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Future perspectives

We are well aware that psychosis is a progressive illness that once implanted is difficult to halt. I hope I have been able to clarify the various reasons why the psychotic process is hard to transform, above all in those patients who have had more than one psychotic episode. The cases I have treated or supervised have almost all been at the first episode, when the patient is still disoriented by the catastrophe that has overwhelmed him, and he oscillates between wanting to leave this psychotic experience behind and enjoying the appeal it exerts on him. Francesco began his analysis in this mental state.

However, in patients who have had various breaks or who have been in a psychotic state over a long period of time, pathological mental structures that distance the patient from reality are already well organised and activate continually, sustained by the brain’s neuroendocrine circuits.

I believe that the psychotic process can begin in childhood in those children who isolate themselves and avoid the company of other children their own age. Some have been severely traumatised, which has brought about suffering or a weakness in their personality; being unable to feel important to others and entitled to a place in the world, they take refuge in an alternative world of dissociated fantasies they themselves have created in order to flee from this intolerable reality.

Often, this kind of child is described as shy and isolated, but these are stereotypes; the apparently shy, isolated child frequently is not really so, but can be impulsive, chaotic and unable to regulate his emotions. According to Nacht and Racamier (1958), these children frequently live in a world of artifice-, they come from very formal families and conform to their parents’ expectations, in the meanwhile developing fantasying that absorbs their emotional energy. Thus, they become automatons, with a life devoid of authentic emotional relations. Given that they rely less on relations and on the world around them, they progressively lose vital aggressiveness needed for development; their tendency to passiveness is in contrast with their fantasy world, which sees them as protagonists of heroic exploits, at times violent and omnipotent. Intuitive-emotional abilities, having the possibility to develop only in the context of human relations and dependence on significant others, therefore become atrophied.

As stated repeatedly, there is a radical structural difference between neurotic and psychotic functioning which must never be overlooked. When we speak

Future perspectives 139 of psychotic anxieties or psychotic nuclei of the personality in analytic clinical work, we are not referring to clinically evident pathological structures but ways offunctioning.

Transference cannot be used as the main tool with psychotic patients, based as it is on the assumption of there being symbolic capacities that process the figure of the analyst; when the psychotic patient equates the therapist with a parent, the therapist is not like a parent; he is the parent. Therefore, being unable to work with transference, we must analyse and sustain the analytic relationship; the risk here is that, being based entirely on the healthy part, the analytic relationship may disappear when the healthy part is invaded by the psychotic part.

The main therapeutic objectives when treating a psychotic patient are two: the first is to try to rid the patient of his perception problems and thought distortions (hallucinations and delusions); the second is to develop his personality, for a long time trapped within the psychotic construction. Patients of this kind have not grown emotionally, so when they improve during treatment and are free of delusions and hallucinations, they find themselves with a structureless, insubstantial personality, thereby preserving inside all the prerequisites for a new break.

As for prognosis, the relationship between the psychotic part and the healthy part needs to be assessed to understand how far the psychotic process has advanced. The most favourable condition for therapy is when the patient has not had a psychotic break and is at the clinical onset of the disease; should he have had a first episode, he will have been hospitalised and prescribed psychotropic medication.

From the start, it is possible to evaluate whether the patient experiences his psychotic part as disturbing and dangerous or whether he prefers to deny or trivialize it to then allow himself to be seduced by it. The pathogenic power of the illness depends also on past life events: if the childhood withdrawal began very early on. it is clear that the psychotic part will have acquired full right to citizenship, making its transformation more difficult.

With Francesco’s case, I believe I have described the therapy of a specific case, each case being different and analogies among various different patients being difficult to establish; despite the specific nature of each case, I hope I have been able to highlight the various articulations of psychosis, its psychic origins and the nature of this process. Therapy is an extremely complex course, similar to guiding a river that has burst its banks back to the riverbed or herding a drove of wild horses into a pen. In a psychotic break, thoughts run in every direction, wreaking havoc. The therapist has to reset a system that began to deviate in childhood, that has turned the rales of thought upside down and has a strong tendency towards self-sensory withdrawal, which is then bound to create perceptive (hallucinations) and ideative (delusions) distortions. Although psychosis does not always involve irreversible deterioration today, the path towards recovery clearly requires considerable effort by patient and therapist alike.

It is not easy to describe the psychotic transformation: that is, what happens when spatio-temporal parameters that organise experience are abolished. Thoughts lose their meaning; they expand to invade spaces that should remain neutral. An occurrence from years past comes to the fore and is experienced as if it were in thepresent, and the mind undergoes endless transformations. In psychotic thought, things do not match up because everything happens within absolute omnipotence. Psychosis is the transgressive manifestation par excellence precisely because it wipes out the rules of thought and becomes as rampant as it sees fit, unimpeded, like that drove of wild horses. It is a condition in which the tools of knowledge are grossly distorted. And needless to say, this runaway mental state tallies with biochemical tempests, alterations to the functions of various brain regions and connections between them.

Francesco constantly produced delusions using language in place of real facts. By using language, he could distance himself from reality and dilate his mind omnipotently. He could play with words, match them up and obtain causal meanings that revealed existent realities through simple relations of contiguity or verbal assonance. I would like to point out that, whereas for Freud the use of words in place of things stems from both a failed attempt by the psychotic patient to recover the world of reality and the fact that he must be content with words only, I had been able to observe that, for Francesco, the use of words in place of things was a privileged path to expanding his omniscient delusional system.

As for the dynamics of the psychotic disorder, my orientation, as I hope is clear from what I have written thus far, is not in line with the theoretical and clinical contribution of the group of analysts inspired by Melanie Klein, including Bion. Naturally, their contributions are enlightening, but in my opinion, they are in need of being developed and integrated into theory and practice. I do not believe, for example, that in order to understand the origin of the psychotic process one must always refer to the death instinct or to destructiveness. I believe instead that the potential psychotic patient distances himself from reality by replacing it with an alternative world built in fantasy; more precisely, this world dissociated from reality is not really a world of fantasy, given that fantasy would correspond to a representation and, by virtue of this, would be modifiable. Fantasy that leads to psychosis is founded not on representations of objects or on aspects of reality, but on sensory impressions proper; and what is produced via a sensory use of the mind is unfortunately not easily modifiable.

In psychotic transformation, awareness of what is happening is maintained for a certain length of time; during the first stage of the delusional experience, the patient can, hi fact, recover if he pays heed to the healthy part of the Self. Later, however, when self-awareness disappears, it becomes very difficult to turn back; the patient ceases to be alarmed and passively abandons himself to the psychosis while it steadily continues to advance.

The seduction that the psychotic part exercises on the healthy part is important: when the patient constructs his world of sensory fantasies, he behaves as if he were God creating the world, convinced that he is superior to other human beings, his analyst included; it is obvious that, in these conditions, the patient lacks awareness and does not understand interpretations directed at his omnipotence. So it is better to work, as I did with Francesco, to develop the healthy part and contain the invasion of the delusion. Megalomania defends from awareness of the mental catastrophe; we may understand Freud’s statement, according to which the delusion would correspond to an attempt to reconstnict reality in this sense.

It must be remembered though, even when Freud’s hypothesis is accepted, that the delusion invasion increasingly compromises mental functioning and, in many cases, proceeds until it leads to a state of fragmentation.

Why is the therapeutic task in psychosis so long and arduous? One of my hypotheses is that it operates in the deepest layers of the unconscious that cannot be easily understood or reached via words. The unconscious matrixes of creative thought have been studied by numerous scholars, among whom are several eminent mathematicians such as Poincare (1908) and Hadamard (1945), who described the feeling of delight that accompanies creative intuition when the chaotic field of phenomena and perceptions organises around a figure that stands out against a background and arranges all the elements present so as to form a meaningful order. It is a moment of pleasure that accompanies scientific discovery and highlights the birth of a new idea.

Besides the unconscious laid down by Freud - that is, the foundations of psychoanalytic theory - there is a host of data on many mental functions of communication that lie outside awareness; one part of contemporary psychoanalysis and neuroscience has focused on these functions, about which we still know relatively little.

Now being investigated is the emotional unconscious, with its knowledge outside awareness that differs from that of the dynamic unconscious, which uses repression.

Psychoanalytic method uses the mind’s natural employment of intuitive emotions connected to the capacity for self-observation of mental and emotional processes. Increasingly mentioned in psychoanalysis are structures outside awareness, implicit relations, the digestion of primitive emotions or unconscious creativity; in psychosis, these functions are distorted or weakened, and it is at this level that the illness is located.

For this reason, psychosis still largely remains an enigma. The psychotic patient does not use intuition that exercises doubt when acquiring knowledge or understanding, but proceeds by revelations and finds unquestionable truths that suddenly appear in his mind. Knowledge by revelation is direct knowledge obtained only by the power of the mind that creates it, unmediated by experience.

Francesco would tell me that the delusion originated in his viscera, like an intuition that flooded his body and mind. Intuitions by revelation or enlightenment cannot be transmitted to the rest of human society - something that does not perturb the psychotic patient, however, as he considers it as confirmation that he is indeed superior: the world remains in the dark while he is enlightened.

Many innovations in the contemporary psychoanalytic movement will, in my opinion, help us better understand the psychodynamics of the psychotic process; among these, as mentioned earlier, the broadening of the concept of the unconscious is surely positive.

Bion is certainly among the forerunners of this direction of research: in his theorizing, the unconscious loses its ontic meaning of place - that is, a space where the repressed is deposited - and it becomes a function of the mind. In Bionian thought, there is no longer that clear contrast between conscious and unconscious, but relationships between objects and functions, links between them intuitable but remaining outside awareness; the dream is not only the product of repression, but also a function that fashions and registers emotions, a daytime activity that is ever present. The unconscious is a metaboliser of psychic experiences that allows the mind to produce thoughts.

An unconscious exists that communicates and understands the meaning of experience: that is, a function of awareness (of external and internal reality, the emotional field, body perception, time and space) that is outside awareness and which becomes altered in psychosis. We still do not know what the processes are that blend individual consciousness, nor do we know how they operate, but we do know that in the psychotic process they become altered; I touched on these processes when writing on the sensory transformation of mental functions, something that can probably be equated with a primordial function of the mind that is yet to be connected to intersubjective reality.

On this subject, we must not forget that consciousness and awareness, at times considered as superimposable concepts, are different processes. A patient may be conscious but unaware, in that, as Bion stated, there are thoughts with no thinker; the psychotic patient, for instance, is conscious of the delusional experience but unaware of what it means.

In psychotic states, thoughts are without a thinker because the Ego has undergone fragmentation. Francesco did not use his mind to think, but to produce a flow of sensory images to the detriment of the thought function. We shall probably understand the mystery of psychosis when scientific thought (psychoanalytic, neuroscientific, cognitivist) has thoroughly investigated the immense territory of the mind’s processes that lies outside awareness, including the construction of thought, territory that was dealt with for the first time by Sigmund Freud who, like Columbus, believed he had arrived in the Indies when what he had actually discovered was a new, endless world yet to be explored.

Another recent achievement of psychoanalysis that can help us understand psychosis in greater depth is new knowledge on child development. We have confirmed the idea that children are born with innate relating abilities and that they acquire communicative and intentional behaviour early on: important messages are communicated between parents and infants when the newborn is only a matter of days old, and they contain all the characteristics of real dialogue, except for the fact that, needless to say, newborns are not equipped with speech. Some analysts, inspired by attachment theory and findings from infant research, have proposed a conception of the mind that is structured according to unconscious organising principles that form in infancy and remain unchanged. The relational and intersubjective contribution to psychoanalysis has brought into the foreground a conception of development immersed in an intersubjective relational matrix. All these openings have seen Freud’s drive model move away from the spotlight while attention has shifted onto models focused on psychological and emotional development and on the reciprocal relationship with the mother. Unfortunately, these openings have not entered clinical work with severe patients in an organised fashion and therefore have not brought about - at least, not yet - substantial enrichment to our knowledge of the psychopathology of psychosis.

A significant contribution has come from neuroscience. Mark Solms and Jack Panksepp (2012) have worked above all on the limbic emotional brain, which communicates with the prefrontal cortex where cognitive and executive functions are located. On this subject, out of the abundant data available, in Chapter 71 have summarised interesting research on hallucinations that are produced when higher cortical functions are inhibited and no longer control the sensory brain regions. I am convinced that neuroscience will provide further knowledge that will help us understand the neuropathology of the delirious experience.

On a final note, we may say that research at a clinical psychopathological and neurobiological level on psychosis is set to continue. At an international level, we can find a number of study groups organised by psychoanalysts on psychosis, several of which are the Association for Psychoanalytic Psychotherapy in the Public Health Sector in England; the Centre Evelyne et Jean Kestenberg in the 13th Arrondissement in Paris; the Turku Schizophrenia Project in Scandinavia, headed by Yrjo Alanen; the International Society for the Psychological Treatments of Schizophrenia and Other Psychoses and the Center for the Advanced Study of the Psychoses, both in San Francisco; and the International Society for Psychological and Social Approaches to Psychosis (ISPS), with its headquarters in New York, which promotes psychological treatment for psychotic patients.

As stated earlier, it seems clear that following the significant development of analytic theory on psychosis, which I sought to describe in the first few chapters, no corresponding advancement has been witnessed in clinical practice. After the initial enthusiasm, it appears that the development of analytic theory on psychosis came to a halt due largely to difficulty in grasping the nature of the illness and the complexity of its process.

Psychoanalytic research on the clinical front could benefit from an organised method permitting comparisons between homogeneous clinical cases with regard to symptomatology and development; what tends to happen today is that each author reports cases that are different, are at different points along development and start from different genetic hypotheses. This is why I decided to provide an extended account of Francesco’s case as it contains several aspects that are common and specific to the psychotic process. In particular, I focused on the delirious experience, on the communicative function of some psychotic dreams and on the patient's extreme identity fragility, his functioning before the crisis seemingly that of a healthy personality that was, in fact, falsified. It was important to identify the direct link between the patient’s childhood and the explosion of the psychotic crisis.

I hope that I have been able to convey some core points in the study of the psychotic illness through simple and precise concepts that, despite the extreme variability of the illness, underpin this process. I sincerely believe that, in order to come to grips with psychosis, several clear core reference points are needed.

I would lastly like to express my gratitude to Francesco, from whom I have learnt so much and whose tenaciousness and determination were fundamental to the positive outcome of the therapy.

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