In the last century psychoanalysis has produced a small number of clinicians with a gift for working with psychotic patients but never a treatment that can be implemented in community clinics, where most chronically psychotic individuals are seen. Said another way, psychoanalysis has produced a limited number of Maseratis but never a family sedan the average well-trained clinician can drive.
Why is this so? It is not because psychoanalytic concepts are irrelevant to the treatment of psychosis. Quite the contrary. The ideas of Freud, Klein, and Bion are of enormous value in understanding psychotic states. In my view, psychodynamic treatments of psychosis have seen limited application because psychoanalysis has paid too much attention to the unconscious meaning of symptoms and too little attention to the patient's conscious experience of the psychotic symptom perceived as an event in the outside world. In psychosis, psychological processes occurring within the mind are experienced as altered perceptions of things and events in the outside world, a phenomenon Eric Marcus has called “thing presentations” of mental life. All hallucinations and most delusions are constructions of this kind. For example, rather than feeling guilty, a man may see indications on the street that FBI agents have him under surveillance. Or, instead of thinking he is a failure, a man might hear voices telling him he is a failure.
If the therapist were to interpret these psychotic symptoms as manifestations of unconscious guilt or poor self-esteem, the patient would likely feel terribly misunderstood. From the patient's viewpoint, “My problem isn't in my mind. It's in the lobby of my apartment building, where the FBI has set up surveillance cameras.” Because thing presentations are experienced like perceptions rather than thoughts or feelings, they are subject to the cognitive processes, which ordinarily govern perceptions and memories of perceptions. For the most part, what we perceive we believe to be real. As long as thing presentations are located in the patient's mental representation of the outside world, they are not amenable to interpretation of their unconscious meaning.
Classical psychoanalytic technique has no effective way of dealing with thing presentations. A modification of technique is required. Thing presentations must first be brought back within the boundary of the self where psychodynamic technique can be effectively applied. Cognitive behavioral therapy for psychosis (CBTp) as developed in the last two decades in Great Britain and elsewhere provides the technical means to do this. The optimal approach to the psychotherapy of psychosis involves an initial phase of CBTp, followed by a second phase guided by psychodynamic technique. CBTp allows the therapist to slowly chip away at thing presentations, casting doubt that the patient is perceiving events outside the self.
Consider the example of a 58-year-old woman who heard voices many hours each day telling her that someone was going to die. The voices dropped vague hints as to who was in danger. Convinced the voices were omniscient, she spent endless hours trying to decode their messages. Voices are thing presentations of mental life. When treatment began she did not recognize the voices as part of her mind. The CBTp phase of her treatment included four months of weekly 45-minute sessions. Jumping ahead to the end of the CBTp phase, when the meaning of the voices could be interpreted, the predictions of death proved to be a psychodynamic expression of her fear of loss of loved ones and her anxiety about her own mortality. In effect, the answer to the question, “Who is next to die?” proved to be, “You are.”
Over the course of treatment her anxiety about death was linked to the loss of her mother and father, anticipation of her dog's death, a saying in her family, “Women in this family die young,” and her experience of her psychiatric illness as a harbinger of her aging, physical illness, and eventual death. Even if the psychological meaning of such a psychotic symptom is vividly apparent early in treatment, it is generally of no avail to interpret its psychological meaning because the patient experiences the “voice'” as a perception rather than a thought or feeling. Preparatory CBTp work is first required to undermine the patient's belief that the voice lies outside the self. This opens the way for the therapist to eventually interpret the voice as an expression of the patient's thoughts and feelings.
Michael Garrett, M.D., is currently vice chairman of psychiatry and professor of clinical psychiatry at SUNY Downstate Medical Center in Brooklyn, N.Y. He is also a faculty member of the Psychoanalytic Institute at NYU Medical Center.
In the CBTp phase of this patient's treatment the therapist enlisted the patient in a collaborative investigation of the “voice hearing experience.” The phenomenology of voices was reviewed at length, allowing the patient to compare her experience with the experiences of others. The patient was surprised to learn that other people heard voices. The psychological and brain processes that generate hallucinations were discussed. At the midpoint of treatment the patient announced that when she heard a voice, she now said to herself, “You are not hearing this. You are thinking this.” With this understanding the thing presentation of the voice began to return within the boundary of the self, where it could be psychologically interpreted. The therapist was now able to say, “Your voices predicting deaths give voice to your grief and fear of more painful losses in the future.”
The therapist-patient relationship in CBTp is more familiar, informal, and self-disclosing than would traditionally be the case. It casts the patient and therapist as co-investigators examining the patient's conscious distressing experiences (psychotic symptoms). CBTp utilizes a special “tool box” of interventions which achieves a skillfully orchestrated massive reinforcement of the patient's observing ego. It is anchored in three concepts. First, psychosis is seen as lying along a continuum with ordinary mental life. The therapist seeks to “normalize” psychotic symptoms by relating them to everyday mental processes. Second, psychosis is explained by the stress/vulnerability model, i.e., that people may have a biological, psychological, or social vulnerability, which when combined with significant stressors may lead to psychosis. Third, patients are taught to understand that their distress over psychotic symptoms is significantly mediated by their beliefs about the meaning of their experiences. In the case above, when the patient's belief in the omniscience of the voices changed, her fear of the voices abated.
When combined with an initial phase of CBTp, psychoanalysts have much to contribute to the treatment of the severely mentally ill. The time is right for psychoanalysis to take a renewed interest in psychosis, to revise technique, and to step up and get busy. The severely mentally ill are waiting for our help to arrive.