Creativity in psychosis has two aspects: the making of the psychotic symptom and the use of these phenomena.
To create a symptom, the primary process captures an area of reality experience of high emotional valence, constructing from it a symbol which reality testing erroneously affirms. This psychotic condensation appears in consciousness as a “thing presentation,” which is an intense, sensory-affect object. Experienced as though it were an object in the external world, it arrives in consciousness over sensory perceptual channels, through which it expresses its associated affect and encodes its ideas. The thing presentation is thus a condensation in reality sensory experience of emotional conflict in a form of compromise.
Choosing the reality nidus and altering it is a creative process using condensation, displacement, symbolization, and secondary revision. Some of these products of the dreamwork phenomena are concrete and hackneyed, others are ingenious and unique. However, once constructed the psychotic symbol remains reified, rigid, unchanging, stereotyped, and stymied in its growth and development. In psychosis, accessory ego functions are damaged and/or dissociated from the psychotic symbol. It cannot be further used creatively, existing in status niscendi, instead of as a true plastic representation. The patient experiences it as literally true and therefore nothing further can or need be done with it.
True creativity does not occur in either reality experience or emotional experience but rather in the plastic mix of both described by Winnicott as the transitional space. Creativity involves both primary and secondary processes, organized by complex ego functions called tertiary processes. First described by Silvano Arietti in 1976, tertiary processes integrate symbolic representations and use them for creative purposes: growth and development, and adaptation to inner and outer worlds. Tertiary processes are complex ego functions that synthesize primary and secondary process products to form complex affect cognitions. They are a hallmark of the highest cognitive functions.
Psychotherapy and psychoanalysis focusing on the psychotic thing presentation look carefully at sensory detail and the affective experiences condensed with that sensory detail. As the affective experiences become more fully conscious, articulated, and investigated, the concepts condensed in the thing presentation emerge. The condensation opens up into its component parts: reality experience, emotional experience, and their symbolic alterations. These different aspects of the experience are all valid but refer to very different epistemological areas and statuses. Decondensation strengthens observing ego and reality testing. Once decondensed, the elements can be recombined in new representations that are truly plastic, expressing an affective rather than a literal or concrete reality.
Psychoanalysts do this well; it is how they work with dreams, with fantasy, with art, with literature, and with group symbolic representations. Medication can be helpful, strengthening percept-concept-affect boundaries.
Personality defenses, which are well suited to psychoanalytic and psychodynamic work, surround the psychotic symbol guarding it from observing ego and reality testing. Core personality conflicts appear in the psychotic symbol.
As the work opens up more of the psychotic process, the observing ego is given more information about the dynamics of the capture of the reality chosen for symbolic use.
One can see these processes at work in art. Van Gogh, Munch, and Rothko, all likely had psychotic mood disorders and painted during episodes, even as their moment of suicide approached. Their works are creative because the artists' trained tertiary processes were intact, though the iconography was impoverished relative to that in earlier work. They were unable to use the representations of their illness in their work. Art produced during an episode of the illness shares the organizing features of the illness.
The ego can be creative even when in the throes of psychosis, whether the patient is an artist or not. As therapists, we use this in our work. We help our patients understand the meaning of their psychotic symbols as they reach creatively for new and more adaptive compromises. Thus, the psychoanalyst has much to offer patients who suffer from psychosis.