ISPS-US 6th Annual Symposium: “Extremes of Experience: Psychosis through Many Lenses”
September 18-19, 2004, Chicago, IL
Danielle Bergeron, MD, FRCPC, FAPA: Psychoanalytic treatment with the psychotic
Chris Burford, MD, MRCPsych: The place of psychosis in Freud's psychopathology
Richard Chessick, MD, PhD: Lucia Joyce, Schizophrenia, Nora Barnacle, Stephen Dedalus, Leopold, Milly, and Molly Bloom, Dreaming, Humphrey Chimpden Earwicker, Isabel, Shaun, Shem, Anna Livia Plurabelle and the River Liffey: James Joyce’s Dublin Phantasmagoria
Martin Cosgro, PhD: Effective Interventions with Derogatory Voices
Françoise Davoine, PhD: Plenary I:Toward a Subject of History
Daniel Dorman, MD: Plenary III: Dante's Cure: A Journey Out of Madness
Elizabeth Faulconer, MD: God’s Silent Creatures: Finding Common Ground
Jean-Max Gaudillière, PhD: Plenary I: Toward a Subject of History
Patricia Gibbs, PhD: The Struggle to Know What is Real
Yulia Landa, PsyD: Group CBT for Residual Delusions and Hallucinations
Nels Kurt Langsten, MD: Piaget Revisited: An Integrated Biopsychosocial Theory of Development
Revella Levin, PhD: Problems Leading to the Burning Out of the Therapist
Catherine L. Penney, RN: Plenary III: Dante's Cure: A Journey Out of Madness
Gertrude Pollitt, DPsa: Melanie Klein’s Contribution to Psychoanalysis and Early Childhood Development
Garry Prouty, DSc: Evolving Beyond Carl Rogers: The Treatment of Chronic Psychotic Regression
Jorge Schneider, MD: Bion's model of psychosis (reading seminar)!
Steven M. Silverstein, PhD: Integrating Psychotherapy for Schizophrenia within a Behavioral Treatment Milieu
Charles Turk, MD: Having Faith in Psychoanalysis
Toby Tyler Watson, PsyD: Nonsense Understood: Creating Meaning Through Empathy & Believing in the Self
Danielle Bergeron, MD, FRCPC, FAPA–Quebec, Canada
How can the psychotic, whom the psychiatrists say "does not speak" or speaks in an incomprehensible way that defies understanding, be treated by psychoanalysis? How can the disorganized schizophrenic be given a chance to engage in psychoanalytic work that restores him as the subject of his own words and enables him to take his place among others and live as a citizen in a society?
Our presentation will demonstrate the clinical strategies that we developed over the years, in our work with psychotic young adults at our psychoanalytic treatment center in Quebec City, known as "388." Our work brings the power of everyday language to the schizophrenic, who until then had spent his life enacting how a cruel and demanding imaginary Being dominated his life.
To exemplify this, we will present the case of Mark. When he first came to us, his voices dictated a "mad writing" that he slavishly recorded. During analytic treatment this writing was transformed into a collection of poetry and short stories that eventually came to be published. This achievement testifies to his having acquired a new relation to language.
Chris Burford, MD, MRCPsych–London,England
Freud's joint psychological study of Woodrow Wilson, published many years after his death by his co-author William Bullitt has been controversial except for the authenticity of Freud's introduction. It is intended to compare some of the passing references to psychosis, which may date from 1930 to the extent to which they are authentic, with formulations on psychosis in Freud's Outline of Psychoanalysis, which was completed in 1938/9 [??]. It is intended to leave a significant proportion of the presentation time for discussion about the overall place of psychosis in Freud's perspectives on psychopathology.
Lucia Joyce, Schizophrenia, Nora Barnacle, Stephen Dedalus, Leopold, Milly, and Molly Bloom, Dreaming, Humphrey Chimpden Earwicker, Isabel, Shaun, Shem, Anna Livia Plurabelle and the River Liffey: James Joyce’s Dublin Phantasmagoria
I begin by comparing the Dublin of Joyce's book " Ulysses" in 1904 with Dublin today, illustrating how under stress the city deteriorates, civility is lost, and psychopathology emerges. Joyce believed if you understand the core of a city you understand the core of Everyman.
I then trace the development of psychopathology from John Joyce to James Joyce to Lucia Joyce, concentrating eventually on the psychodynamics of Joyce's relationship to and the ultimate schizophrenic collapse of Lucia. The use of Lucia as part of Joyce's Dublin phantasmagoria is emphasized. I hope to illustrate how there is a parallel between the deterioration of Dublin and the deterioration of Lucia Joyce, consistent with Joyce's thinking about cities. I conclude by discussing the crucial issue of the capacity of people of creative genius to wall off their psychopathology or conversely to be invaded by it, using John Joyce, James Joyce and Lucia Joyce as examples.
Martin Cosgro, PhD–San Luis Obispo, CA
Techniques, guided by theory and illustrated through case material will be presented.
Katerina Daniel–Pittsburgh, PA
This paper examines some of the issues involved in developing research strategies and theoretical formulations that are robust enough to attend to the experience of psychotic patients. Social phenomenology may be helpful because it seeks to understand the experience of others beyond the dichotomies of the inner vs. outer, experience vs. behavior, and individual vs. others. The strength of the Lacanian psychoanalytic approach is that it emphasizes the ways in which psychotics relate to the symbolic register and construct meaning towards themselves and others. Working toward a rapprochement between these two approaches may help to generate more meaningful information about the psychotic experience, and, as therapists, to intervene more effectively.
Following Merleau-Ponty and Laing, the self is always engaged in the world and interdependent on others. Unlike the Cartesian views, we are not constituted as a deep-seated self or agents of a series of states of consciousness and thoughts, but rather as agents always in dialogue with the world. For R.D. Laing (1961), the schizophrenic patient is known as the ontologically insecure person who feels disembodied, perceives the world and his own body in a profoundly distorted way, and fears a “real dialectical relationship with real live people” (p. 80). For Lacan, psychosis is due to the unsuccessful establishment of the ego-ideal, the predominance of the imaginary, and the inability to use the structure of language the way neurotics can (Fink, 1997).
Integrating social phenomenology and psychoanalysis, we avoid the assumptions that the experiences of the schizophrenic can be analyzed adequately in terms of the genetic, biochemical, and environmental variables and, consequently, reduce the schizophrenic to the status of a mechanical system. Instead, these two approaches help us to understand therapy with schizophrenics as an attempt to both reveal and create a meaningful human existence and co-existence with others as well as an attempt to provide kind interpretations that would help patients to reiterate the symbolic register and understand the surrounding world in a relatively stable and enduring way.
Fink, B. (1997). A Clinical Introduction to Lacanian Psychoanalysis. Massachusetts: HarvardUniversity Press.
Laing, R.D. (1961). Self and Others. Penguin Books.
Françoise Davoine, PhD andJean-Max Gaudillière, PhD–Paris, France
We will present two papers successively, each of about half an hour. This summary however, as a proposal, intends to frame our general topic for this presentation.
Through clinical vignettes of critical moments of the therapy which lead to successful outcomes of the psychoanalytical treatment with severe cases labeled schizophrenia, bipolar, borderline, etc…, we will stress the consequences of the foreclosure of History in classical psychoanalysis, this issue challenging both patient and analyst.
We will present our bearings through our own Lacanian background, and discuss how we use it and question it, against the stereotypes which reduce and freeze the field of research opened by the patients. Our common target consists of getting out from objectifying structures, irreversible foreclosure, belittling descriptions of the actual work of the patient in the transference. The psychodynamic orientation leads us to use the very criticism issued by the patients, regarding both techniques and theories. In that respect the psychotic transference is considered as a co-research in the field of socio-historical catastrophes, at whatever scale.
We will show how an historical narrative is issued at the intersection of frozen temporalities in the patient’s fragmented history and the analyst’s own story. These specific encounters occur during a few sessions, very recognizable, which can be commonly validated afterwards as turning points, by patients and colleagues, with the same simple words.
Clinically, this field is the same as the field of trauma. As the title of this meeting emphasizes, this is the field of the extremes of experience in the social bond, where one encounters the unspeakable and the unimaginable, in an attempt to create the agency of Otherness, where it was impossible. This is the very definition of the domain of the Réel by Lacan. As he never theorized the transference with psychosis, this symposium represents for us a good opportunity to tackle these specific issues: the creation of the Subject of History (cf. Freud’s Moses); the inscription of a cut out unconscious (versus the repressed unconscious); which “Other” is implied in such a catastrophic process and its eventual positive outcome, producing a new potentiality for expectancy.
Participants will be introduced to the key lacanian concepts regarding psychosis. The presentation will also proceed through a necessary criticism of the static use and conception of psychosis. The clinical experience with such patients conveys a common field of research, where we meet European and American pioneers in the psychoanalysis of psychosis: W.R.Bion, Frieda Fromm-Reichmann, Harold Searles, Gaetano Benedetti, etc… This co-research led by patient and analyst is currently crossing other fields of sciences: History, Literature, Sociology, etc…
Max Day, MD–Newton Center, MA
"Group therapy with paranoid people in office practice." Such a group of people is obviously selected by nature of their ability to hold on to reality, despite their delusional systems. The groups were not pure cultures of paranoid people. They were treated in groups with mixed diagnoses and character problems. Usually they worry and rile up the therapist by means of their delusions, which is merely a cover story for the misery of their lives. Freud (1911) first identified it as a form of contradiction and this was later elaborated by Rycroft (1959). Their tendency to project worries everybody. In addition they have an intolerance for closeness in the form of warmth, disappointment or anger, in other words almost the gamut of human emotions. Nevertheless with some of them, with luck and a felicitous mix of other patients, who with the therapist's support can tolerate such people, they can somehow attach themselves in a distant way to the therapist and at least to one other person in the group. Then they may safely relax enough to either pour out their tale of current woe and some of the psychogenetic background and woe that led to this kind of character structure and this kind of problem. Then they may recompensate, do some of the psychogenetic work and go their own way. If the patient attaches himself to only the leader or only to one other member, there is little likelihood that they may do the kind of work that has to be done.
Day, Max and Elvin Semrad. 1978. Paranoia and ParanoidStates. In, A. Nicholi ed., "Harvard Guide to Modern Psychiatry", pp. 243-252. Belknap Press: Cambridge.
Freud, Sigmund. 1958. Psycho-analytic Notes on an Autobiographical Account of a Case of Paranoia (Dementia Paranoides). Hogarth Press: London, S.E., XII, 1-82 (1911).
Glover, Edward. 1932. A Psycho-analytic Approach to the Classification of Mental Disorder. Journal of Mental Science 78:819-842.
Rycroft, Charles. 1959. Miss Y: the Analysis of a Paranoid Personality in "Psycho-analysis and Beyond". University of Chicago Press: Chicago.
Daniel Dorman, MD–Beverly Hills, CA
Catherine L. Penney, RN–Morongo Valley, CA
Plenary III: Dante's Cure: A Journey Out of Madness
Dante's Cure: A Journey Out of Madness, published in 2004 by Other Press, describes the successful psychotherapy of a severely schizophrenic young woman. No medications were used. The therapist acts as a guide, which is defined as helping his patient understand the context of his experience by representing (interpreting) both internal and external reality, mostly in the here-and-now. Change in the psychotherapy of schizophrenia is the gradual superseding of primitive perceptions and adaptations to that state by more reality-based (more abstract) adult thinking and feeling. Treatment lasted 8 years, 3 1⁄2 of which were in-hospital. It has now been 26 years post-treatment. The patient, Ms. Catherine Penney, lives a rich and full life. Dr. Dorman and Ms. Penney will discuss Ms. Penney's treatment from their respective points of view.
Elizabeth Faulconer, MD–Chicago, IL
How to pursue psychotherapy with a silent patient has been the subject of several papers. Glenn Gabbard, Harold Searles, Thomas Ogden, and Dr. Purdy, among others, have written about how to make therapeutic sense out of a silent patient’s refusal to participate in psychotherapy. The idea of using one’s own experience of the patient’s projections to begin to understand and to find a method to explore the meaning of the silence proved helpful in the case that I present here. In this case, from Chestnut Lodge, I plan to show the use of the wildlife on the hospital grounds as displacements for projections as a safe transition to the patient himself and to his health. He had made it clear to me from the outset that God was his best friend, that he was not interested in the human world, and that he did not need me.
I discuss how the therapeutic relationship developed with a schizophrenic patient, how we tolerated and used the silence, and how we eventually were able to deal with his severe physical problems, including cancer, in a realistic way. I discuss how I was able to make use of my counter-transference reactions to understand what the patient was sharing with me. The patient made progress.
Patricia Gibbs, PhD–Dearborn, MI
The paper is about my work with a regressed patient over a decade. The paper focuses on the patient’s struggle to know what is real, and her struggle to distinguish real from not real, especially in terms of object relations (is this a good person for me, and a trustworthy person, or not?), and in terms of establishing right vs. wrong. I understood her development in the transference to involve her slow internalization of affect regulation that allowed her to eventually mourn, as she worked through the massive depression she had used to avoid losing her symbiotic relatedness to me/mother. As this happened, there was more of a capacity to judge right from wrong, and as her superego developed, she experienced more guilt. I also discuss how I weathered the patient’s murderous rage, and how my analysis of her was somewhat influenced by my unconscious identification with those who had trained me, who saw this patient as unanalyzable.
This is a lengthy paper, which has been accepted for publication by The Psychoanalytic Review. (tentatively to be in print November 2004.) In terms of compressing it into a 25 minute presentation, I would probably present clinical material that centers on the murderous rage in the transference/countertransference, as tolerating this was one of the case’s greatest challenges. I may also include relevant material from another case not included in the paper, and focus on the “living death” both patients dealt with as they slowly came to terms with the trauma and hatred comprising each of their internal worlds.
Joanne Greenberg, DLH –Golden, CO
Mimi Neathery, MA–Chicago, IL
Utilizing the case of Joanne Greenberg, this paper shows how the theoretical framework of contemporary relational psychoanalytic theory can be applied to the treatment of schizophrenia in terms of attachment. In this paper, I explain Frieda Fromm-Reichman’s analysis of Joanne Greenberg from the Contemporary Kleinian framework and show how the attachment between them was the key element to Greenberg’s successful recovery. This paper includes an interview with Greenberg regarding her analysis with Fromm-Reichman as well as a theoretical analysis of her novel, I Never Promised You a Rose Garden.
Sullivan (1962), Fromm-Reichman (1960), and Karon (1981) are just a few examples of psychotherapists who have successfully applied psychoanalytic therapy to the treatment of schizophrenia. One of the primary reasons for its success is the formation of a relationship between patient and therapist. Bowlby (1988a) interprets this relationship as a secure base from which the patient can explore the unconscious. Since Bowlby (1969) primarily examined the external behaviors related to forming attachments, attachment theory as interpreted by Mitchell (1988, 1997) is utilized in this paper. The case of Greenberg was selected because her successful recovery from psychosis stemmed from psychoanalytic interventions rather than pharmaceutical treatments. Because schizophrenia has been successfully treated from a psychoanalytic approach and is thought to be an illness stemming from interpersonal relationships, this paper utilizes the theoretical concepts mentioned in this abstract to show how attachment influences the development and treatment of schizophrenia and how the defensive processes and subjective experiences of attachment influence the meaning and perceptions of these attachments.
Yulia Landa, PsyD–White Plains, NY
Steven M Silverstein, PhD–Chicago, IL
Promising findings from recent studies in the United Kingdom show that individual Cognitive Behavior Therapy (CBT) can be useful for the treatment of drug resistant psychotic symptoms. Group CBT allows for a combination of CBT techniques and psycho-education, and has been found to be effective in addressing cognitive distortions in such conditions as Borderline Personality Disorders, Social Anxiety, and Depression. These data suggest that additional studies of group CBT for residual psychosis are warranted. We conducted a study of the effectiveness of group CBT for residual positive symptoms in patients with schizophrenia and schizoaffective disorder. Outcome measures included: Characteristics of Delusions Rating Scale; Topography of Voices Rating Scale; Psychotic Symptom Rating Scales. At baseline all admitted to the group patients (N=6) reported auditory hallucinations and delusions of various types, including: persecution, external control (passivity), grandiosity, mind reading, and religious themes. After 13 sessions there was a significant reductions in delusional conviction, unhappiness associated with thinking about a delusion, intensity of distress associated with delusion, and an increase in ability to dismiss a delusional thought. We also observed a significant decrease in the frequency of AH and a number of voices. We found that the group format was beneficial since it allowed patients to share their experiences and beliefs, thereby eliminating shame and providing support and coping strategies; as well as it allowed for peer-peer discussion of irrationalities and inconsistencies in each other beliefs, which weakened delusional conviction.
Nels Kurt Langsten, MD–St. Paul, MN
This paper is a review of the work of Jean Piaget. His writings provide a biological theory of human development which integrates neurological and psychological functioning and sheds light on the preverbal period of mental development essential to understanding psychotic symptoms. His work provides the framework for a biopsychsocial theory of development from the reflex behavior of a newborn, through the preverbal sensory-motor stages of early infancy, to the development of symbolic and representational thought, the acquisition of language, and the development of social and moral values.
The paper begins with a discussion of Piaget's basic thinking about the functional continuity of mental processes with physical biological processes, the relationship between mental and physical organization, his view of intelligence as a form of adaptation, defined as an equilibrium between assimilation of the environment by the organism and accommodation of the organism to the environment.
The paper goes on to describe how Piaget used this theory and the concept of schemata to understand the psychological aspects of infantile behavior with theoretically informed, carefully documented observations of his children's behavior as it changed hour by hour, day by day.
The core of the paper is a discussion of the importance of Piaget's theoretical contribution to our understanding of the development of our perceptions (conceptual and emotional) of self and other (the world). This contribution has been relatively ignored by neuropsychological researchers, including psychoanalytically informed developmental researchers like Daniel Stern. We cannot understand disturbances in perceptions of self and other unless we first understand how these perceptions develop normally. It is the preverbal period of development which is most important to our understanding of psychotic persons. This is the period most opaque to our analytic lenses. It is the period which Piaget's work illuminates most brightly.
Revella Levin, PhD–Elmhurst, NY
I became interested in this problem several years ago because although I have been treating schizophrenic children and adults since I was 27 and am now a senior citizen, burn out is a foreign concept to me. However, I met several therapists for whom it was a problem. It aroused my curiosity just because it seemed foreign to my own experience.
I recall that when I was in graduate school, an experienced therapist asked me what I wanted to do when I got out of school. (He was someone who worked for Loretta Bender.) I said I wanted to work with schizophrenic children. To my great surprise, his response was, "you'll get over it." I'm still waiting. Of course, in those days there were no anti-psychotic drugs.
It occurs to me that that might be one of the reasons that therapists burn out. They seldom get to see what I call naked schizophrenia. The picture, is so to speak, muddy. But I was fortunate. I got to see the illness in its "pure" form. I have always found that pure form fascinating.
But I think there is something else that may be connected with the problem. In speaking with a colleague recently, we spoke of the effect of medication on therapy. She said that while she could work with patients who were on medication, she had no trouble working with patients who were not medicated. I added that while it was possible to work with such patients, one could not work so well, because the patient could not hear one so well, nor did the therapist see the nuances of the pathology as well. My colleague agreed, saying that some therapists had no tolerance for extremes of emotion. I agreed saying this was especially true in reference to hostility.
I am not saying I have a cure for burn out as of this writing. But I do want to explore issues that I believe are tangential to it.
Paul Lysaker, PhD–Indianapolis, IN
Personal narratives are the stories people tell to themselves and others to place daily experiences in context and make "meaning" of them. They connect past to future, bringing together remembered and felt experience, lending coherence and structure to the foundations of identity. In schizophrenia, however, personal narratives often appear to have lost their synthetic power. Persons with schizophrenia may experience difficulty placing themselves as active agents within their narratives and may experience difficulties with metacognition or "thinking about thinking." While difficulties with narrative coherence and metacognition are commonly targets for individual psychotherapy less is known about the natural history of changes in these domains over time. To examine this issue transcripts from 33 months of individual psychotherapy of a 50 year old male with schizophrenia were presented in random order to a trained rater who was blind to the date of the transcript. The rater rated each transcript on narrative coherence using the Narrative Coherence Rating Scale and metacognition using the Metacognition Assessment Scale. Results suggest significant linear trends with metacognition and narrative both increasing in a linear fashion over time (r = .65 p , .0001; r =.67 p < .0001). Exploratory analyses suggest that changes in metacognition may prefigure improvements in narrative coherence. Implications for conceptualizing outcome and process of individual psychotherapy for schizophrenia are discussed.
Clancy McKenzie,MD–Bala Cynwyd, PA
A major mechanism that accounts for the psychodynamics of psychosis has been overlooked. This mechanism is backed by hard data on 6,000 schizophrenics in the Finnish database and 2,669 in the Danish cohort.
The mechanism is delayed posttraumatic stress disorders from infancy. It is similar to delayed PTSD from combat. Physical or emotional separation from the mother is as overwhelming to the infant as war trauma to a soldier, because for 150 million years, early mammalian separation meant death.
Then 10-20-30 years later, instead of a loud noise precipitating the flashback, it is a similar separation, from some other “most important person” or group, which precipitates the initial step back in time – and instead of combat reality and behavior, it is infant reality and behavior that we see.
A parallel shift to earlier brain reactivates the regions that produce more dopamine etc., and a corresponding shift of activity away from higher cortical centers results in disuse atrophy. Thus biological change largely is the result of the psychological process.
The original trauma is the precursor of the precursors of schizophrenia, and the age when it occurs is symptom-defining, because clinically it is easy to determine the age the symptom-defining trauma occurred – based on age-of-origin specific reality, feelings, behavior, body movements and level of affective expression.
Negative symptoms and precursors of schizophrenia represent an attempt to suppress and repress the original trauma and all that it becomes in the unconscious mind.
Gertrude Pollitt, DPsa–Highland Park, IL
Melanie Klein, the originator of the object relations theory will be discussed in this paper, using a historical perspective. One of the foci will be on the Controversial Debate between Melanie Klein and Anna Freud, which resulted in a break up of the psychoanalytic schools in England; the British School of Psychoanalysis and the Vienna School of Psychoanalysis. Klein focused on the treatment of young children. She developed a new methodology of play therapy which we today take for granted. Her developmental concepts of the infant’s early awareness to reality, the schizoid paranoid position and the depressive position are one of her great contributions. Klein developed new concepts of transference and counter-transference in children and the mechanisms of defense, i.e. splitting, projective identification, and introjection and projection. She forged her concepts with a great conviction in spite of the adverse situation she found herself in and the bickering that ensued within the psychoanalytic circles. Her theories prevailed, although somewhat modified by the new Kleinian circle, her contributions to psychoanalysis are monumental.
Garry Prouty, DSc–Tinley Park, IL
Carl Rogers was a pioneer in the quantitative exploration of the psychotherapy of schizophrenia. His relationship approach concerned the application of "core attitudes"--empathy, unconditional positive regard and congruence. Research provided limited support for his view. The first or "pre" condition of a therapeutic relationship according to Rogers is Psychological Contact; but, he failed to describe clinical or quantitative operational definitions. Pre-Therapy is a clinical and quantitative theory of psychological contact.
The theory is structured in three parts. Contact Reflections- the work the therapist does. Contact Functions- The psychological process of the client. Contact Behaviors- Behaviors measured for research. Emerging from the practice and research in Pre-Therapy is the meta-theoretical concept of the Pre-Expressive Self. Pre-Therapy is the facilitation of a pre-expressive state to a full expressive state; thereby making psychotherapy accessible. This paper will provide clinical case material as well as quantitative verification for the concept of psychological contact.
Jorge Schneider, MD–Chicago, IL
Bion’s Model of psychosis (Reading seminar)
Steven M Silverstein, PhD–Chicago, IL
Integrating Psychotherapy for Schizophrenia within a Behavioral Treatment Milieu
Psychotherapy is rarely practiced on behavioral treatment units for people with chronic schizophrenia. It is possible, however, for outward behavior to change without accompanying changes in symptomatology or phenomenology. This presentation will discuss such issues, as they emerged in the psychotherapy of a "treatment-refractory" schizophrenia patient on a nationally recognized, long-term, inpatient behavioral rehabilitation program. The patient was quickly able to learn the rules of the token economy, and quickly demonstrated reductions in delusional speech and inappropriate behavior. However, the intensity of his delusional beliefs (his primary symptom) was not affected by the behavioral program, where discussing the content of his beliefs in public was penalized. Initial attempts at cognitive-behavioral therapy were unsuccessful as the patient refused to consider the possibility that his beliefs could be untrue or problematic. Subsequent individual psychotherapy with this patient was conceptualized largely from within a self-psychological perspective, and the Jungian technique of amplification was used as an entrée to normalize and explore the personal meanings of his delusional beliefs and the anomalous experiences on which they were based. After 4 months of twice weekly therapy, the patient was discharged from hospital, and has remained in the community for over two years without a relapse. Issues related to this patient's conceptualization and therapy, in addition to the dilemmas faced when conducting exploratory treatment within a behavioral milieu will be discussed.
Against the current prevailing ideology, this presentation is an argument in favor of psychoanalysis as the treatment of choice for the psychotic patient. Certainly, as in this case, such work promotes the expansion of delusional thought, but if the crisis ensuing from the patient’s questioning of the delusion can be negotiated, its contents provide the material for emancipatory work.
This presentation demonstrates how sustained faith in the psychoanalytic method sustained a woman named Faith and enabled her to rid herself of the voices that had plagued her with persecutory and erotic messages for decades. Certain families name their offspring after ideal qualities of character, and so I chose a pseudonym close enough to her actual name to capture an important assonance. Both her self-absorbed mother and her physically abusive sister frequently called her “Fay” Faith took this to mean that they wanted her to “fading away.”
This was emblematic of her inability to find a place within her family – and provoked vulnerabilities that led to an acute psychotic breakdown in her twenties. Now in her sixties Faith eventually engaged in psychoanalytic treatment, that first precipitated a crisis attendant upon an initial breach in delusional certainty, and this led to at last “own her illness.” that is, to recognize as delusion what she had long held to be “the way the world was.”
In the next phase the waning of voices produced a crisis where strongly persecutory voices led to a return of suicidal impulses that she had not experienced in twenty years. After two suicide attempts, a benign voice emerged that told her that her cherished thoughts were “crazy.” Faith was able to describe the link between our work and the benevolent voice that now advised her, “You’ve got to stop thinking that all that is true.”
Wilfried Ver Eecke, PhD–Washington, DC
In this paper I want to start an alternative theory of schizophrenia, alternative to the philosophy behind the Practice Guideline for the Treatment of Patients with Schizophrenia.
I want to start by affirming a theory of truth developed by Heidegger but already implicit in Hegel. Truth as revelation of the richness of reality is always partial. Even stronger, all truth as revelation of reality also hides aspects of that reality. If one is not aware of the perspectival nature of truth then one unavoidably goes in the direction of making errors, even grave errors.
Human beings do have a body and that includes a brain. The body and the brain can be defective. However, the human body and its brain is a dynamic reality. The human body and its brain try to perform as best it can the functions it is called to perform.
A human being is destined to perform communication with other human beings. This is an emergent property. An emergent property makes use of the body and the brain and thereby changes that body and its brain. If that emergent property is not exercised then the body and the brain loose the ability to elegantly provide the basis for that emergent property.
Rene Spitz provides a basis for my thinking. He argues that there is development in the child and that such development is not linear. Rather, the development occurs in spurts. These spurts happen when a specific plateau of development has been reached. Spitz names three such plateaus revealed by three indicators: the social smile (emerging statistically around three months of age); stranger anxiety at about eight months of age; and saying no around fifteen months. Deficiencies in each of the plateaus is a bad omen for the future of the child.
The early Lacan can be used to provide a similar way of thinking about the origin of schizophrenia. Commenting upon Freud’s analysis of Judge Schreber, Lacan argues that the crucial deficiency of a person afflicted with schizophrenia is a linguistic deficiency. In the beautiful article on “THE LANGUAGE OF SCHIZOPHRENIA AND THE WORLD OF DELUSION” Michael Robbins demonstrates that some people afflicted with schizophrenia profess to refuse the translation of schizophrenese into normal language. Lacan argues that the pain of the Oedipus complex is necessary for human beings to be able to use normal language. Lacan claims that the pain of the Oedipus complex-called castration in psychoanalysis– includes the acceptance of finitude, of death and incest prohibition. To be willing and to be able to speak requires the acceptance of these painful moments. Lacan refers to this complex of phenomena as the symbolic.
Antoine Vergote and his students revisit Lacan’s study of Judge Schreber and point out that persons afflicted with schizophrenia have also an additional deficiency: they have a defective unconscious relation to their body. For developing a proper relation to the body the child relies upon a maternal figure. Mirroring plays an important role. Here one can see an overlap between Lacan and object relations theoreticians (Winnicott in particular). Lacan refers to the mother- child relationship as being mainly imaginary.
With the help of Vergote’s correction to the theory of Lacan we can then claim that human beings must have the benefit of both a properly presented imaginary and symbolic dimension.
I have analyzed extensively three successful therapy methods of persons afflicted with schizophrenia: the methods of Bertram Karon, Palle Villemoes and Gary Prouty. These methods are quite different, but I have been able to discover that each of these therapists skillfully uses both imaginary and symbolic moves to help persons afflicted with schizophrenia. I intend to give examples of such skillful interventions.
I propose that such a view of schizophrenia is different from the one implied by the Practice Guideline for the Treatment of Patients with Schizophrenia. I will propose that this view is a forgotten and overlooked truth by the Practice Guideline. I will start enumerating the disadvantages of such an oversight.
Toby Tyler Watson, PsyD–Ingleside, IL
This presentation will describe the course of treatment of a 17-year-old Hispanic female living in a residential treatment center, and will describe how the relationship built between her and her doctor aided in the reduced need for strained reasoning. The Psychotic defensive maneuver of the mind for the management of fear, appropriation of the self (i.e. thoughts and feelings) and the management of feeling abandoned will be discussed. The therapy process, progress and what lead to the reduction in psychosis will be discussed from viewing a timeline of themes presented in psychotherapy (e.g. Safety, Remembering Trauma, Fear, Aggression, Intimidation and Threats, "Mr. Thiefy", "The Camera's", telephone connection, and finally "Dr. Tob" goodbye will be reviewed). Finally, conclusions will be drawn from the case presentation and interventions for future treatment shall be discussed.