Relational Perspectives on Psychosis and Anxiety
Object relations theories focus on the catastrophic sense of futility, terror and powerlessness which underlies psychotic states. The disintegration of the person’s subjectivity or sense of an embodied self which accompanies such states is experienced in pervasive feelings of external threat and danger and internal persecution and paranoia, and in feeling either utterly isolated and disconnected in their relationships or massively engulfed and intruded upon. These disturbed phenomenological states may reflect, in part, the breakdown of the capacity to discriminate between “me” and “not-me” objects - between self and non-self. Winnicott describes this perceptual process as “the perpetual human task of keeping inner and outer realities separate yet inter-related.”
Psychosis is principally associated with delusion, and delusion is taken as the hallmark or basic characteristic of madness. Thus, psychosis confronts us with the problem of consensual meaning – how are we to understand the “mad” person in the absence of a shared reality? While overtly psychotic individuals form a small part of the general population, madness is an implicit thread in the discourses which inform our social and political life. Images of madness are used to depict human destructiveness, violence and evil. As Mike Eigen has pointed out, “it (psychosis) is one of the phenomena of human life that takes us to the edge of what is possible to experience”. Nevertheless he describes psychosis as the “Cinderella of psychoanalysis”.
This situation reflects Freud’s view that those suffering from psychosis are not suitable for psychoanalytic treatment. Freud contended that the ego’s alienation from reality is the pivotal disturbance in psychosis. However, he argued that there is not only meaning in madness, but also a fragment of historical truth. Indeed, it was Freud’s deep awareness of the precariousness of our hold on reality that led to the foundation and elaboration of psychoanalytic theory. His understanding of psychosis also led to his illuminating exploration of dreams and the unconscious, and to the construction of theories to interpret, or find meaning in, mental phenomena that at first sight appear opaque and nonsensical.
For over a hundred years the mainstream view has been that psychosis is an inherited organic illness or disease, the result of lesions, or an imbalance in brain chemistry. Irregular brain patterns and abnormal neural transmission have been intensively studied, but the results have been inconclusive. Many psychiatrists today would argue that organic and biochemical explanations of psychosis are limited in their explanatory value, emphasising, instead, psychological and social factors. In terms of the treatment of psychosis, the debate focuses on whether biological and psychological interventions can be effectively integrated.
Within contemporary relational psychoanalysis, psychosis is seen as part of the human response to overwhelming stress and perceived danger. For example, Stolorow and Atwood understand delusions as functioning to communicate that the self is crumbling and attempting to hold itself together in whatever way it can – “a last stop before the abyss”. They argue that delusions “cannot be understood psychoanalytically apart from the intersubjective contexts in which they arise and recede”. From a self psychology perspective, the psychotic person’s primary need is to have his or her subjective reality validated by an empathically attuned other. An approach also found in the enlightened writing of Harold Searles.
R. D. Laing emphasised the person’s experience of “ontological insecurity” in the development of psychosis. He saw the transition from sanity to insanity as one in which “in order to be safe in the world the self has cut itself off from relatedness with others … it is not possible to go on in a sane way if one tries to be a person disconnected from all others”. Laing contends that “what is called psychosis is sometimes simply the sudden removal of the veil of the false self”, a veil behind which the person “plays at being sane”. He also stressed the importance of recognising the sense in which the person’s “delusional” accounts are true rather than absurd, arguing that this requires setting these accounts in their social context, particularly in “power relations in the family”. Indeed, Laing and Esterson aver that experiences and behaviour that are taken to constitute schizophrenic symptoms may appear socially senseless without reference to the person’s original family context. The authors’ clinical studies in Sanity, Madness and the Family demonstrate in a compelling fashion the way in which such “schizophrenic” behaviour becomes socially intelligible once set in an interpersonal, familial context. Despite this, as Read notes in Models of Madness, the possible role of families in eliciting “schizophrenia” has become a taboo subject in mainstream psychiatry.
From a narrative perspective, Roberts contends that delusions are “creative attributions of meaning to the experience of psychotic disintegration”. He argues that the formation, elaboration and persistence of delusions “are significantly mediated by narrative processes”. Thus, the stories mad people tell themselves function to create meaning and organise experience that has become disorganised and meaningless in the wake of a psychotic breakdown. Roberts contends that delusions arise from “the healthy part of the person who attributes meaning to anomalous experiences as a way of compensating for significant losses, traumas and destructive events” that are too painful to directly acknowledge to the self. To understand the delusional story in the here and now, we need to pay attention to the person’s socio-cultural context, biographical history and formative interpersonal experiences.
On discussing infantile psychosis from an ego psychology approach, Mahler and Furer argue that “The salient feature in childhood psychosis is that individuation, i.e., a sense of individual identity, is not achieved.” The authors found that the most extreme separation reactions occurred in infants whose mothers were “too exclusive and too parasitic”. They contend that the infant’s reaction to separation in these dyadic relationships are “reminiscent, clinically, of the annihilation dread of adult psychotics”. Following Trevarthan and Hubley, Daniel Stern sees such developmental failures as deriving from a traumatic disturbance of affect attunement in the mother-infant relationship which results in a deficient capacity to share emotional, intentional and attentional states of mind in the intersubjective domain of being and relatedness.
The view that the origins of psychosis lie primarily in early environmental failure has received increasing support from the scientific community, particularly in the light of neurobiological evidence detailing the impact of disorganised attachment and cumulative developmental trauma on the child’s neurological and emotional development. Findings indicate that childhood experiences of neglect, stress and trauma can compromise brain development. Ito et al., and Sapolsky, respectively found that the effects of early trauma on the developing brain are very similar to the dysfunctions found in the brains of adult “schizophrenics”, as well as in those diagnosed with post-traumatic stress disorder and dissociative disorders. The evidence that children’s immediate social environment affects brain development would now appear to be unequivocal. Such findings challenge bio-genetic explanations of psychosis and again support psycho-social explanations. Findings from this area of research are consistent with developmental theory which holds that an infant’s relationships are founded upon, and mediated by, repeated interpersonal interactions between caregiver and infant.
Schore, in building on Mary Main’s development of the Adult Attachment Interview, links such findings to a compromised ability to monitor states of consciousness and regulate affective and bodily states when under interpersonal stress. Environmental failures of these kinds leave the person impervious to attachment communications and interactive psychobiological regulation and therefore initiate the child along a potential developmental pathway that may culminate in psychological breakdown in later life.
Similarly, Peter Fonagy and his colleagues have suggested that a well-developed capacity for reflective functioning or mentalisation is what enables the person to distinguish inner reality from outer reality, pretend modes from “real” modes of functioning. From this perspective, the capacity of the parent as mediator, reflector, interpreter and moderator of the child’s mind cannot be overemphasised. Disturbed and abusive parents obliterate their children’s affective experience. The lack of mirroring and marking of affective states leaves the child with an inner life that is experienced as barren and unknowable. Such feelings of alienation and isolation become fundamental to a fragmented and empty sense of self, and to the failure to develop sustaining and nurturing relationships with others in adulthood. In short, affects that are not held in mind by the caregiver, or, more significantly, are misrepresented or distorted, remain diffuse, terrifying and unrepresentable. This may lead to a range of borderline phenomena and pathology of the self in later years.
Studies such as these emphasise the way in which caregiver behaviour that is aggressive and intrusive, or fearful and withdrawn, as well as parental miscommunications and misattunements, are critical in the intergenerational transmission of attachment and trauma, resulting in a compromised capacity for affect regulation and mentalisation. Indeed, data from attachment research indicate that significant disruptions in caregiver-infant affective communications may result in child disorganisation. These findings also highlight the extent to which unresolved experiences of loss, neglect, sexual, emotional and physical abuse, and concomitant symptoms of post-traumatic stress, have been overlooked in the treatment of psychotic people. Research focusing on combat veterans has identified a massive overlap between dissociative symptoms and the symptoms of people diagnosed with schizophrenia. This suggests that the coping strategies and mental defences that people adopt to cope with trauma, such as dissociation and hyper-vigilance, confers vulnerability to psychosis. Read argues that it may be more productive to view symptoms of PTSD, dissociative disorders, schizophrenia, BPD, and so on, as related components of a long-term process that begins with adaptive responses to early aversive events, rather than persisting with the current practice of separating the trauma/abuse sequelae into discrete categories of “disorder”.
The impact of institutionalised racism within the psychiatric system has been explored by Fernando in the context of the disproportionate diagnosis of people from the black and minority ethnic communities as “mad and dangerous”. Franz Fanon, an early pioneer in this field, understood the experience of racism as psychic trauma. Similarly, Barbara Fletchman Smith argued that African-Caribbean peoples’ experience needs to be understood in the historical context of slavery. Thus, she contends there is a need to consider the impact of powerlessness on the mental health of persons from black and ethnic minorities alienated from the mainstream white culture, and the way in which illness may function as a form of communication in a context of overwhelming mental confusion and intrapsychic conflict.
Labelling Theory attempts to understand how persons categorised as schizophrenic or personality disordered may have been subjected to arbitrary and despotic social processes – the way in which the person’s social characteristics, e.g. their class, status or ethnicity, may influence the severity of the societal reaction, independent of psychiatric condition, and how, once successfully labelled, the person becomes stuck with the deviant label.
Research findings and the development of relational theories have contributed to the re-evaluation of the traditional exclusion from psychoanalysis of those deemed “unanalysable”. Relational perspectives are at the cutting edge in psychotherapeutic work with persons whose sense of a secure psychological self has been severely blighted by loss, abuse and trauma. Indeed, on discussing the hope and dread that characterises such work, Mitchell asserts that “pseudo-normality is the clinical problem of our time”. This assertion resonates with McDougall’s “plea for a measure of insanity” so as to preclude us from developing a stultifying “normopathic” personality, the function of which is to maintain “a well-compensated psychotic state”. Writing much earlier, Winnicott argued that “we are poor indeed if we are only sane”. In a later self-reference he wrote “I was sane, and through analysis and self-analysis I achieved some measure of insanity”.
Laing, in his preface to the Pelican Edition of The Divided Self, regrets having drawn too great a distinction between persons suffering from psychosis and persons deemed to be sane, suggesting that it is not a matter of “Them or Us”. Similarly, Heinrich Racker seeks to dispel the myth that there is one well person and one sick person in the analytic encounter, contending, instead, that there are two ill people! With these humbling thoughts in mind, it may be argued that in order to build empathic bridges and emotionally connect with the subjectivity of persons isolated from human relatedness by psychosis we need to be in touch with our own deepest anxiety and existential dread and terror – to intimately know the “mad” parts of ourselves while remaining “sane”.
Suggested Further Reading
Dozier, M., Chase Stowall, K. & Albus, K.E., “Attachment and Psychopathology in Adulthood” in Handbook of Attachment, edited by Cassidy and Shaver, New York: Guilford Press, Ch 34, pp 497-519.
J. Holmes, “Suicide and attachment theory” in Attachment, Intimacy and Autonomy: Using Attachment Theory in Adult Psychotherapy, Northvale, NJ: Jason Aronson, Ch 6, pp. 143-157.
Stolorow, R.D., Brandchaft, B. & Atwood, G.E. (1987). Treatment of Psychotic States, Ch 9, pp 132-172. IN Psychoanalytic Treatment: an Intersubjective Approach. Hillsdale, NJ: The Analytic Press.
Laing, R. D. and Esterson, A. (1964). Sanity, Madness and the Family: Families of Schizophrenics. Penguin.
Roberts, G. (1999). The Rehabilitation of Rehabilitation: a narrative approach to psychosis, Ch, 8, pp 152 – 180. IN Healing Stories: Narrative in Psychiatry and Psychotherapy, G. Roberts & J. Holmes (eds.). Oxford: OUP.
Laing R.D. (1990). Ontological Insecurity, Ch 3, pp 39-64. IN The Divided Self. Harmondsworth: Penguin Books. (1st pub 1959)
Laing, R.D. (1990). The Embodied and Unembodied Self, Ch 4, pp 65-77. IN The Divided Self. Harmondsworth: Penguin Books. (1st pub1959)
Searles, H. (1993). The Effort to Drive the Other Person Crazy: an Element in the Aetiology and Psychotherapy of Schizophrenia, Ch 8, pp 254-283. IN Collected Papers on Schizophrenia and Related Subjects, London: Maresfield Library. (1st published in 1959).
Racker. H. (1968). Transference and Countertransference. Routledge.
Mollon, P. (2001). Schizophrenia and Depression: the Fragmented Self and the Thwarted Self, Ch 8, pp 165-190. IN Releasing the Self: The Healing Legacy of Heinz Kohut. London: Whurr Publishers. **
Werbart, A. & Lindbom-Jakobson, M. (2001). The ‘living dead’ – survivors of torture and psychosis. IN A Language for Psychosis: psychoanalysis of psychotic states. Paul Williams (ed.). London: Whurr Publishers.
Read, J., Goodman, L., Morrison, A. P., Ross, C.A. & Aderhold, V. (2004). Childhood trauma, loss and stress, Ch 16, pp 222-252. IN Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia. Read, J., Mosher, L.R. & Bentall, R.P. (eds). London: Routledge.
Kahr, B. (1993). Ancient Infanticide and Modern Schizophrenia : the Clinical Uses of Psycho-historical Research, Journal of Psychohistory, Vol 20, 267-273.
Williams, P. (1998). Psychotic Developments in a Sexually Abused Borderline Patient, Psychoanalytic Dialogues, Vol. 8 (4), pp 459-491.
Black, M. (1998) Fracturing drive or fracturing connections: Commentary on paper by Paul Williams. Psychoanalytic Dialogues, Vol. 8 (4), pp 493-500.
Fletchman Smith, B. (2000). A Little Girl’s Story, ch 6, pp 77-92. IN Mental Slavery: Psychoanalytic Studies of Caribbean People. London: Rebus Press.
Read, J. (2004). Poverty, ethnicity and gender, Ch 13, pp 161-194. IN Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia. Read, J., Mosher, L.R. & Bentall, R.P. (eds). London: Routledge.
Fernando, S. Race in the Construction of Dangerousness. Paper presented at the Bowlby Memorial Lecture, 1999.
Eng, D. L. & Han, S. (2001). A Dialogue on Racial Melancholia, ch 7 pp 233-267. IN Bringing the Plague: Toward a Postmodern Psychoanalysis, S. Fairfield, L. Layton & C. Stack (eds.). New York: Other Press.
Lesser, R. C. (2001). Discussion of A Dialogue on Racial Melancholia, ch 7a pp 269-278. IN Bringing the Plague: Toward a Postmodern Psychoanalysis, S. Fairfield, L. Layton & C. Stack (eds.). New York: Other Press.
Holmes, J. (2004). Disorganised attachment and Borderline Personality Disorder: A clinical perspective. Journal of Attachment and Human Development, Vol. 6 (2), pp. 181-190.
Winnicott, D. W. (1974). Fear of Breakdown. International Review of Psychoanalysis 1:103-107.
Vas Dias, S. (2004). Cumulative Phobic Response To Early Traumatic Attachment: aspects of a developmental psychotherapy in midlife. Journal of Attachment and Human Development, Vol. 6 (2), pp. 163-179.
Laing, R.D. (1990). The ghost of the weed garden: a study of a chronic schizophrenic, Ch 11, pp. 178 – 205. IN The Divided Self, Harmondsworth: Penguin Books.
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With a commitment to mental health, Mr Renn provides services in English, including Psychoanalysis.
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