As I was presenting my doctoral work at the International Society for Psychological and Social Approaches to Psychosis in Chicago a couple of weeks ago, we had an interesting discussion during the Q&A. In my paper, I shared my work of a two-year case study with a patient who was occasionally psychotic and I described a couple of uncanny experiences I had with the patient. My first experience occurred during one session when I was daydreaming about eating eggs once the session was completed. Instantly, the patient shifted the discussion to describe a new diet he was planning to begin. He reported that this new diet would require him to eat many eggs. Shaken from my reverie, I was baffled to hear the patient discuss eating the exact food that I had just been fantasizing about. The patient rarely described food and had never before mentioned eggs (this was around our 80th session together). Another instance happened when he was describing his religious beliefs and principles. During the conversation, he disclosed to me that he believes that I have an extensive religious background and that I know a lot about religion. I asked if he meant that I had some sort of pastoral background and he replied that I had simply studied religion on my own. His intuition was completely spot on although I had no idea how he discerned this about me. I never spoke about my religious background nor did I ever encourage him to talk about religious matters (except when he wanted to). During the Q&A, my professor described another uncanny experience when he was working at an inpatient hospital where both he and his wife used to work. One day a patient verbally attacked him and told him to go home and ‘fuck his wife already’. Unbeknownst to my professor, at that exact moment his wife was buying a pregnancy test, and it turned out that was she actually pregnant. My professor described that certain psychotic individuals have a ‘radar’ for understanding such matters.
Well how do we understand these experiences psychoanalytically? Psychosis is an experience that is related to the unconscious. Freud described the unconscious as operating with primary process thinking, which is the same logic that underlies psychotic processes. Moreover, in psychosis the repression barrier between id and ego is much more porous. Neurotics are notoriously defensive and they spend their entire life trying to avoid the terror of the unknown unconscious whereas psychotic individuals are often much more intimately acquainted with it. Perhaps this porous internal boundary (what Federn called the inner-ego boundary) allows these individuals to unconsciously detect the repressed and dissociated elements of the other person’s mind. Searles often spoke about the ways in which the therapist’s unconscious processes can drastically impact the psychotic individual. Searles reported that these individuals are much more susceptible to the other person’s unconscious and can in fact internalize those feelings and fantasies and express these through the creation of new symptoms. In analytic theory, we tend to think of psychotic individuals as constantly projecting internal impulses, wishes and fantasies into the outside world (e.g. paranoia) but Searles realized that they also are vulnerable to introject the unconscious processes of others. I also heard at the conference a quote that in almost every case of suicide one can find in that individual’s history a person who harbored deep and intense murderous fantasies towards that individual.
I don’t know if others have had similar experiences but I’ve found in my clinical work that working with psychotic individuals is the greatest proof of psychoanalytic theory.