While many may find psychosis frightening or untreatable by psychoanalytic methods, I never have. In fact, I feel excited and privileged to work and create at the frontiers of human experience. I have devoted three decades to studying and writing about creativity, and during that time I have treated dozens of individuals diagnosed as psychotic. I have come to view psychosis as a creative response to some unbearable situation, a daring and dangerous radical departure from ordinary forms of coherence that almost always contains the hidden key to its own creative resolution.
Additionally, I perceive some similarities between psychotic experiences and the products of creative artists, though the two endeavors are clearly different. Both involve fluid, regressed self states and access to unconscious processes; both create new worlds to deal with pain; both are attempts at healing what is broken; both offer alternative ways of viewing and experiencing reality. All acts of creativity take place on the threshold of the unknown.
Danielle Knafo, Ph.D., is a professor at Long Island University, faculty and supervisor at NYU's Postdoctoral Program in Psychoanalysis. Her most recent book is titled Dancing with the Unconscious: The Art of Psychoanalysis and the Psychoanalysis of Art (Routledge, 2012).
My experience working with individuals in hospitals, institutional settings, and private practice has convinced me that regression is sometimes a necessary part of the healing process; we sometimes must go back in order to go forward. Like Winnicott, I view regression as a psychic interruption or breach whose underlying purpose is to return the patient to a traumatic episode or constellation of such episodes in which a reactionary, armored self developed. The defenses formed against such trauma prevent psychological growth and limit the self's possibilities. The regressive return offers the opportunity for self-repair by working through the original trauma in a safe, holding environment.
…regression is sometimes a necessary part of the healing process; we sometimes must go back in order to go forward.
Despite convincing evidence connecting psychosis to trauma (Monica Aas, Warren Larken, Anthony Morrison, Andrew Moskowitz, Ingo Schäfer, Martin Dorahy, John Read), this tie continues to be overlooked or minimized in modern psychiatry, which prefers to relieve symptoms with medication rather than explore their meaning with the patient. There has been a medicalization of mental illness, a development that I believe has deleteriously affected the care of those who suffer. Other than studying the brain's neurobiological functioning, too few continue to study how the mind goes astray. Beginning in the 1960s, for reasons which Orna Ophir explicates well, psychoanalysts by and large turned over the care of psychotic individuals to psychopharmacology, thereby relinquishing their unique methods of treatment and research. One patient said to me in the midst of a psychotic break, “My childhood was one big emergency. I couldn't get out of it. I could only hide. Now they want me to hide inside a pill jar.”
So many patients I have seen have told me that though their doctors asked whether they heard voices, they hardly bothered to inquire what their voices said, or whose voices they were, or whether the voices were experienced as helpful or harmful. In response to not being heard, the Hearing Voices Network represents a wonderful development: Those who hear voices congregate to help themselves and each other by asking exactly these questions and more, as described by Gail Hornstein.
It is not true that all psychotics are rigid, lack motivation, and fail to develop transference feelings or that they cannot experience conflict or insight. A patient I saw became delusional and insisted he was going blind. He then exhibited what Ping-Nie Pao called “organismic panic.” No sooner did we complete a session where he felt a sense of progress, than he dismantled it completely, renouncing any perceived gain. His thoughts were broken; his self was in pieces. Here was Bion's idea of “attacks on linking” in the flesh. He had seen and felt too much and so he blinded himself in his attempt at restitution. To convey the primal terror he was experiencing, he said, “I feel so helpless, as if I was literally just born and someone is saying, run this company for me.” His destruction of sight reflected the need to rid himself of perception and thought, the very structures that could distinguish the subjective and objective aspects of reality. His “sickness” became the manifestation of his breakdown.
My patient insightfully observed that he did not know if he was experiencing “a breakthrough or a breakdown.” I have learned that sometimes a breakdown is, with effective treatment, the beginning of a breakthrough. Little by little, we began to observe what Franco De Masi termed “psychosis-free intervals,” during which he started to do some psychological work aimed at understanding and “seeing” the meaning of his psychotic construction. As the intervals of lucidity grew, the psychosis dissipated. Insight gave way to eyesight.
Though psychoanalytic work with psychotic patients can be extremely difficult, it can also be highly effective and profoundly rewarding. This is why I chair a doctoral program in clinical psychology that trains students to work dynamically with serious mental illness. As far as I know, it is the only one of its kind in the United States. Many of my students tell me it is the first time they hear that schizophrenia is not necessarily a lifelong illness whose symptoms must be stabilized with medication and for which there is no recovery. Imagine what options this opens up for them as well as their patients! Now my students report helping their patients' progress in many ways: Their patients learn to smile more, interact with others, and cultivate more interests. They learn to have hope.
I have always seen psychotic individuals in my private practice. Thankfully, I am not alone. I have been influenced by British object relations analysts who never shied away from extreme states of human experience, people like Klein, Bion, Winnicott, and Khan. I am a member of the International Society for the Psychological and Social Approaches to Psychosis (), an organization whose goal is to promote humane understanding and treatment of psychotic distress and does not regard medication as being, necessarily, primary in this treatment or the first treatment of choice.
Recently, I was thrilled to hear Christopher Bollas say that psychoanalysis is the treatment of choice for psychotics. He explained that when a patient of his is having a psychotic episode, he cancels all other sessions for the week and sees that patient every day for the duration of his workday. Bollas's approach is to see the psychotic person four to five days a week, attempt to understand his or her reasoning, and then communicate that meaning to the patient. He emphasizes how it is reasonable for that person to behave and think the way he or she does given the specific historical and psychic circumstances. When I work with someone in an acute state of psychosis, I, too, maintain daily contact with the person until the episode subsides.
Working analytically with psychosis requires dedication and patience. It involves meaning making on the part of both analyst and patient. In fact, one of the main reasons patients stop taking their medication, aside from the severe side effects, is because their symptoms contain the meaning they give to their lives and without meaning humans prefer not to live.
Michael Eigen, author of The Psychotic Core and many other books detailing therapy for serious psychopathology, has worked with psychotic patients for 50 years. He told me, “Through contact with ‘madness’ I contacted myself in important ways.” Indeed, it behooves us to consider the ways we can grow by working with those experiencing extreme states of consciousness. Again, Eigen said, “This work enabled me to develop and use myself, to grow in caring and resourcefulness.” Eigen's comments remind me that Harold Searles, in 1977, wrote that the more ill the patients, the more they become our therapists. It is common knowledge that psychotic patients read our unconscious minds and that “reading” can benefit us by expanding our self-awareness. Their use of projective identification also requires that we “stretch” ourselves from habitual ways of being to inhabit others' fantasies, Thomas Ogden said.
It is common knowledge that psychotic patients read our unconscious minds and that “reading” can benefit us by expanding our self-awareness.
I find it helpful in my work with psychotic patients to be alert for what Edward Podvoll called “islands of clarity,” areas where function and ego integrity still exist. No one is 100 percent psychotic. What parts still function well? How does one align oneself with those parts? Podvoll, a Buddhist, reminds us not to be too symptom focused and to take a history of sanity as well as one of illness, paying special attention to the patient's repulsion to his or her symptoms, as well as the wish to feel well again, his or her sense of courage, and the urge for discipline and order. An example is a patient of mine who confessed to battling rats for nearly one hour each day outside my building prior to our sessions. One could easily chalk her statements up to dark and pervasive hallucinations confirming her schizophrenic diagnosis. Or one could see, as I did, her courage to fight through her symptoms in order to reach me and her determination to let nothing stop her from continuing our treatment. Podvoll called for compassionate action in the treatment of psychosis. Indeed, the ground of the treatment is a compassionate relationship.
My experience has shown me that it is frequently feasible to reverse a psychotic process when one intervenes quickly after a first break. Daniel Mackler's recent documentary, Open Dialogue, demonstrates how in Finland an approach to the treatment of psychosis has been developed which involves immediate intervention (after the first break) with teams of practitioners working on a daily basis with families and the client, in order to avoid lifelong hospitalizations and stigma. Medications are used in only about a third of cases. They have the highest success rate (approximately 85 percent) in the world. Mackler is tracking alternate forms of treatment of psychosis, mostly in Europe, and delivering a harsh critique of traditional psychiatric approaches.
Indeed, it is unfortunately eye opening to consider that psychotic patients fare much better in third world countries than in our own, according to Kim Hopper, Glynn Harrison, Aleksandra Janca, and Norman Sartorius. The findings of Courtenay Harding's remarkable longitudinal research show that over half of psychotic patients recover without treatment, a finding that flies in the face of the popular belief that “once a schizophrenic, always a schizophrenic.” I find it rather frustrating to hear professionals comment on a recovered schizophrenic patient by claiming they were surely misdiagnosed because they could not truly be schizophrenic if they recovered. Yale graduate, law professor, schizophrenic, and author of The Center Cannot Hold, Elyn Saks wrote that though medication helped her, it is psychoanalysis that saved her life.
Our entire approach to treating severe and persistent mental disorder in the United States needs to be seriously reevaluated. Sometimes medication is necessary and helpful. But the person is first and foremost a living relational being whose derailment is often rooted in trauma. Unless we take the time to listen to our patients and hear what they are saying, the problems are likely to persist and become chronic. Ronald Bassman, a psychologist who was hospitalized and diagnosed with paranoid schizophrenia when he was young, writes to the real psychiatrists he has known and to those he never met:
This state you call schizophrenia has a vastly different meaning to me. Dangerous, yes, but for those of us who must battle the “disease” of feeling too much, of seeing what others do not see, and not meeting expectations that were never our own, it is ripe with opportunity to transform ourselves.