Currently, I’m making my way through Robert Whitaker’s Mad in America, which documents the treatment of psychotic individuals in America over the last three centuries. What is so startling is about the history of the treatment of psychotic individuals is how intent psychiatry has been on avoiding everything but psychological therapy as a means of treatment. For instance, we have tried the following bizarre and violent interventions: spinning chairs, hydrotherapy, lobotomies, dental surgery, electroshock, sterilization, bloodletting, insulin-treatments and neuroleptics. It seems important to consider why psychiatry has avoided speaking with psychotic individuals about their experiences. One of the major assumptions must be that psychotic speech is not true. From this perspective, psychosis does not reveal anything of relevance about the individual’s mind and their “symptoms” are absolute nonsense. Or, perhaps they will grant us that the “content” of the hallucinations or delusions might be relevant to the individual’s history but ultimately less important than addressing psychosis with a biological or medical intervention.
Harry Stack Sullivan, the radical psychoanalytic psychiatrist, wrote this in 1940 in his critique of electroshock therapy:
“These sundry procedures, to my way of thinking, produce “beneficial” results by reducing the patient’s capacity for being human. The philosophy is something to the effect that it is better to be a contented imbecile than a schizophrenic. If it were not for the fact that schizophrenics can and do recover; and that some extraordinarily gifted and, therefore, socially significant people suffer schizophrenic episodes, I would not feel so bitter about the therapeutic situation in general and the decortication treatments in particular.” (Whitaker, Mad in America, 98-99).
Sullivan was famous for saying that “we are all more human than otherwise”. Despite the fact that society wants to marginalize and trivialize individuals who experience psychosis, Sullivan recognized that the struggles of psychotic individuals are similar to the issues with which we all contend. His interpersonal therapy focused on the relationship the clinician formed with the psychotic individual.
This leads me back to the question of psychosis and truth. There seems to be two competing psychoanalytic ways to understand psychosis. First, we have the notion that psychosis is a defense, an attempt by the patient to avoid some truth that is emotionally unbearable. Psychosis affords the individual the opportunity to avoid addressing this traumatic kernel of their experience and is a violent defense to ignore this painful reality. I think that this is particularly useful when working with psychotic individuals who have histories of trauma. For instance, adult survivors of childhood sexual abuse and physical abuse commonly experience psychotic symptoms such as auditory hallucinations (particularly command hallucinations) and paranoia. In these cases, psychosis does provide a way to seal over the reality of the traumatic experience. Another way of understanding psychosis is that the individual’s “repression” barrier between the conscious and unconscious parts of the mind is too permeable. Primitive thoughts and wishes arising from the unconscious overwhelm the ego and are discharged and expressed in psychotic symptoms. For instance, I had a supervisor who told me that he once asked a psychotic patient to draw a picture of his family. This young man drew a picture of him having sex with his mother while stabbing his father. Clearly, the Oedipal fantasies and wishes are not sufficiently repressed and these generate overwhelming anxiety and lead to the creation of symptoms to distance the patient’s psychological proximity from their uncomfortable wishes. Hallucinations and paranoid delusions serve to locate these wishes outside of the patient’s mind and allow them to create space from their unconscious wishes and fears.
As someone who has a strong interest in the psychological treatment of individuals who have psychotic experiences, I have come to realize how scary it can be to work with these individuals. It is terrifying to bear witness to madness. Society tends to act in very paranoid and violent ways towards psychotic individuals because they terrify us. For example, the gun control debates have unfairly targeted psychotic individuals as if they are violent criminals we should lock up immediately. Well, the truth of the matter is that psychotic individuals are ten times as likely to be victims of crimes rather than victimizers. Currently more individuals diagnosed with schizophrenia are spending the night in jails rather than in hospitals in the US. Also, the rates of childhood mistreatment are staggeringly high in the histories of psychotic individuals. Moreover, “they” are generally terrified of “us”, and that’s not just paranoia. Let’s not forget that we often manipulate them into taking medication that can be dangerous. Antipsychotic medications prevent clarity of thoughts and restrict the individual’s affective range. The current overmedication of psychotic individuals in the US is incredible considering that only 1 out of 3 patients actually respond favorably to anti-psychotics. And, the medical side effects are pretty terrible. Bertram Karon, the psychoanalyst/psychologist, described schizophrenia as a “chronic terror syndrome”. These individuals are experiencing overwhelming anxiety and fear. They frequently have fears of being murdered or tortured. Yet, we’re scared of them. And we do everything in our power to not listen to what they have to say.
Working with psychotic individuals in psychotherapy can be extremely difficult and we are constantly tempted to trivialize or explain away their fears by claiming that their anxieties are simply the by-product of a brain disorder. I was recently speaking with a patient about his anxiety about speaking about psychotic experiences. He made the point that people don’t like to hear about these experiences, as they make others very fearful and uncomfortable. I think this is very much the case. Seeing someone who is having psychotic experiences stirs in “us” some of our deepest fears such as: loneliness, death, unintelligibility and helplessness. As someone who had decent success working with psychotic individuals in psychotherapy, I want to make a modest proposal on useful principles to keep in mind when working with psychotic individuals in psychotherapy:
1) Psychosis can be both a way to avoid truth and an expression of the truth of the unconscious. The clinician must hold both in tension while engaging in the work.
2) Genuine respect about these experiences helps to destigmaitze them and lowers the individual’s anxiety when speaking about psychosis.
3) Taking the psychotic individual seriously rather than infantilizing them provides them to opportunity to think differently about their mind. Demonstrating curiosity about how the patient began having these experiences and the symbols embedded in the symptoms invites the psychotic patient to take an interest in the cognitive and emotional antecedents of the symptoms. Moreover, it fosters the patient’s observing-ego capacities.
4) Creating an empathic relationship allows the patient to feel less alone, especially considering that society tells them to stay silent.
5) Expectations determine outcome. Psychologists and psychiatrists who have little to no hope that individuals with schizophrenia can recover drastically impact the patient’s hope in their ability to recover.
6) Medication is not a long-term solution. It should be used sparingly whenever the individual cannot tolerate the anxiety and pressure of psychosis. Medication often suppresses anxiety whose presence is absolute mandatory for psychotherapy. As Lacan said, “anxiety is the one affect that doesn’t lie”, and it is the clinician’s best friend.
I should also say that another reason we avoid conducting psychotherapy with psychotic individuals is because psychiatrists and psychologists tend to be pretty terrible at the work. It makes us feel incompetent and stupid. We have to tolerate the unknown which is frustrating and hard to manage. This leads most psychiatrists and psychologists to pretend that therapy is totally worthless and we blame the patients for our failures.