“We are all more human than otherwise.” Of all the memorable statements made by Harry Stack Sullivan, this one—with its pithy Irish eloquence—might best summarize his years of working with and learning from psychotic patients. The news these days, from Tucson and elsewhere, appalls us so deeply that it tests our willingness to take seriously Sullivan's remark. It strains our capacity for empathic understanding as it also frightens us about our own human vulnerabilities.
We all know the statistics. The vast majority of deeply troubled people are never violent toward others. Their violence, if it can be called that, is toward themselves and their connections to the world. They withdraw from human discourse and seem to simply want to be left alone. What we may have lost sight of, in today's mental health climate, is that many people suffering major mental illness, including psychotic conditions, are quite treatable. From my vantage point at the Austen Riggs Center in Stockbridge, Massachusetts, where close to a quarter of our patients present with psychotic problems, the variability of these conditions, the surprising and sometimes idiosyncratic paths toward recovery, and the patient's longing to escape isolation impress themselves upon us regularly.
Riggs became a psychoanalytic hospital in 1947 when Robert Knight, eventually the president of the American Psychoanalytic Association, brought a cohort of impressive young analysts—David Rapaport, Roy Schafer, Margaret Brenman, Merton Gill, and eventually Erik Erikson—to study and treat what came to be understood as borderline conditions. Many of these patients had clear psychotic liabilities. Knight's successor, Otto Will, brought with him years of experience at Chestnut Lodge in Rockville, Maryland, and a wish to treat the overtly psychotic patient in the context of Riggs's open therapeutic community setting. In this article, I will touch on the roots of Will's effort, its conceptual frame, and its evolution at Riggs.
In some ways, the thread of Riggs's work with psychotic patients began in Berlin, in 1923, the year of The Ego and The Id, the year Winnicott began his 40 years of mother-child consultations at Paddington Green Hospital, the year Sullivan opened his unit for psychotic patients at Shepard-Pratt, and the year 33-year-old Frieda Reichmann began her psychoanalytic training at the Berlin Psychoanalytic Institute. Led by Karl Abraham, the Berlin Institute combined a scientific attitude, a standardized training program, and intellectual rigor with an avant-garde spirit, a socialist inclination to offer free analyses to the poor, and an encouragement of innovation, especially in the treatment of psychotic patients.
Frieda Reichmann had already run a hospital unit for brain-injured soldiers, where she learned that neurologically damaged people differed markedly, one from the other, in their pathologies and their paths toward recovery. In Berlin, she was inspired by Ferenczi's examination of countertransference impediments to a patient's progress and Georg Groddeck's insistence that no patient was beyond hope. And she was inspired by Freud in whose work she found a confirmation of her own intuition: “I had known from the first day I was in psychiatry that something funny went on in the doctor-patient relationship, but nobody seemed to know anything about it and nobody talked about it…And this man said he knew it happened!”
Where she eventually differed from Freud was in his conclusion that psychotic patients could not form transferences. Indeed, her experience led her to a near-opposite conclusion: that they could only form transferences, that psychotic fragmentation represented the ongoing disaster of pathology in the earliest phases and relationships of life, and that the task of the analyst included differentiating herself out of this chaotic matrix and into the role of, as Clare Winnicott put it, “the other person.” Forced to flee the gathering storm in
M. Gerard Fromm, Ph.D., is director of the Erikson Institute for Education and Research, Austen Riggs. He is on the faculties of the Massachusetts Institute for Psychoanalysis, the Berkshire Psychoanalytic Institute, Harvard Medical School, and the Yale Child Study Center.
her beloved Germany, she wound up at a small hospital outside Washington, D.C. She would spend the remainder of her career at Chestnut Lodge, treating psychotic patients, promoting the interpersonal perspective of Harry Stack Sullivan, and, in the late '40s, welcoming Otto Will to the Lodge staff.
Will had heard Frieda (now) Fromm-Reichmann speak while he was working at St. Elizabeth's Hospital, amidst its 8,000 patients. Listening to “her version of the 'mentally ill,' I began to see individual persons in the masses that were crowding the facilities of the federal hospital.” At the Lodge, he undertook a training analysis with Sullivan and then with Fromm-Reichmann. Theories were not fancy at the Lodge, Will's included. Patient and therapist meet and while a story unfolds, “bonds of attachment form. Attempts are made to understand how and why each participant experiences what is happening between them. The self is revealed—to some extent—and the question 'Who are you?' begins to be answered. Then comes separation.” Attachment, self-revelation, mutuality, change, separation, the most basic aspects of human relationships. This was the evolving Sullivanian framework of understanding at the Lodge, including the need-fear dilemma and twin dangers of annihilation or abject loneliness for people whose early development has included profound boundary disturbance. As Will wrote in 1982, “What is now called attachment theory is a vital part of my own work as a therapist.”
When he came to Riggs, Will brought with him a number of Lodge staff, most notably Martin Cooperman, whose concept of the “defeating process” recognized that when a patient feels deeply injured by his therapist, he may destroy the therapy in response. Like Will, Cooperman held the core conviction that therapist and patient were “in it together” and, like Winnicott, believed that the earlier the trouble, the less the patient would be able to think in two-person terms. Cooperman saw any move backwards as an unconscious communication that something had gone wrong in the relationship with the therapist. Tracing things back to the injury or disconnection interrupted regression and got the therapy process moving forward again.
This fine attention to the mini-history of the therapeutic relationship was mirrored in a different way by Francoise Davoine and Jean-Max Gaudilliere, who began a series of visits to Riggs in 1978, the year that Otto Will completed his tenure. Their outpatient work with psychotic patients had led them toward seeing meaning in the “area of death,” so intrinsic to both the patient's and the therapist's experience of such treatments and so related, they thought, to the Big History of social catastrophe in the families of patients. Indeed, they discovered in the work of Thomas Salmon, a World War I psychiatrist, a version of the principles that had come to underlie their approach: simplicity (no jargon), proximity (being with the traumatized person's raw experience), immediacy (depending on intuition and on the seeming coincidences within the transference), and expectancy (the dimension of hope, of getting better because those at the front need you).
In their 2004 book, History Beyond Trauma, Davoine and Gaudilliere argue that psychosis and trauma go hand-in-hand, and that the psychotic patient is madly conducting a research into the rupture between his family and the social fabric, a rupture brought about, more often than we realize, through large scale trauma (wars, mass displacements, societal regression), betrayal by those in authority, and suppression of the truth. They agree with Lacan that psychosis is a disorder “at the most personal juncture between the subject and his sense of being alive.” Their work powerfully links the clinical arena with the historical and the political, and suggests that the patient's psychosis is not simply an attack on the social order, but at a deeper level, a frantic effort to bring a foreclosed social order into existence.
Recently, a chronically and quietly psychotic patient, following the death of her mother “wanted to be psychotic for awhile” and so discontinued her medication. She became uncooperative and incomprehensible, and required the highest level of containment Riggs can provide. When she decided to resume her medication, she did so finally feeling “real.” Indeed, her breakdown came to seem like a breakthrough. “I want to find my voice. I want to be heard,” she said, and she seemed to have integrated anger for the first time. She also had advice for her therapist: “If it happens again, tell me you are not my mother.” There is indeed a Big History of trauma and betrayal in the generations before her, but in the Little History of the therapeutic relationship, this is a patient who lost her mother at a time when her therapist did as well, and a new twosome seemed now to be forming from this context of death both parties were now in.
With psychotic patients, we often find major traumatic histories, problems of unbearable loss, and obliterating forms of denial in the preceding generation or two.
The patient-to-be seems to receive the dissociated fragments of this history and to be charged, in the double sense of both an energy and a duty, to represent it, and with luck, to communicate it to someone. Davoine and Gaudilliere, as did Cooperman, offered a frame for the treatment of such patients that recognized meaning in a potentially dissociated history, the history of the therapeutic dyad itself or the larger histories shared by both parties. Not only did they show us how psychotic patients can be treated successfully with psychoanalytic psychotherapy; they also show us how psychosis—far from being a violent disorder in itself—is actually an effort to bring varying levels of interpersonal violence to the light of understanding.
How are we to understand the violent eruptions that, rarely but very publicly, come from people who seem to be psychotic? The work at Riggs suggests that we should look for the interrelatedness of the mini-history of the individual's life with the larger history of their family and societal context. What tragic history is the individual carrying as the representative of what Freud called the family's “archaic heritage”? But there are larger questions as well, including the one that surfaced immediately after the Tucson shootings: How susceptible are vulnerable individuals—perhaps especially those with fragile boundaries, concrete thinking, and impulse problems—to the rage and incendiary speech of those around them?
And perhaps there is a yet larger question, which builds on the work of psychoanalyst Michael Robbins with psychotic patients. Robbins argues that a simplified psychiatric approach to the psychotic patient, within a disease model, is actually enacting the disorder at a sociocultural level. For example, thought disorder is split off from the person, to be treated as a symptom without meaning, mirroring the psychotic person's depersonalized splitting of his thoughts from his feelings and from his relationships to people. Similarly, though studies document degree of denial as a pathogenic factor in high-risk families, multiple forces have pushed the treatment culture toward its own denial of interpersonal, developmental factors in the shaping of psychosis and toward seeing the psychotic patient as an isolate, ironically mirroring a primary defensive strategy while it replicates pathogenesis.
It would be a small step further to wonder about the free-floating rage, intolerance of difference, and paranoia in our society and to consider the possibility that it is not only projected onto vulnerable people, but perhaps into them as well. Indeed, the rationalizations that allow for such unlimited access to weapons—really weapons of mass destruction—in our country seem full of the denial, splitting, projection, and even delusional thinking we ordinarily associate with psychotic processes. To other civilized countries, this looks insane. What happens if we take that diagnostic term seriously? Does it make any sense to think of a collective societal process as psychotic? What would be the implication for its psychotically vulnerable members?