Thinking about Voices: A Clinical Framework for Using Psychoanalytic Psychotherapy to Recover a Non-Psychotic Self-Representation in a Schizophrenic Patient

In this paper, I have reported how a woman with a long history of paranoid schizophrenia was able to use psychoanalytic psychotherapy in the NHS to work through a delusional belief of having her father's child. As a result of the therapy she was able to recover a reflective function and to represent herself, again, as a non-psychotic person. I have described the clinical framework of the therapy as based on the psychodynamic developmental therapy and the mentalization model, as developed by Fonagy and Target (1996), which posits that the development of a core or psychological self is not a given and can occur only through early object relationships with a caregiver who enables the child to integrate two modes of functioning, the psychic equivalence and the pretend modes. If the care-giver is abusive or unable to acknowledge or think about a piece of reality the child will not be able to do so on her own and, as a result, will experience the unthinkable thought in a psychic equivalence mode. In the clinical setting, the role of the therapist is, first, to acknowledge the reality of the patient's internal world and eventually enable her/him to think about the unthinkable thoughts.

I have emphasized, also, the technical importance of balancing interpretation of unconscious strivings with ego-supporting communications.

I propose that this framework can be used to enable some people suffering from severe and incapacitating mental illness to lead more satisfactory and fulfilling lives through the exploration of delusional formations and the recovery of a non-psychotic part of their selves.

‘At this point of my existence, I cannot imagine leading a normal life without both taking lithium and having had the benefits of psychotherapy. Lithium prevents my seductive but disastrous highs, diminishes my depressions, clears out the wool and webbing from my disordered thinking, slows me down, gentles me out, keeps me from ruining my career and relationships, keeps me out of hospital, alive, and makes psychotherapy possible. But, ineffably, psychotherapy heals. It makes some sense of the confusion, reins in the terrifying thoughts and feelings, returns some control and hope and possibility of learning from it all. Pills cannot, do not, ease one back into reality; they only bring one back headlong, careering, and faster than can be endured at times. Psychotherapy is a sanctuary; it is a battleground; it is a place I have been psychotic, neurotic, elated, confused and despairing beyond belief. But always it is where I have believed — or have learned to believe — that I might someday be able to contend with all of this.’ .