Working With Psychotic Patients

I will start this paper by discussing briefly an interpretative model I find useful in working with psychotic patients, a model we regularly discuss among a group of colleagues in the National Health Service. It is basically to do with the view of a person - whether patient or therapist - not as ‘one’, not as ‘many’, but as ‘two’. How a person happens to be two people rather than one is open to question. Is a person born as ‘two’, or as ‘one’, becoming ‘two’ subsequently, perhaps through impact with life? In the latter case, is the ‘second’ an unaccepted part of a still dominant ‘first’ or is it a fully independent person coexisting with the other? In other words, if we admit there is a split in the personality, why, how, where, and when does the split take place and what are its consequences (Richards 1990)?

The psychoanalytic literature provides us with many insights on this subject - in the texts of Breuer, Freud, Fairbairn, Klein, Bion, Rosenfeld, Winnicott, Kohut, Kernberg, Mahler, and others (Grotstein 1986). Following Bion's terminology, I call one self, or state of mind, ‘non-psychotic’ and the other ‘psychotic’ (Bion 1987). I regard the non-psychotic as including both neurosis and normality. I take it that the relative proportions or the ratio of ‘non-psychotic’ and ‘psychotic’ varies along a wide spectrum from individual to individual, and also within the same individual, according to circumstances.

Jung remained interested in psychosis throughout his life. In 1907 he related psychotic disturbances to the presence of ‘complexes’ or ‘split off parts of the personality’ or ‘splinter psyches’ (Jung 1907). He said: ‘The ego complex is no longer the whole of the personality; side by side with it there exists another being, living its own life and hindering and disturbing the development of the ego complex.’ In 1928 he said, in discussing ‘paranoia’, that it consists in a ‘doubling of the personality’, with ‘two egos’ (Jung 1928). He wrote: ‘