Psychoanalysis Meets Psychosis

Attachment, Separation, and the Undifferentiated Unintegrated Mind

Michael Robbins

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9780367191177
• eBook ISBN: 9780429575563
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Psychoanalysis Meets Psychosis proposes a major revision of the psychoanalytic theory of the most severe mental illnesses including schizophrenia. Freud believed that psychosis is the consequence of a biologically determined inability to attain and sustain a normal or neurotic mental organization. Michael Robbins proposes instead that psychosis is the outcome of a different developmental pathway. Conscious mind functions in two qualitatively different ways, primordial conscious mentation and reflective representational thought, and psychosis is the result of persistence of a primordial mental process, which is adaptive in infancy, in later situations in which it is neither appropriate nor adaptive.

In Part I Robbins describes how the medical model of psychosis underlies the current approach of both psychiatry and psychoanalysis, despite the fact that neuroscience has failed to confirm the model's basic organic assumption. In Part II Robbins examines two of Freud's models of psychosis that are based on the assumption of a constitutional inability to develop a normal or neurotic mind. The theories of succeeding generations of analysts have for the most part reiterated the biases of Freud's two models, so that psychoanalysis considers the psychoses beyond its scope. In Part III Robbins proposes that the psychoses are the result of disturbances in the attachment-separation phase of development, leading to maladaptive persistence of a primordial form of mental activity related to Freud's primary process. Finally, in Part IV Robbins describes a psychoanalytic approach to treatment based on his model. The book is richly illustrated with material from Robbins' clinical practice.

Psychoanalysis Meets Psychosis has the potential to undo centuries of alienation between society and psychotic persons. The book offers an understanding of severe mental illness that will be novel and inspiring not only to psychoanalysts but to all mental health professionals.

PART I

Not fully human

The unwitting collusion between medicine and psychoanalysis

1

NOT FULLY HUMAN

Psychiatric and psychoanalytic understandings of psychosis

Neurosis and psychosis are both mental illnesses with no specific organic cause – other than the subtle genetics that underlie ordinary personality idiosyncrasies – despite decades of costly research. Yet there is a historically based chasm of social acceptance and understanding separating them based on the belief psychosis is an organic disease whereas neurosis is not. Over the course of hundreds of years western culture has engaged in a search and destroy mission, sometimes blatant and other times more subtle, toward persons manifesting extremes of socially deviant behavior and mentation. However legitimized by medical jargon and papered over by a veneer of medical compassion it is widely accepted that such persons suffer from an organic defect or degeneracy that renders them morally and intellectually deficient, pariahs, not fully human. They are not ordinary folk like “us” who suffer from the range of personality quirks or idiosyncrasies, or suffer from an illness like diabetes or depression. The medical-psychiatric edition of this prejudice, for it is a judgment reached by committee without substantiating organic data, is the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM). The belief dates to the dawn of modern medical psychiatry and the work of Emil Kraepelin and Eugen Bleuler. It is based on observation and description of signs, symptoms, and behavior of persons considered abnormal or socially deviant, and inferences about causation. In that model, psychosis, more or less synonymous with schizophrenia and manic-depressive illness, is considered to be a form of organic degeneracy of early adult onset. In his textbook of psychiatry Bleuler, who is responsible for the diagnosis schizophrenia, was of the opinion that such persons are racially inferior and should be sterilized to prevent species contamination.

Psychoanalysis represents an entirely different tradition, one that considers mind as a meaningful system and seeks to understand it in an accepting humanistic way. It seeks to understand the “inner” and less conscious workings of mind, dynamic and structural, the ways in which they are unusual, and their relationship to individual psychosocial development. It is no accident that Freud created psychoanalysis in the course of his attempt to understand his own mind. Its paradigmatic problem is neurosis, a variant of normal mature mind that he believed afflicts many of us and limits our potential and sense of satisfaction. Psychoanalysis defines neurosis as the symptomatic manifestation of unresolved unconscious mental conflicts. Because of this humanistic history one would expect, and most psychoanalysts believe, that it depicts the psychoses in a more humanistic way. But such is not the case.

Freud and psychoanalysis did not knowingly venture into the land of psychosis, the territory of medical psychiatry. Freud had a private practice in his office and did not work in a mental hospital. He more or less accepted the belief prevalent among his psychiatric contemporaries Kraepelin and Bleuler that psychosis is a genetically determined mental/moral deficiency caused by an underlying genetic-organic deficiency.

Freud’s background in medicine and neurology meant that he was no stranger to biological reductionism and therefore open to accepting such conclusions. The term he chose to designate psychoanalysis’ flagship disorder, “neurosis” was coined by the Scottish physician William Cullen in 1869 to denote a disease of the nervous system. Freud borrowed the term and re-defined it to designate those conditions characterized by symptomatology arising from repressed unconscious conflict, one pole of which is usually driven by biological drive derivatives. In the introduction to his 1895 “Project for a scientific psychology” he writes “The intention is to furnish a psychology that shall be a natural science: that is, to represent psychical processes as quantitatively determinate states of specifiable material particles” (1895, p. 294). A quarter century later he wrote:

The deficiencies in our description would probably vanish if we were already in a position to replace the psychological terms by physiological or chemical ones. … We may expect it [biology] to give us the most surprising information … which will blow away the whole of our artificial structure of hypotheses.

(1920, p. 59)

Psychoanalytic historians tend to focus on how Bleuler, who was one of Freud’s earliest followers, was influenced by Freud, citing a number of psychoanalytic publications authored in the first decade of the 20th century by Bleuler alone and in conjunction with Jung, which unfortunately have not been translated into English (Falzeder, 2003), and by a series of letters exchanged between the two between 1915 and 1925 (Alexander & Selesnick, 1965). Of particular interest with regard to psychosis is the reciprocal question, how Freud may have been influenced by Bleuler.

Unlike Freud, who treated affluent patients sufficiently independent to live outside a hospital and come to his office, Bleuler practiced in a mental hospital, the Burghölzli, was its director beginning in 1898, and lived there with his family. He and Jung, who also practiced there, were colleagues and professional collaborators, as well as followers of Freud and his new discipline. Bleuler was a member of Freud’s Vienna Society and helped Jung publish the Jahrbuch, a forerunner of what is now the International Journal of Psychoanalysis. Jung and Bleuler were especially interested in Freud’s work on dreaming and fantasy, and in the concept of free association (1896, 1906). Bleuler published his well-known textbook in which he coined the term schizophrenia in 1911, the year Freud published his analysis of the Schreber case.

Bleuler resigned from the psychoanalytic society around that time. He was distressed by what he believed was the authoritarian religious element Freud was promoting. Of particular relevance to this book, he had a theoretical disagreement with Freud’s conclusion that Schreber’s illness was essentially neurotic, the consequence of repressed Oedipal conflicts over homosexuality and castration anxiety (Bleuler, 1912). He continued to admire Freud, however, and subsequently tried to nominate him for a Nobel Prize.

Although he was much more psychologically minded and humanistic than Kraepelin, Bleuler fundamentally concurred with Kraepelin that schizophrenia is a neuro-degenerative dementing disease. What he called the primary symptoms, the well-known “four A’s,” disturbed affect, autism, ambivalence, and disturbed associations, along with mental splitting or failure of integration, presumably reflect the degenerative organic core. Bleuler believed that what he called the secondary symptoms, delusions and hallucinations, are psychologically meaningful, susceptible of analysis using Freud’s theories, but the implication is that the meaning is epiphenomenal, not related to the origins of the illness. Brill (1944) quotes Bleuler’s 1906 paper on Freudian mechanisms in psychosis:

It is impossible to know the meaning of delusions without considering the Freudian discoveries. The content of many delusions is often nothing but a poorly concealed wish-dream, which by the means offered by the particular disease (hallucinations of the various senses, delusions, paramnesias) seeks to represent the wish as fulfilled – I say seeks to represent, for even in a delirium and in a dream, a person does not always entirely forget that his wishes are confronted by obstacles. The latter become symbolized as “persecutions,” just as similar experiences of healthy persons created Ormuz and Ahriman, God and the Devil.

(p. 98)

Bleuler’s basic belief, however, is reflected in his advocacy for sterilization of schizophrenics so that their hereditary dehumanizing taint not be passed on to others (Joseph, 2003, p. 160). He believed the secondary symptoms of hallucination and delusion were optional, so that it was possible to diagnose schizophrenia even in their absence. This belief is of interest with regard to the model advanced further in this book of a psychotic continuum, and the concept of psychotic personality disorder, a condition in which there are no blatantly obvious delusions or hallucinations.

Freud was conditioned to accept the opinions of Bleuler and others for two reasons. Unlike them he did not work in a mental hospital and did not knowingly have clinical contact with individuals deemed schizophrenic. And his neurological background led him to believe that his theory should be reducible to biology. The concept of fundamental organic deficiency rendering the person less than fully human runs through two of his models. First, his model of inability to form a human relationship, and second, his model that psychosis represents defect or deficiency in the mental equipment necessary to develop and maintain a normal or neurotic psyche, leading to splitting of the personality into more mature and progressively regressive or degenerative parts. He never pursued his most promising model that he derived from the phenomenon of dreaming, the primary process. He was committed to the concept of unconscious mind and the idea that the primary process was its modus operandi. He was unable to understand that the primary process is a modality of conscious mind as normal as that which underlies neurosis, and that just as ordinary thought can evolve into neurosis under suitable circumstances, so primary process consciousness can evolve into psychosis. Such an idea would lead to a model not of one human and one subhuman condition, but of two different but equally understandable mental disorders and their separate lines of development. Those who followed in Freud’s footsteps formulated models related to his and failed to recognize the extent to which they elaborated his basic assumptions, and that their idiosyncratically conceptualized efforts have perpetuated the prejudices and limitations of his model.

While psychoanalysis has made a number of efforts to extend its psychological theory of mind and meaning to psychosis in general, and schizophrenia in particular, these have by and large been unsatisfactory. With a single exception, the work of Ronald Fairbairn, psychoanalysis defines the psychoses, more or less, as failures or deficiencies in the maturational capacity to attain and sustain a normal/neurotic personality organization. Psychoanalysis has not succeeded in defining a realm separate but equivalent to the neuroses that we can accept and recognize in ourselves and those around us that is not tainted with the stigma of defectiveness. It has not articulated a model of illness and treatment that can be used to help the vast majority of the world’s mentally ill whose afflictions are beyond the purview of the theory of neurosis and an office psychoanalytic practice with the “worried well.” The relevance of Fairbairn’s (1952) contribution to psychosis is not widely recognized. In contrast to the majority of psychoanalytic theory, which is oriented around a conception of normality that holds that we are all neurotic, more or less, Fairbairn’s theory of schizoid personality holds that we are all psychotic, more or less, ranging from milder forms of schizoid personality that afflict all of us, to the severe conditions like schizophrenia.

In the pages to come I elaborate the hypothesis that there are two forms of normal mental activity and that depending on the vicissitudes of attachment and separation one may evolve in the direction of neurosis, the other in the direction of psychosis, and that both conditions are fully human, meaningful, and comprehensible by psychoanalytic theory. I propose that in addition to the more extreme conditions such as schizophrenia, there is a psychotic personality organization that many of us who are perceived as respected constructive members of society suffer from. The model I propose is intended to make psychosis a problem as ordinary and socially acceptable as neurosis, and in so doing bring it under the umbrella of psychoanalytic theory and therapy.

It is the thesis of this book that psychosis, in most instances, is a particular manifestation of personality that is no better explained as the result of neural defect than any other variant. Neurotic individuals are able to negotiate the major transitions of separation and individuation reasonably successfully, and as a result are capable of experiencing intrapsychic conflict. They suffer distress and limitations resulting from difficulties consciously recognizing the nature of the conflicts and resolving them. Psychosis, by contrast, arises from failure of attachment and consequent inability to separate from the mothering person and integrate a mind of one’s own. The result is inability to live independently and experience and resolve internal conflict. While genetic factors no doubt play a role in some instances, as they do in all personality variations, there is no convincing evidence that they are more than ancillary forces influencing conditions whose origins lie within the family of origin, and most specifically in the mother or caregiver–infant interaction.

Psychosis manifests itself in a variety of guises. Unlike neurosis it does not present as a complaint about internal suffering. Its manifestations tend to be external and to involve social perturbations in relationships and self-care. These may go unnoticed until they come to social attention around times in the life cycle that require new steps or transitions toward separation from family of origin and establishment of an independent identity and sense of self. The most severe manifestation, child psychosis, emerges when children cannot separate sufficiently from their primary relationship and home to begin school. During the second separation phase in the normal life cycle, in late adolescence and early adulthood, the configuration known as schizophrenia emerges when the person is unable to separate successfully from home and family of origin to make an independent life involving college, work or career, intimate relationship, and starting a family. From a social adaptation perspective the least severe form, psychotic personality, comes to light still later, when those who are apparently able to negotiate both separations but on closer examination have depended on the shaky scaffolding of a façade, perhaps even a socially successful and constructive one, are unable to form and sustain an intimate relationship and a stable work life. Currently they are labelled things like addictive personality, sociopathy, narcissistic personality, schizoid personality, or even PTSD. I call this condition psychotic personality disorder. For those who equate psychosis with schizophrenia and cite hallucinations and delusions as defining characteristics it is instructive to note that both Bleuler (1911b) and Jung (1939), who collaborated with him in the first decade of the 20th century, believed that it is what Bleuler called the primary symptoms that define psychosis/schizophrenia, and that the presence of the secondary symptoms of hallucinations and delusions is not essential to the diagnosis.

2

THE MEDICALIZATION OF MADNESS

Evolution of the equation of psychosis with degeneracy

The prevailing view of psychosis is the result of a collaborative and financially lucrative effort by a quartet comprised of psychiatry, neuroscience, and the pharmaceutical and health insurance industries. They maintain that psychosis is an organic physical illness of genetic origin, whose mental manifestations are secondary products of a chemical disruption or an electrical storm in the brain that are either meaningless or whose meaning has no relevance to treatment. However cloaked with medical caring, this view is dehumanizing and stigmatizing. Unlike our attitude toward persons afflicted with diabetes or cancer, conditions that do not primarily affect mind and behavior, or conditions that do, such as neurosis and depression, most of us would have trouble acknowledging or wanting a close relationship with someone diagnosed schizophrenic. This is a culturally determined prejudice, not an objective assessment, as many cultures, ancient, tribal, and non-western, make a special place for such persons and designate them with names that reflect reverence not revulsion, like seer.

In order to understand the reasons for this prejudice it is important to understand the history and genealogy of the current view of psychosis. The history of the concept involves a journey of at least several hundred years, from the prisons and so-called hospitals like Bedlam of early industrial England to the hospitals and clinics of contemporary society that function according to the dictates of the Diagnostic and Statistical Manual (DSM).

The history of denigrating social judgment about persons whose mental expressions and behaviors are disruptive to others dates back hundreds of years to long before there was a medical profession. It includes labels and associated “treatments” that to our modern ears sound degrading and horrifying. This history has included the belief that the person is subhuman or bestial, genetically defective, lacking morals and the capacity for reason, possessed by demons, criminal, and more. As medicine slowly evolved into a profession with scientific pretensions such blatantly denigrating labels have slowly been replaced by ones that we assume are more “scientific” because they are supposedly related to brain disease, and technology has been developed to map and measure neural activity.

A brief history of the evolution of mental illness from social dehumanization and rejection to medical legitimization can be divided into three parts. The first of these, which I will call Pseudoscience I, spans the 18th and 19th centuries, including the beginnings of medicine as a profession and its treatment of the mentally disturbed, and its first efforts to differentiate itself from theologically inspired efforts to exorcise the devil. Benjamin Rush, one of the signers of the Declaration of Independence, helped to found the first medical school in the United States in the late 1700s. He became interested in the treatment of mental illness during his training in London, and after returning to the United States established the first mental ward within a hospital. For this he is known as the father of American psychiatry. However, he perpetuated many of the dehumanizing views about mentally disturbed persons and their treatment he had learned from practices common in England in institutions like Bedlam, which housed and treated the insane beginning around 1500. Rush considered himself a humanist, and while he did not use practices common in England ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Theorists of psychosis whose contributions are discussed in chapters 4, 5, 6, and 7
• Preface
• Acknowledgments
• Introduction
• PART I: Not fully human The unwitting collusion between medicine and psychoanalysis
• PART II: Psychoanalytic models of psychosis
• PART III: A new beginning: Distinguishing psychosis from neurosis
• PART IV: Treatment of psychosis
• References
• Index