. Not to be overlooked is that during the psychotic process, the Super-ego is often party to hallucinatory and delusion phenomena, wielding its power via intimidatory accusations and orders.
Befuddlement marks the superegoical psychopathological organisation of the psychotic. As mentioned earlier, an exciting and thrilling Super-ego frequently manifests during the first stage, and it convinces the patient that he has reached a superior, omniscient and pleasurable mental state. Here, the Super-ego acts as a force that can change the mental state for the better, providing it with a feeling of excitement and well-being. Under the influence of this propaganda, the patient convinces himself that he is equipped with special powers sustained by divine guidance, divinity often being a theme in delusion constructions.
A second stage sees a transformation in the opposite direction: the patient is convinced by one or more voices that his state of well-being, superiority and omniscience is not a divine gift after all, but a destructive, diabolical disposition; at a certain point, he convinces himself that he is like Lucifer, who challenges God in order to seize his powers (see Chapter 6) and that having now become diabolical, he rightly deserves punishment. This transition from superiority/goodness to negativity/destructiveness is an extremely frequent occurrence: the delusional accusation of being diabolical becomes unbearable, and feeling destructive, the patient thinks he can annihilate the world, including the people he is connected with, to the point of being killed himself or driven to suicide.
The Super-ego’s befuddling action is clear also in the hallucinatory state. Typically, hallucinations are initially positive, pleasant and seductive; only afterwards do they become negative and aggressive, constantly plaguing the patient with accusations and intimidatory comments. At times, the friendly voices switch all of a sudden to aggressive voices, like psychic splinters gone mad, all jumbled together; each piece belongs to a part of the patient’s now dissociated and fragmented personality. The voices come forward as separate entities that converse but that also fight or get into arguments with one another. Dialogue of this kind increasingly leads to confusion and to the healthy part being held captive within the psychotic structure.
On occasion, the psychotic Super-ego’s accusations convey truths, however distorted they may be. The voice that accuses the patient of being diabolical casts light destructively on one truth: the patient, believing that he is God, has actually managed to subvert the order of the mind and destroy the rules of thought. Accusing, scornful hallucinations stem from the same Super-ego that prompted the megalomania; the patient therefore finds himself bombarded by disparaging invectives: the voice accuses him of being a failure or a homosexual or a loser, and
Trauma and the Super-ego in psychosis 95 these hallucinatory accusations are projected onto the world around him. In thrall to the psychotic Super-ego, the patient sees normal human weaknesses as proof of cowardliness or unworthiness. Dominated by a mad unopposable voice, he projects hallucinations onto everyone, including those who accidentally enter his life.
Worth noting is that several past scholars postulated a kinship between schizophrenic psychosis and manic-depressive psychosis, sustaining that they were possibly one and the same illness. Although never confirmed, it can be seen that the psychotic Super-ego most certainly often assumes manic-depressive features, going from maniacal exaltation to melancholic destructiveness.