Psychosis (Madness)

Paul Williams

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780953710508
• eBook ISBN: 9780429918193
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

In this volume a number of British psychoanalysts introduce us to psychoanlaytic definitions of intra-psychic and subjective meaning in patients suffering psychotic conditions. Irrespective of the particular type of psychotic illness under consideration of the context or treatment, each paper illustrates how the psychoanalytic clinician searches to establish meaning from events which are highly complex and often overwhelmingly confusing.Contributors: "Psychosis and violence" Leslie Sohn; "Sorrow, Vulnerability and Madness", Michael Conran; "How Can You Keep Your Hair On?", Michael Sinason; "The Delusions of the Non-Remitting Schizophrenias - Parallels with Childhood Phantasies", Thomas Freeman; "Managing Psychotic Patients in a Day Hospital Setting", Richard Lucas; "Desctructive Narcissism" and "The Singing Detective", David Bell.

1
Psychosis and violence

Leslie Sohn

Last year, in another place, I presented a paper on unprovoked assaults, and discussed some patients, one of whom will appear in this paper. From that I wrote a paper which appeared in the International Journal of Psychoanalysis (Sohn 1995).

I want to take a farther look at the patient I described in order to emphasise the relationship of his psychotic state to the events of violence which brought him to our attention. And then, in contrast, I want to talk about a young psychotic woman who never resorted to physical violence, although she had had delusional ideas of having murdered - or somebody having been murdered, or somebody having murdered somebody - and she felt that she'd seen the dead body. Then I want to talk about two other men; one a borderline case with almost delusional belief in his sanity, whose violence was solely directed unwittingly to his own mind and its contents, and to the mind of others who were exposed to him, and we were expected to believe implicitly in his conclusions. To do so, and to believe that, would mean that the listener's mind would have totally given up its own scepticism and independent thinking. In other words, that the listener's mind would have felt murdered, or dead. This man deigned physical assault; he was above it, and I think he even deigned physical contact as well.

Originally this paper had a double title, and it had derived from a man called Mr M B, During our first meeting, Mr M B said to me: 'If the bloody black and white dog hadn't crossed the road at that moment, the police would never have thought of me. Anyway,' Mr M B then said, 'I didn't do what they said I did.' In fact he had violently attacked a man whom he thought he knew. He could never have done what the police thought that he had done. He had merely acted quite normally and acceptably. On the ward, Mr M B had threatened frequently to attack a fair-haired young man who was a fellow patient, for what he, Mr M B, thought were perfectly validly reasons. The fair-haired man, he believed, laughed and mocked him. He had no idea why the young man behaved in such a provocative way. Mr M B was not fair-haired: he was dark and swarthy, the son of a South American black man and European white woman. As I got to know more about Mr M B this question of his black and white origins arose in our meetings. He was ashamed of his mother and hated her for being with a black man who later had abandoned the family. He was similarly ashamed and hated his father for spoiling his own pedigree, and diluting his blackness. Mr M B's blackness and whiteness had dogged most of his 24 years.

The telling of these clinical moments leaves out the diagnosis. Mr M B was a paranoid schizophrenic, and experienced mental and environmental events according to the pattern laid down by his illness, He did not connect in any way the facts I've related to his attack on his victim: he was totally involved in the conviction that he held about the little black and white dog that had led the police to his door. The attack on the victim was seen by many who knew the victim and our patient. Mr M B not only wanted things to be either black or white, but he had simplified them in a strange story which explained everything to him. For Mr M B, a psychotic man, external reality is treated as if it were internal reality - something that can be manipulated at will. Internal reality itself is treated as though it consisted of simple, unalterable facts about the world. For Mr M B the dog might be described as the substantive noun of the present participles of his mind: thus it explained everything, as did the condensation of the thought represented by the black and white dog. He could tell me historical facts about his life and its contents, about his violent father, and facts about his mother: in fact, facts about his mother invaded his thoughts and his life. I could sense that they were significant to the genesis of his illness and its outcome, which had made him a particularly dangerous man, in my view. He, however, was detached from a capacity for mental continuity, and free of the significance of the facts he recounted. A condensed, literal version of his mind's hatreds operated in the black and white fashion I have outlined. Our patient would like to be the other young man on the ward - fair, or white, or pure - or, in contrast to this - black. In the short time I knew him, 'fair' seemed to signify the antithesis of the total unfairness of life that he had been dealt out. All these facts were waiting for a psychoanalyst to interpret to Mr M B.

However, if Mr M B had said, 'Right, Doctor, all that's very true. In the first place, I hated the facts of my parents' sexual relations; I hated it even more when I was old enough to know I would feel a mongrel amongst mongrels; my mother's post-natal long-term depression was equally disturbing to me; but tell me, dear Doctor: why couldn't I, why didn't I deal with all these facts and their repercussions in a mature way, so that I would know my story - its vicissitudes, its dangers instead of my being desperately concerned with these fragmented versions of my mind's contents? Why is my mother's whiteness, which was not visited on me, so important? Or my idealised version of my father's blackness - why do I have such difficulty in tolerating mixed thoughts and feelings? And why do I simply corral my history into this black and white dog business? Why do I do it so violently, and why do I try to evacuate my unconscious totality into that nice white boy on the ward?' Mr M B never asked me these questions. He moved to safer territory. So I was left thinking I knew so much about him, and he knew so very little about himself. It's a classical forensic psychiatric phenomenon, wherein exists a major discrepancy between what the psychiatrist knows and what the patient knows, or rather doesn't know.

I'll try to answer Mr M B's unasked questions by talking about one of a group of patients all of whom possess a similar pattern of behaviour for similar reasons. This may create the possibility of explaining things to Mr M B when an opportunity arises, and it may explain why Mr M B didn't ever say to himself, 'What is there about me that makes me the way I am? Firstly, why do I never ask myself such a question? Why does my mind operate in this peculiar way, so as to avoid original causes and effects, and present me with strange thoughtless quandaries? For instance, do I ever actually stop to think, or do I replace thought with shallow, ready-made ideas?" The group of patients to which I refer and from which Mr M B comes (there are nine patients in the group in total) were all seen at the Dennis Hill Unit at the Bethlem Hospital, which is part of the joint Maudsley-Bethlem Hospital. I shall concentrate on one patient only and discuss him; as it turned out I could discuss any one of this small group as there is such a definitive similarity in them regarding their illnesses and behaviours. My original approach to these patients was to further an enquiiy into their suitability for psychotherapy on the in-patient unit. Gradually, however, they became of interest as part of a more general investigation into their illness, and the particular patient to be reported upon was treated by myself.

The initial presentation of all these patients was a keen wish to speak and to be spoken to, but not necessarily to be spoken about. Gradually, a life-long mental illness manifested itself, and this induced truancy and a general unwillingness to attend sessions. Mostly there seemed to be a lack of interest in their own, sane selves. I think that their initial enthusiasm represented a vain hope to fully regain and reestablish their delusional objects, felt to be possibly lost as a result of finding themselves in a new hospital treatment system. From the outset one of the men (I will call him Mr J P) permitted us, by the nature of his referral, to formulate a long-term view of this man's treatment. There were no limitations on time regarding his treatment or length of admission. His future was intimately related to long-term treatment, and I was conscious throughout of the fact that, should there be any untoward developments in his illness and therefore in the therapy, I could rely on a full back-up system for further in-patient care on the unit. Another factor was Mr J P's capacity to be interested in and to maintain, to the best of his ability, his interest in being my patient. We met regularly over a three-year period. The best of his ability included the vicissitudes of his capacity to act out. A minor version of this was physical illness, clearly attributable to excessive smoking and which with minor short intermissions stayed excessively dangerous. and on a few occasions he was cared for in bed. His sessions were interfered with as a result of acting out on two occasions, once for a period of a fortnight. Generally he dealt with this with a cheerful, manic, carefree smile. Far more serious were episodes of excessive drinking, and I am sure that on a few occasions he smoked cannabis. All these facts may point to a view that one could not call this a truly psychoanalytic setting, whatever that means. A further complication was that, by the very nature of their treatment in a medium secure unit, all these patients were under varying categories of certification, and they were clearly told at the onset of their seeing me, that they could expect confidentiality, unless there was breach of security. Our contractual relationship would allow me to notify the unit authorities if such a breach occurred. Fortunately, this never had to take place.

By the time I saw Mr J P he was a 6o-year-old, worn-out man. He'd been an in-patient in a secure special hospital for 15 years, having been admitted under Section in the late 1970s. He was emphysematous, and he smoked heavily. Until he got used to the possibility in his sessions that he could speak to me in an ordinary fashion, he spoke in an ordered, sycophantic, apologetic way, as if I were a pompous superior officer who not only demanded this but would punish him if he did not address me in this way. He would agree with everything I said to him, as if disagreement were highly dangerous. He'd waited a very long time to come to the Dennis Hill Unit, and this was the only means available to him to ensure treatment and to restore balance in his unbalanced mind. He would interlard his ideas, occasionally at the outset but more frequently later, with statements from literary and dramatic sources, and was clearly well read and informed. He claimed an attachment to racist political thoughts, and to Roman Catholicism. He certainly had a history of racist attitudes, and was occasionally overtly racist and superior. He'd grown up in the north of England, the fourth and youngest child in a coal-mining family. His father, a heavy drinking man, was described by the patient as having no status in the mining community. The patient, who himself worked underground for a year, failed to stay in his community and ran away from home at 16 to join a circus. Later, he went into the Guards, following one of his older brothers. His good record in the Guards was periodically spoilt by drinking bouts, but he finished his service despite a long period in detention. Various occupations, interests and wanderings followed. There are constant reports in his various hospital notes that he was felt to be rather a good journalist or a good actor, but invariably something would always interfere with and spoil the situation. The first admission took place in his late twenties followed by a series of subsequent admissions, most of which were terminated by apparent cures, promises to stop drinking, and promises of refusal to take drugs. He was frequently discharged because of aggressive, destructive behaviour and some violence towards the staff.

Throughout all this, the diagnoses were all the standard ones of schizophrenia. But there were phases when he read, worked well, and even published short stories and literary criticism, and some poems. But he never seemed able to attach himself to anybody or anything for very long. He was married twice; both women left him. He was promiscuous, and there was a history of homosexual prostitution; not quite the sort of case that gets taken on at the Institute of Psychoanalysis! His story about the index offence varied in two essential details - firstly regarding the preface. He originally told me that his welfare benefits were a day late in arriving, which worried him. Later he corrected this. He had arrived at the DHSS office a day late because he'd been drinking heavily, and he'd expected that the nice lady at the office would be helpful, because she'd always been nice to him. She was unable to help him, however, and asked him to return later, but expressed doubts as to whether his benefits would be available. This doubt transmitted itself forcefully to him, reaching a climax on the platform of the tube station where he was going to take the train home. He stuck to this version of the story throughout his time with me. Somebody (ostensibly, the nice lady) who had been so helpful and kind was giving up on him, but it was his own fault. He was angry, excited, miserable and penniless. During his wait for the train home at the tube station he had grabbed a man - a total stranger - and pushed him forcibly towards the line. Fortunately, though the man's legs ended up dangling over the edge, he was saved from ghastly injury. This is where the second change in the patient's story occurred, and this fact is interesting in the light of my ideas about such patients. Our patient behaved in telling me his story as if he were utterly convinced that the man he pushed was trying to commit suicide. He remembered this in his sessions with me, and admitted that he had great difficulty in giving up this belief. He added in this context that his own behaviour was merely to frighten the man out of committing suicide. In the later version of the story, he said the man had insulted him by calling him a Jew, and this had upset him. Actually, the two stories, though in a physical sense so far removed from each other, are not so dissimilar on close examination. In the first instance, he clearly projects his murderously suicidal ideas into the man; by trying to frighten him he is also indicating how he split the conflict that existed in the psychotic part of his mind. We also know, in the second instance, about our patient's racist attitudes. Jews were not very much higher in his social map than 'niggers'. Here, once again, in his picture of himself at the time of the offence, is a depressing disparity between a despised figure and his mind's idealised view of himself. After the attack, his behaviour was described as grandiose. He claimed to have won the VC and seems to have justified himself by making racist comments about Jews and black people. In my description of what I believe to be his psychopathology, we are looking at events taking place in the psychotic part of the mind of this man; so that if I say that he feels himself to be inferior to the person he was before the traumatic disappointment in the welfare office, this is a way of using ordinary language to describe the workings of the psychotic part of his mind. In him, such a feeling is furnished not only by the character defects of a racist, but also with the added exaggerations of maniacal superiority that a psychotic mind can produce. Projections are split off violently and suddenly, and carry the need for delusional certainty. His good object, exemplified externally by the lady in the office, is but a protective veneer against his mind's adherence to delusional objects. She might be considered a possible symbol of his mind's delusional objects with which he communes and ruminates. Thus the total imagery of his psychotic mind, at that moment, is unaffected by any mitigating sanity, so that the feeling of murderousness to the nice lady has to be got rid of extremely quickly, if only to protect his own mental contents. When he feels inferior, he feels it as if he were an inferior Jew or black man, or combination of both. He successfully rids himself of such identifications, and this is confirmed by the material when he said he was accused of being a Jew, or that the man was suicidal. Our patient was merely 'trying to frighten' him. This is related to the projection of psychotic anxieties engendered by the events. But the question arises, however, once he's achieved a relatively bland, hypocritical position visa-vis his victim, why isn't it enough to enable him to walk away smugly, feeling all is aright with his mental world - thank you very much? After all, this sort of thing must have happened to him many times before. It could be seen, for example in his continuing to smoke despite his crippling emphysema, over which he triumphs, and not only by denying it, but by treating it as a statement of inferiority in somebody else. He spent much time persecuting his emphysema. But this time it's different. His mind is about to lose its feeling of having good, albeit delusional, objects within itself. And he can't project that feeling as he did the others without the physical enactment of reassurance. Later I'll discuss my view of how this happened.

Mr J P experienced a sense of grandiosity after the events I described above. This featured in two of the others belonging to this small in-patient group and is connected to the experience of loss. Loss, and the various responses and results of it, featured in Mr J P's sessions with me. In an indirect fashion he could talk about what was, what had been, what could have been, what so-and-so said or wrote and said or wrote no more. He seemed always to be protected from actual experiences of loss by a veneer of superiority, which in his everyday dealings on the unit irritated some people. He read and he discussed what he read, and wrote for the hospital magazine perfectly readable material. Gradually, statements about his childhood entered into the sessions. He could not understand why everyone made such a fuss of the failure of his family to be in touch with him, and he with them. It was a simple continuation of his childhood experiences. He felt (incorrectly) that he was by now inured to deprivation. For him and his own egocentric world, what counted was what 'they' thought of him. I never got to the full constitution of'they', but he admitted that he daydreamed all the time about him and 'them', and how he fantasised conversing and smoking with them all whilst they drank together. He once joked that if he published his thoughts, there would be a large market for their pornographic quality. Clearly Mr J P's dreamworld kept him well thought of and warmly welcomed by his so-called private circle. Mr J P's analysis was so different to the ordinary, everyday analytic situation, not least in the strangely restrictive world this man had lived in for over four decades. I am referring in the first instance to real interferences and inroads his illness had made upon his mind. There were his psychotic illnesses, the long alcoholic episodes and their interference with ordinary life; and the fact that he'd been enclosed for nearly two decades in a maximum security hospital. For Mr J P, the odd situation of having an analysis in a medium secure unit was curiously acceptable and easy to tolerate. The sessions themselves had a peculiarly enclosed and enclosing character, almost a claustrophilic quality, which I felt were a reflection of his mind's penumbrated quality. But behind this, he was also having the opportunity of experiencing a long-term relationship of total privacy and primacy. He was the subject of interest, though sometimes unfortunately only to myself {which in the perverse areas of his mind served their own purpose). He could be as delinquently careless, even as mad, as he wished to be and there was always a figure listening to him and caring about him - a situation Mr J P had never known.

I was perturbed by the perverse quality of Mr J P's behaviour with me, which would vary from sleepiness and inattentiveness to paroxysmal episodes of sleepiness of almost narcoleptic intensity. On the other hand there were periods of manic chatting and gossiping. These patterns were linked to his identification with his heavy drinking father and his own feeling of himself as being like his father, a man of poor status and little respect, which he was busy denying by his behaviour patterns. Later, the perverse character of his behaviour was further linked to his periods of homosexual prostitution, when he enjoyed not the physical, but what he called the social lives of these relationships; some casual, others repetitious. Gradually a more thoughtful person began to emerge; unfortunately, even this had a quality of ambiguity and cynical jokiness.

In one particular session he had decided (on his way to the session) that he would like to, or perhaps that he would, smoke. He had previously given up smoking during sessions. He felt that we were beginning to recognise his capacity to be provocatively aggressive because he knew that I disliked his smoking, and I felt he was behaving in this way to me. In the session he became silent after a while. I was suddenly doubtful about the sincerity of his presentation, as if I were being invited to believe something that I would later feel foolish about having believed. I shared my doubt with him, and added that he didn't know if he was being sensible or trying to please or trick me. He replied that he was having difficulty in keeping me out of his pornographic conversations that he had with himself. I said that he felt relieved that I'd openly questioned his sincerity, that he was afraid of corrupting me as he did his own mind, sometimes consciously, with his fairy stories, or more seriously by his behaviour, as had happened in his index offence. I said that all this occurred when this time it was he himself who had not kept his promise to himself not to smoke in the session. He then spoke about his anxieties about the future, as to where he was going to live and work when we ended his treatment. He said he looked so much like the comedian on the TV who could distort his face so completely and become so unlike himself, but at the same time become the person his face was alluding to. I felt he was talking about his weird identifications again, and their distorting effect upon his mind and behaviour, and how easily he lost his sense of self. This session was typical of the last few months of his stay on the unit, which gave us the opportunity to reflect on the kind of treatment his illness required. His serious problem in this and other sessions was that a joke could rebound; and he could be left feeling empty of future and purpose. The joke is however also serious, in that his mind is distorted into a belief that it can't work properly and he feels freakish. In later sessions, the metaphor of the comedian with the distorting face was replaced by the various psychiatrists he'd known over the years, who had avoided knowing about his mind and its vagaries by being very friendly and talking in advisory generalisations. As he said himself, 'Fancy advising me!' These denigrating portrayals were a graphic re-presentation of his own previous thoughtless and somewhat condescending attitude to himself. This outlook lay at the centre of the problem of tricking, of being tricked, and of trickery itself. He felt that he had either tricked the doctors into stupidly believing in a potential in him which he couldn't possibly maintain, or that they now contained his own trickery and condescension. This is why he felt so relieved in the session I have described when I queried his sincerity. At the same time, life had tricked him, by giving him so many talents but not the equipment to use them. And this sad situation carried the unhappy identification with his father who drank and had no status, a fact which was relieved by further drinking. Mr J P ended treatment and left with an awareness of his aggressive behaviour and potential, and its role in the index offence. He asked, 'Was I born insane, or did something make me insane?' I suppose the answers might be 'Yes, you had a predilection' (though I didn't know enough about his earlier years) and 'Yes' to the fact that something(s) had affected him to give rise to his insanity. He also knew that there were times when the only thing that interested him was drinking. Maybe it would have been more profitable if we had met 30 years earlier: I am not sure. However, he had become interested in himself and the sessions, not in a narcissisti...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Acknowledgments
• Introduction
• 1 Psychosis and violence
• 2 Sorrow, vulnerability and madness
• 3 How can you keep your hair on?
• 4 The delusions of the non-remitting schizophrenias: parallels with childhood phantasies
• 5 Managing psychotic patients in a day hospital setting
• 6 Destructive narcissism and The Singing Detective
• Index