ISPS-US 7th Annual Meeting: “The Validity of Experience”
November 11-13, 2005
Ignoring the Validity of Human Experience: How Can We Best Respond to The Tragic Consequences of an Anti-Analytic, Biological Approach to “Schizophrenia”?– Presenter: Daniel Kriegman, PhD; Discussants: George Atwood, PhD, Robert Whitaker
The validity of the psychoanalytical experience in the case of psychosis is, in our experience, evidence based after a few rough sessions, when “what cannot be said, but is shown” through the symptoms, reaches the level of speech and of metaphor. I will give short vignettes, taken from our practice, of the birth of the symbolic dimension out of areas of death (Benedetti). They eventually occur in the text of dreams, but also in shared and validated narratives, in the analytic setting and beyond. My major example will be taken from the validity of Aby Warburg’s transference with Binswanger. An historian of the art of Renaissance (1866-1929) A. Warburg became delusional during WWI. Confined in Binswanger’s clinic, he hollered, when Hitler was writing Mein Kampf, that the Jews were exterminated and that Binswanger was the chief perpetrator. Still, he went out of madness through a conference he gave about the Snake Dance among the Hopis, pronounced at Binswanger’s request in front of psychotic patients at Kreuzlingen in April 1923. Interesting for the site of our conference is the fact that this conference, tells us about his journey among the Pueblos Indians in 1895, in order to find among contemporary animist cultures, the missing link, between the art of Antiquity and of the Renaissance. A great number of the artifacts which he brought back at that time were given by him to the Peabody Anthropological Museum at Harvard. His teaching fits our findings and validates our psychoanalytical experience, which is by itself transcultural and transdisciplinary, with trauma and psychosis.
Manifest or consensus-reality definitions of advocacy work run parallel to latent or altered state definitions. This paper presents the campaigns of the survivor group Freedom Center, run by and for people diagnosed with severe mental illnesses, simultaneously as both a conventional narrative and as a result of navigating and negotiating fragmentary locations of self and other impinging from aspects of personality considered “psychotic” or “delusional.” Concrete hallucinations, documented ideas of reference, evidence-based energetic fields, the misidentified patient, and apocalyptic human rights will all be considered as we explore the conjunction of a “good enough” container for community reintegration and the retroflection of forsaken thought insurgency.
Three World Health Organization (WHO) studies show that prognosis and outcome for schizophrenia is better in “developing” than in “developed” countries. An ill-defined factor labeled “culture” is said to moderate illness course. Despite debate about the meaning of “developing” and “culture,” most analysts agree the discovered differential is real, not merely artifact. Some hypothesize that the prognosis differential results when cultural beliefs about the nature and meaning of mental illness mediate a status for patients that protects and includes them. Expressed emotion research draws a similar conclusion; predictors of schizophrenia relapse are less common in developing world families studied. An alternative hypothesis rests on outcome data gathered by the WHO itself but rarely analyzed as potentially causal. That is, persons diagnosed with schizophrenia in developing world research sites were far less exposed to neuroleptics than were subjects in Europe and the U.S.
As an occupational therapist and medical anthropologist, I have been affiliated with a psychiatric hospital in Zanzibar, Tanzania for 17 years. A dynamic amalgam of traditional spirit beliefs, Islamic orthodoxy and bio-medical ideology informs narratives of illness experience there. Using detailed patient and family narratives, observational data and psychiatric case records, I examine illness trajectories of five patients diagnosed with schizophrenia in light of hypotheses about identity and emotion, cultural beliefs and practices, and neuroleptic exposure. The meanings ascribed both to illness and its treatment are foregrounded.
The presenters have collected all the medical records documenting the patient’s psychiatric hospitalizations over a 40 year period. The results demonstrate the profound strengths and weaknesses in our models of mental illness and psychosis, raising significant questions about the validity of our current diagnostic and treatment systems. Despite numerous hospitalizations, medications, and diagnoses including schizophrenia, the patient’s resilience and perseverance resulted in her receiving a BA in Sociology, BSN in Nursing, and MPH in Public Health. As a registered nurse, her experience includes clinical, research, and health education activities. She also serves on various boards of mental health agencies. The presenters will discuss the helpful and damaging aspects of the patient’s treatments, and highlight the importance of trauma in the etiology of mental illness.
Dr. Semrad, fresh from the Second World War, where he had learned about group therapy, became Clinical Director at Boston State Hospital. There he was faced with 3,000 patients and what to do with them.
He encouraged all the professional staff, doctors, psychologists, social workers, nurses and ministers to run groups of 15 psychotics twice w eek for an hour and a half. He encouraged the staff to publish papers on their findings and arranged for them to participate in group therapy weekends with teachers and others. His approach to psychotics was that "we are all messes. They are bigger messes". The important thing was to help them become aware of feel, acknowledge and make use of their feelings. Especially important was to bear pain, which strengthened them.
After early optimism a psychodynamic-analytic approach to the treatment of schizophrenia has waned. Partly, because (i) a self-perpetuating cycle has evolved between an over reliance on Type 1a evidence and a belief that physical explanations and treatments are sufficient and (ii) psychoanalysis has failed to adequately unpack and modify its key principles to enable the cross fertilisation of clinical techniques from the "couch" to the "clinic". This workshop draws on trauma based models of psychosis and the newly emerging relationship between psychosis and posttraumatic stress disorder, which suggests that the search for meaning of impending "madness" by both the patient and the practitioner, are important mediating and or maintaining factors. Informed by the lived learned experiences of a diagnosed "schizophrenic" patient and a therapeutic community practitioner and supported by the consensus of expert opinion, the workshop outlines how a contemporary object (human) relations framework can help the sufferer and their primary caregiver make sense of, live with and potentially recover from what remains the essentially contested concept but excruciatingly painful human condition of "schizophrenia". The workshop comprises (i) a virtual reality component that replicates and bears witness to a "psychotic experience" (ii) an experiential phenomenological account of the "psychotic" mind and the psychiatric treatment thereof and (iii) a didactic component which draws on case material to stimulate group discussion and debate as well as illustrate key theoretical principles and techniques.
The workshop is used routinely as part of Threshold’s internal training programme for all staff and has been presented to mental health and allied professionals in various settings across Northern Ireland to raise awareness and encourage them to think outside of a reductionist, less than reliable but dominant diagnostic "medical" box that ignores individual human differences and experiences. The workshop was presented at the ISPS-UK Conference Tuning into Psychosis in Manchester, 13th – 14th September 2005 and will be presented at the forthcoming Boston-Threshold Group Therapy Conference at Cultra, Holywood Northern Ireland 18th – 19th August 2005.
In a joint project between Threshold and the Institute for Recovery, the key theoretical-experiential underpinnings of the workshop will form the embryo for developing an evidence-practice based work-book/manual for working with psychotic experiences. This alternative to the traditional psychiatric model will be grounded in working collaboratively “with the service users frame of reference – whether he/she sees the experience primarily as medical, psychological or perhaps even spiritual phenomenon” (British Psychological Society, 2000). In practice this will mean attending to the uniqueness, heterogeneity of subjective emotional experiences, potentially creating meaning out of “madness”to instil hope and redefine and reinstate relationships with “non-diagnosed-non-psychotic” healthy parts of the self and significant others that will promote recovery.
Ignoring the Validity of Human Experience: How Can We Best Respond to The Tragic Consequences of an Anti-Analytic, Biological Approach to “Schizophrenia”?– Presenter: Daniel Kriegman, PhD; Discussants: George Atwood, PhD, Robert Whitaker
We have been warned not to repeat the error made when psychoanalysts attempted to understand and treat “schizophrenic” patients. (2) Let us not be caught “with our pants down again,” so to speak; soon new advances in neurobiology will show that many neurotic conditions are just as biological as schizophrenia. Note: The case is built upon the biological nature of schizophrenia, which is taken as a given; it goes without saying.
In contrast, all the empirical research demonstrates unequivocally that the belief that “schizophrenia” is a biological, mental illness has no more evidentiary basis than the biological nature of any other human behavior. While all human behavior has biological influences, there exists no evidence for the assumed wisdom about heritability, genetic, neurotransmitter, or any neurological differences between “schizophrenics” and “normals.” The history of the bad science underlying this universal misunderstanding will be summarized.(3)
Brief clinical examples of how respect for the validity of “psychotic” experience can lead to a return to stable functioning and well-being will be presented. The first vignette is of a psychotic, serial rapist treated in prison. The second is of a lifelong “schizophrenic” who, after two decades of treatment without drugs, no longer exhibits any psychotic symptoms, though she still suffers terribly from the severe trauma and tardive dyskinesia brought about by more than 25 years of involuntary treatment in traditional mental hospitals.
The holocaust of soul murder, tardive dyskinesia, and death can now be calculated. A conservative estimate of the devastation wrought by the pharmaceutical response to disturbing emotional distress leads to the conclusion that 20,000,000 lives have been thoroughly destroyed by unnecessary, damaging “treatment.” So far.
2 Willick, M. S. (2001) Psychoanalysis and schizophrenia: A cautionary tale. Journal of the American Psychoanalytic Association, 49, 1, pp-pp.
3 Whitaker, R. (2002). Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. NY: Perseus Publishing.
Joseph, J. (2003). The Gene Illusion: Genetic research in psychiatry and psychology under the microscope. Herefordshire: PCCS Books.
Leo, J. (2003). The fallacy of the 50% concordance rate for schizophrenia in identical twins. Human Nature Review, 3, 406-415.
Since the late 1980s a dialectic has existed in psychiatry between the ‘medical model’, and the ‘patient-centred ethos’. Both dialectical components have been incorporated into national and international governmental policies on mental healthcare provision. We sought to determine to what extent the patient-centred ethos (as exemplified by ‘subjective experience’ research) penetrated international schizophrenia research between 1988 and 2004.
A definition of ‘subjective experience’ research was developed and applied to all non-duplicated research abstracts presented at the Biennial Winter Workshop on Schizophrenia, the International Congress on Schizophrenia Research (n=9284) and the International Society for the Psychological Treatment of Schizophrenia, between 1988 and 2004 (n=980). These abstracts were categorised into ‘subjective experience’ or ‘non-subjective experience’ research.
516 (5%) of the total number of abstracts satisfied the definition of subjective experience research. 333 (34%) of the ISPS abstracts addressed subjective experiences as opposed to 183 (2%) of the ICOSR/BWWS abstracts, and 774 (79%) of the ISPS abstracts examined psychosocial issues as against 449 (5%) of those from ICOSR/BWWS. 29 (3%) of the ISPS abstracts addressed biological issues, whilst 6963 (75%) of ICOSR/BWWS did same.
By ignoring the subjective experiences of schizophrenia sufferers, the international schizophrenia research effort of the last two decades has not been patient-centred. There are clear ‘disconnection’ and ‘laterality’ effects affecting the international schizophrenia research effort that mirror key causal theories about the disorder itself. If both subjective and objective perspectives are necessary to understand mental disorder is it any wonder that schizophrenia remains an enigma?
_’Decade of the Brain’ Proclamation - Presidential proclamation 6158 – July 17th 1990 _WHO (2001). World Health Report 2001. Mental Health: New understanding, new hope, World Health Organisation.
This presentation describes the experience of personal annihilation as the phenomenological core of the so-called psychoses. The study of such experiences has played an extremely important role in the development of the intersubjective viewpoint in psychoanalysis over the last 30 years. A series of dramatic clinical stories is given to illustrate the intersubjective approach to the phenomena of personal annihilation. These clinical illustrations focus on the importance of the validation of experience in the psychotherapeutic process.
The Labyrinth of Recovery: Early Trauma, Dissociation and the Healing Process– Dorothy Scotten, PhD, LICSW
This workshop examines the integration process of four persons who had experienced psychological trauma before effective language production and who subsequently were diagnosed with Dissociative Identity Disorder. The presentation will be in a didactic and experiential format focusing on recovery as a soul-centered and cognitive activity strengthened by the use of the creative arts. Reflection on in-depth participant interviews that consider the impact of early trauma on their cognitive, socio-emotional, and spiritual development may demonstrate how they successfully negotiated their healing. Key findings address spirituality as the undergirding of their healing. Conjunctive themes of recursivity, social change, metaphor and cognitive restructuring are discussed as existential, developmental accompaniments in the healing process. The findings from this study might inform the development of effective clinical training/teaching strategies in the understanding of the nature of the recovery process for severely dissociative persons traumatized in infancy.
By the end of this workshop participants may be able to:
1. define early trauma and distinguish and define the interdisciplinary domains that impact on the development of affective and cognitive splitting;
2. define recovery and integration and recognize the similarities inherent in the creative, spiritual and cognitive processes involved in recovery from Dissociative Identity Disorder;
3. develop and apply clinical/teaching strategies that will enable clients and students to make internal connections between their emotions and intellect.
Allison, R. B., with Schwarz, T. (1999). Minds in many pieces: Revealing the spiritual side of multiple personality disorder. Los Oslos, CA: CIE Publishing.
Eigen, M. (1998). The psychoanalytic mystic. Binghamton, NY: ESF Publishers.
Kluft, E. S. (Ed.). (1993). Expressive and functional therapies in the treatment of multiple personality disorder. Springfield, Ill.: Charles C. Thomas.
Krippner, S., & Powers, S. (Eds.). (1997). Broken images, broken selves; Dissociative narratives in clinical practice. Washington, DC: Brunner/Mazel Publishers.
Nelson, J. (1994). Healing the split: Integrating spirit into our understanding of the mentally ill. Albany, New York: State University Press.
Share, L. (1994). If someone speaks, it gets lighter: Dreams and the reconstruction of infant trauma. Hillsdale, New Jersey: The Analytic Press.
Stern, D. (1985, 2000). The interpersonal world of the infant. New York: Basic Books.
Vankoneu, K. (1993). On manifestations of early traumas in symptoms and character traits. Scandanavian Psychoanalytic Review, 16, 1-21.
No description available
In the United States, therapeutic communities for treatment of substance abuse are well known. But practitioners who have been in the field many years remember that, from the fifties to the early eighties, a somewhat different mode of treatment, also called therapeutic community, was the “best practice” of the time for people with mental illness. Therapeutic community is a milieu treatment with roots in psychoanalysis, group work, and social psychology, and was born in military psychiatry during WWII. Therapeutic community emphasizes a “culture of enquiry” where all events of the day are grist for the mill, a flattened hierarchy of staff and clients, openness of communication among all participants, patients helping one another as a crucial factor in treatment, and the utilization of community meetings and staff support meetings.
In order to find out whether the therapeutic community movement of the mid twentieth century continues to exert influence on contemporary programs for people with mental illness, I conducted interviews with directors of milieu programs in several states throughout the US.
In this paper I will present the results of my research, along with a short history of therapeutic community. I will give special attention to the overlap between therapeutic community and related approaches such as the club house model and psychiatric rehabilitation. Since many mentally ill people are treated in group settings, I will conclude with recommendations for how existing milieu programs can most effectively encourage their communities to maximize client participation and recovery through therapeutic community principles.
This is a paper in which the analyst and a severely withdrawn man struggle to achieve contact through the medium of the man's intentional fantasies and day dreams. It is the story of acquiring a difficult, at times obscure language which, nevertheless, enabled the opportunity for a beginning engagement and a more progressive eventual communication. Analyst and analsand reveal in the process of their work together the obstructing aspects of their subjective experience of each other, as well as the treatment. The evolution of the process of learning to listen to each other's subjectivity as they acknowledge their own finds ultimate expression in a manuscript which is in part a mutual reconstruction of the past in the present. Through which, as co-creators, a progressive defining, differentiation and validation of their voices takes place. New levels of perspective, relationship and therapeutic possibility are the consequence.
No description available
A panel discussion of involuntary psychiatric treatment with 4 panelists, including clinicians, legal experts, patients/ex-patients, and relatives of patients. The discussion will be framed by a presentation (or presentations) summarizing current laws regulating involuntary treatment and how they are applied. Questions to be addressed by panel members will include (but are not limited to) the following: Is involuntary treatment necessary? Are persons diagnosed with mental disorders more dangerous than others? Are existing laws helpful or harmful to patients and to society? How can they be improved? Are civil right of patients, and others, adequately protected by current laws? What ethical issues are raised by involuntary treatment?
Utilizing a previously examined sample of schizophrenic patients (n=33; Karon & Vandenbos, 1981), this study investigates the comparative efficacy of three different treatment interventions: psychodynamic-based psychotherapy only (Group A), both psychodynamic-based psychotherapy and psychopharmacological treatment (Group B), and psychopharmacological treatment only (Group C). All patients were administered the Thematic Apperception Test (TAT) at pre- and post-treatment (20 months). We applied the eight-variable Social Cognition and Object Relations Scale (SCORS; Westen, 1995) to these TAT narratives in order to assess changes in the cognitive and affective aspects of patients’ object relations. The Reliable Change Index (Jacobson & Truax, 1991) was used to measure clinically significant change for each individual patient. Paired t-tests were utilized to examine all pre- and post-treatment group changes. We found that patients receiving psychodynamic-based psychotherapy without medication (Group A) fared better relative to the other two groups. Impact of initial length of hospitalization and cognitive functioning will be addressed empirically and theoretically. Few studies have utilized the SCORS rating system as an outcome measure, especially with an experimental design. Thus, our study represents a potentially useful application of this innovative assessment instrument, in addition to a potential contribution to our understanding of the different treatment approaches to schizophrenia. At the time of the original study (1960s), Karon and Vandenbos did not have access to a rigorously validated object relations measure capable of maximizing the collected TAT narratives. As such, this study adds incrementally to earlier findings reported by Karon and Vandenbos.
My paper is an attempt, closely tied to research and clinical experience, to arrive at a less reductionistic and more comprehensive model of the schizophrenic disorders. It is a translational perspective grounded in research in the following domains of scientific inquiry: neurogenetics and epigenetics; neurobiology; developmental psychobiology; affective and cognitive neuroscience, including neuroimaging research; neuroplasticity; epidemiology and sociocultural factors; attachment theory; phenomenology; and importantly, psychoanalytic and psychotherapeutic experience with hundreds of individuals with a diagnosis of schizophrenia. The critical role of chronic and profound fear and anxiety, separation and attachment as well as identity processes, will be underscored in this model.
The world is a big place and we need many maps (biological, sociocultural, phenomenological, etc.) to orient us within its many terrains. A comprehensive model of the schizophrenias needs to be able to explain the extant data as to why schizophrenia is more common in migrant groups and in urban areas as well as why patients in the developing countries fare significantly better than patients in the developed nations, just as much as it needs to explain the presence of ventriculomegaly, atrophic processes in prefrontal and temporal areas and why ectopic pre-alpha cells sometimes occur in the parahippocampal gyrus. Importantly, what is not understood must also be articulated and overarching models should be avoided lest they silence the emergence of novel approaches and ideas.
The symposium explores the importance of addressing the patient’s defensive avoidance of understanding the broader validity of their experience. One paper offers a solution to stalemates that frequently occur in malignant regression. The patient sees the analyst as the parent and concretely demands re-parenting in malignant regression. There is a loss of reality testing. Stalemates can be avoided if the analyst appreciates that thinking has become concrete. A particular demand is endowed with excess meaning because thinking about the meaning of the demand generates too much anxiety. The analyst needs to help the patient think about their needs more broadly. A second clinical paper addresses a mental retreat from aliveness through autistic defenses of encapsulation and entanglement. Being "born too soon" psychically results in a deadening of him/herself in order to protect against sensory overload, profound agony and unbearable aloneness. This paper describes the clinical experience of moving from the concrete towards freedom to express the "self" within the therapeutic relationship.
1. Working with malignant regression: helping the patient appreciate the broader validity of their experience
Benign regression is a regular occurrence in psychoanalytic treatment. A person experiences childlike feelings, views the analyst ‘as if’ they were their parent and uses the experience for growth. Malignant regression occurs when the person demands the analyst actually function as the parent that they always wanted and gratify their unmet needs. They don’t simply treat the analyst ‘as if’ they were the parent but rather as the parent. This lapse in reality testing gives the transference a psychotic like quality. Malignant regression has typically led to treatment failure where the analyst gives and the patient demands until one or both quit.
My thesis is that thinking becomes concrete in malignant regression and a particular demand is endowed with excess meaning that the patient is unable to think about. The analyst needs to refrain from tendencies to respond to aggressive demands for gratification with counter aggressive rejections. He/she needs to help the patient think about the broader validity of their demands for stalemates to be avoided. How the analyst responds to the regressed state will determine whether the patient will withdraw and truncate future emotional expression or open up and deepen exploration of needs. Some symbolic gratification of demands may be necessary to avert tendencies to withdraw into autistic states. The analyst
needs to be sufficiently emotionally available so that the patient feels cared about. Feelings cared about by the analyst helps the patient 1) feel safe exploring the meaning of regressed mental states and 2) gives the patient permission to exist and have desires.
2. An Experiential Understanding Of Primitive Mental Disorders: The Importance Of Hope And Meaning Of The Concrete
This clinical paper will explore the necessity of hope and the empathic understanding of concrete expressions of patients suffering from primitive mental disorders.
Three patients will be presented. All three patients were extremely bright but demonstrated concreteness, suffered from a psychotic transference and had difficulty expressing abstract thought rather than actions. All improved markedly with two of the three making significant contributions to society.
Additionally, all three patients appeared of have an early failure in the stage of "illusion". In normal development the "good enough" mother encourages the infant’s essential belief in the mother-infant as "one". The baby experiences "I am good because I cause my mother to care for me." This mental state of "positive omnipotence", with a belief in positive cause and effect, is essential in launching normal development.
When trauma interrupts this illusion a "too soon psychological birth" occurs. The infant retreats to states of encapsulation or entanglement. This defensive pattern avoids awareness of the trauma of precocious separateness, with its agony of disillusionment. Concreteness, terror and the inability to develop "real" words are the aftermath.
The Healing House was created to contain the pain of early trauma, the fear of separateness, the lack of a "self", the despair of environmental failure and the hurt of not feeling understood. The Program will be described.
No description available
This paper discusses aspects of the outpatient treatment of a now 65 year old man with paranoid schizophrenia who marginally exists in the community. After rebelling, the patient over-used his drugs as magic to bolster his confidence (doctors were the ultimate authorities, meds their extensions, which he could incorporate and be "normal" under their influence).
The client talked regularly about musical theories (which he had expertise in). His reasoning did not follow logic and the symbolic meaning of his musings did not become clear to the therapist, but he would have "aha!-experiences". The therapist worried about the patient’s ruminations because they highlighted his para-logic, but did not intervene. After months of this, the patient straightened out the couch at the beginning of a session and then commented that in the past he had lacked confidence to do that. This was the first time that the patient had commented on himself in an observing manner.
It appears that the patient's uninterrupted ruminations were a precursor to his increased autonomy. The therapist intervened indirectly by letting the patient pursue his thoughts: behaviorally it had communicated trust in the patient's ability to organize himself.
Spotnitz's theories of treating pre-oedipal patients, Tomkins' theories on the connection between emotions and stimulation patterns, Ekman's link of imitation and emotion, Fout's ideas of gestural precursors to language, and the classic emphasis of clinical social work on process will be discussed to provide a framework for these interactions and their transference implications.