Establishing Empathy by Analyzing Psychosis

Today, we are more inclined to use psychoanalysis not as a treatment method but as a way to understand the conflictual forces—the psychodynamics—that underlie both the outburst of the psychotic episode and the continual roiling within the patient's unconscious that keeps the psychosis “alive”—for brief periods, if the patient is fortunate; for many months or years in less fortunate situations. The ameliorative steps may vary.

Here are a few clinical examples.

In my work at a forensic psychiatric hospital, I was asked to treat a man in his thirties. He suffered from a paranoid schizophrenic psychosis, which appeared to be a genuine example of the hereditary type. He had his first breakdown while in graduate school for one of the professions. He took a leave of absence; supportive and psychopharmacological treatment alleviated his psychosis and he was able to complete his studies.

At that point he began to date a woman, to whom he eventually became engaged. His fiancée became pregnant. After she told him, he again lapsed into a psychotic state. He believed powerful forces from a foreign government held him in their power, commanding him to do away with his fiancée for reasons the voices did not make clear. His best guess was that killing her was his only way to prove his complete devotion to this exotic power, from which he dared not “walk away.” A man of high intelligence and wide reading, he could converse with me in a most rational way on any number of unrelated topics: Egyptian history, prime-number theory, Elizabethan drama…but whenever I broached the subject of the murder, trying to understand the dynamics behind it, he would smile, shrug his shoulders, and once again speak of himself as the unfortunate plaything of mysterious forces.

After a year of twice weekly sessions (he was also taking hefty doses of antipsychotic medications), his grasp of what had led him to this terrible act remained unchanged. But I felt more and more convinced that the “mysterious forces” were nothing more exotic than the prospect of husbandhood and fatherhood, along with the necessity to function well professionally so as to provide adequate monetary and emotional support for his family. Sensing (correctly, in my view) that he was not up to this demanding task, he was left only with the options of abortion (which the fiancée had adamantly opposed), abandonment (too shameful a choice for him), or murder (under the guise of bowing to the implacable “force”). His reaction, in the form of a persecutory delusion, allowed him to save face.

Having worked with a number of prospective fathers who have killed their mates, I feel convinced my assessment of the psychodynamics was on the right track. Looking back, I can appreciate that it was better that I had not succeeded in getting through to my patient, a man of high moral standards, since to do so would subject him to the agony of realizing he killed her because he was too weak emotionally to succeed with marriage and fatherhood. That would be the path to suicide.

Roots of a Delusion

Some years ago, I had occasion to treat a single woman in her early thirties who had been hospitalized many times for suicide gestures. She suffered from a schizoaffective psychosis, the affective component of which was predominantly depressive. Accompanying her psychosis was an obsessive-compulsive disorder that focused on “germs.” She sent her bed sheets, pillows, dresses, undergarments, overcoats—everything—to the cleaners on a daily basis, incurring staggering expenses, which her family's wealth allowed them to overlook. She was also morbidly fearful of becoming pregnant, which in her unmarried state, she equated with sinfulness. To be fat or to be pregnant were the same to her, and she would become frightened if a fat woman walked past her in the street, as though by some eerie magic, she too might become fat/pregnant. In a car, with a boyfriend, she feared his sperm could leap from his trousers onto the steering wheel, thence into her, making her pregnant.

Fortunately, this woman, highly intelligent, cultured, and remarkably sweet in disposition, was less engulfed in psychosis than was the man of the first example. The psychodynamics, as they were revealed in her conversation and her dreams, related to the sternness of her upbringing: Her mother used to beat her severely if she caught her daughter masturbating or even appearing to have done so. If, when she was six or seven, she played with another girl behind closed doors, her mother understood this as a prelude to some unmentionable sexual play—and again, the beatings. She grew up as a result with an oppressively heavy sense of sinfulness and dirtiness.

With highly paranoid patients the psychodynamics become transparent, but improvement does not occur.

For a long time in our work, she feared discussing the beatings, lest her mother “hear” what she said. But as she became more courageous in speaking about her traumatic early life, her fears and preoccupation with dirtiness and sinfulness diminished. She was able to benefit from an exploration of the psychodynamic issues. Because she was fragile and potentially suicidal, she came four times a week during the first year. Eventually, she recovered sufficiently to meet a suitable man, marry, and have a child. When I saw her again, 10 years later, she was still fastidious, dressed with the utmost care, but cheerful, contented as a mother, and free of the signs of psychosis.

In general the psychodynamics are easier to unearth and easier for the patient to grasp, when the psychosis is in the affective domain (depression or bipolar disorder), and much more difficult when in the cognitive domain (as schizophrenia or “delusional disorder”). With highly paranoid patients the psychodynamics become transparent, but improvement does not occur. I think in this regard of a man in his twenties from a prominent family of which he was the only dysfunctional member. He had been humiliated severely by both parents early on, especially by his father, who mocked him for his academic slowness and imprecision of speech. As compensation, he became grandiose with paranoid delusions. If the phone rang but the other party hung up (having misdialed, for example), he would assume the call had come from a “super model” he had chanced to meet at some gathering and who had said “Hi” to him. He could not prove it was the super model and I could not prove his idea was most unlikely. I felt sure, though, that his misinterpretation could best be understood as a psychotic defense by which he attempted constantly to overcome his crushing sense of inferiority and ineptitude.

I took the tack of encouraging him to study and excel in some area where he had the capacity to do something effective and thence feel justifiably proud, no longer the hopeless loser. I put my psychodynamic understanding to work in this indirect way in hopes of helping this man whose reflective capacity was meager and whose paranoid distortions were too great to attack frontally.

Once we understand the psychodynamics we can grasp the purposefulness of the psychotic elaborations. What before appeared to us as “crazy” and alien becomes meaningful and human. In the place of estrangement we experience compassion.