Psychoses

An Integrative Perspective

Johan Cullberg

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317710417
• Topic: Médecine
• Subtopic: Psychiatrie et santé mentale

Psychoses provides a unique perspective on the challenges associated with understanding and treating psychoses, bringing together insights and developments from medicine and psychology to give a full and balanced overview of the subject.

Johan Cullberg draws on his extensive experience working with those suffering from first-episode psychosis to investigate issues including vulnerability factors, phases of psychosis, prevention, the potential for recovery and contemporary attitudes to psychosis. Particular attention is paid to how therapeutic interventions can either support or obstruct the 'self-healing' properties of many psychoses.

This sensitive and humane perspective on the nature and treatment of psychoses will be of interest to all mental health professionals interested in increasing their understanding and awareness of this subject.

Part I
The psychotic crisis and the schizophrenic disability

Hidden behind his psychotic life, in every schizophrenic a normal psychic life is proceeding. We might add that hidden by everyday behaviour, a schizophrenic life proceeds in every healthy person.

Manfred Bleuler, 1979

Chapter 1
Reason – a thin veil over chaos

Without you there is no me.

E. G. Geijer, 1856

A look at our existential position is hardly encouraging. As specks of dust in an infinite universe we are of no more interest than a single grain of sand on the seashore. We are born and die on time’s narrow isthmus in an unfathomable ocean. We struggle, yearn, strive and suffer, gathering knowledge and experience, until it is all over and totally forgotten in a matter of generations.

At the same time there is another part of us on which everything centres, a point where we feel our specific weight and defend our identity, nationality and world view as being self-evident in relation to the different identities, nationalities and world views of others. We assert our existence and the ways in which we consider that the social order should be maintained and improved. In our conscious outlook we make little or no allowance for our own mortality. The risks we perceive have to do with loss of love or property and the possibility of being wronged or put to shame. As a means of preventing such things we construct both conscious and unconscious strategies that hopefully will not be too far out of step with the strategies of others. We aim to build them on what we consider to be a reasonable foundation.

The notion that reason, normalcy and self-esteem are things we can take for granted plays an important part in our adaptation and sense of security. But we are also aware that our rationality is rather fragile. Every night in our dreams, time, space and logic are all suspended. We also daydream to a varying extent, though for many people recalling one’s daydreams is more embarrassing than what we dream in our sleep. In our daydreams we are pleasure-seeking, vengeful and engaged in hazy fantasies of power. Although these are our own fantasies and dreams, we find it hard to accept that daydreams express the deeper reaches of our personality. But on looking back at our earliest days, we recognise that our personality has its roots in the fertile soil of childhood to which the daydreams hark back.

We inevitably live in an impossible existential divide – between being just a speck of dust in the universe and simultaneously being its immeasurably important focus. In addition, we live in a psychological divide between respectable reason (our moral code) on the one hand and asocial self-assertion and pleasure seeking on the other. Our lives involve an ongoing dialectical alternation between these two positions and realities. Apart from the occasional impulse to do things that can seem incomprehensible, this alteration leaves little outward trace. Moreover, it is rendered less hazardous by the existence of states of repose and being able to cross bridges to our inner life. If these bridges are absent or break down, finding our way in the world becomes more difficult; our mental health is endangered. In some cases our reaction may amount to a loss of contact with reality – a psychosis.

Regression in the service of the ego

Sigmund Freud (1856–1939) distinguished between primary process thinking and secondary process thinking. The latter is the rational, logical mode of thinking that we are all trained to develop as an essential instrument for survival as a biological and social being. Secondary process thinking is governed by the reality principle.

Primary process thinking is associated instead with the world of dreams, including daydreams. It is governed by the pleasure principle, with wish ful-filment more or less untrammelled by space, time and persons. Morality and ethics have hardly any say in this omnipotent form of mental functioning.

The possibility of escaping for a time from the strict categories of rational thought and dwelling in its dialectical opposite means a lot for our mental health. The term regression implies that thinking and behaviour are governed to a greater degree by earlier levels of development. A classic psychoanalytic description for this is ‘regression in the service of the ego’, in contrast to the more destructive and pathological forms of regression that include psychosis. Here are some regressive bridges that span the divide between rational and irrational thought:

• fantasy and play
• creativity
• intimate relationships and sexuality
• religion
• magical rituals and predictions (e.g. horoscopes and astrology)
• intoxication.

Fantasy and play

These vital functions are similar in that they bring together or allow us to find a ‘middle ground’ between our inner world and the real world. We cannot completely survive in a world of rational order nor can we sustain for long a world of fantasy. The young child, in its fantasy games, animates his ‘blanket’ into something which allows a transition to take place between play and reality. According to the English psychoanalyst and paediatrician D. W. Winnicott (1971), children create a ‘transitional space’ between the real mother and the fantasised inner representation of the mother by means of a ‘transitional object’ – the blanket, cloth or whatever might be favoured. The child engages in a creative act, which allows him or her to deal with the disappointments engendered by its parents and reality. According to Winnicott, the blanket (or the alternative transitional object chosen by the child) represents and is, for the two to three year old, an aspect of the mother which allows the child to attain complete control over her. The capacity to use fantasy in play, play which is entirely serious, to transform reality constitutes the groundwork for the possibility in later life to create contact with the transitional space. The child will also be able to test out his illusions against reality with the use of his transitional object.

Winnicott wants us to understand that it is through this original transitional space, between reality and illusion, that the adult’s creative freedom is born. This is a perspective which has proved fruitful in considering the psychology of creativity. In psychosis the boundary between fantasy or play and reality has been lost.

The intimate relationship

In close conversation as in physical intimacy we venture outside the boundaries of our selves and reinstate a ‘symbiotic’ contact with another being.¹ This is something, which the existentialist philosopher Martin Buber calls ‘the experience of “you”’. It occurs with intensity, yet at the same time exists outside rationality, within such a symbiotic space.

An active ‘you’ experience is decisively meaningful in the evolution of our ability to hold on to and function within our experience of a continuous self. This is why unwanted and excessive isolation constitutes a risk for psychic health. One of the most important phenomena in acute psychosis is that the ability to function within the other ‘you’ category has been temporarily suspended (see Chapter 4 for more).

Sexuality

In today’s western world, sexuality is perhaps the factor that has come to provide the most accepted method of reassurance. In its commercialisation it has acquired something like the function of a drug. In the different kinds of sexuality, ‘normal’ and ‘perverse’, in reality or fantasy human beings regain contact with an earlier form of pleasure seeking. Through sexuality’s connection with procreation it becomes the most potent bridge to our biological-animal selves. Up until the 1960s sexuality was seen as the most dangerous of man’s needs and had been held under strict social and psychological control. Man has developed powerful defence mechanisms in relation to his sexuality, repression from consciousness, projection onto others or splitting between an antisocial sexualised part of the self and a socially desirable part.

This kind of splitting mechanism can most easily be seen in certain disturbed personalities. Although outwardly – and possibly in their attitude to themselves – they are experienced as perfectly ‘normal’, they can secretly behave in a way which is considered from a cultural point of view as unacceptable sexual behaviour. It might concern the priest who indecently abuses children; the politician who regularly consorts with prostitutes and who has a fetish for sado-masochistic rituals; the psychotherapist who has intercourse with his patients; or the farm labourer who engages in bestiality. In such instances the relationship between the moral aspects of these disparate parts of the personality is lax. There is not enough strength in the struggle against acting out to prevent it, even though a part of the personality is presented as acceptable. Many learn to live with foolproof defences against experiencing concern and guilt. Regression does not take place ‘in the service of the ego’; rather it happens as an obsession. Although contact with the irrational self is experienced, it is maintained via a destructive and risky splitting of the personality. Those who become aware of their split behaviour or who are dependent on this part of the personality can conduct themselves with the same degree of irrationality as the psychotic. The difference is that psychosis re-establishes the threatened inner continuity by means of the delusion while the mechanism of splitting allows for the maintenance of the self in spite of the contradictory contents.

Religion

A ‘you’ relation can be experienced outside human relationships in religion or in a mystical union with nature. For those who find in God a person, a ‘you’, the sense of togetherness can be like that which can occur with their fellow humans or often surpassing that. Religion is also accepted by most people as having a place within the rational community. Today it can be practised either privately or openly.

Religion is expressive of a permanently set vision of the world and an unshakeable ethic. Within this vision a relationship is entered into with something holy which demands complete devotion. Rock solid symbols for good and bad present themselves in stories and traditions carried over many generations, which can be worshipped through pictures and icons. For example, the Christian Holy Communion offers a sublimated strengthening meal that, while expressing an inner communion with mankind, has an unmistakable, symbolic cannibalistic undertone. This act spans the extremes between spirit and nature. The incorporation of the good, which either appears in a metaphorical form as with Protestantism or in the form of transubstantiated body and blood as in Catholicism, psychologically speaking, has the same roots as corresponding rights in earlier cultures where the consumption of a valued body part from an animal or deity offers participation in the equivalent power.

Without entering debates regarding religion, I want to show, with this reasoning, what the essential bridge to our unconscious and deepest personal life is about. Such phenomena as the experiencing of concrete spiritual forces, the hearing of God’s voice, belief in Christ as miraculously risen from the dead, in a non-religious context would be considered diagnostic of psychosis with recommendation for medical treatment.

The Swedish author, August Strindberg (1849–1912) went through a deep personal mid-life crisis (‘the Inferno crisis’) which culminated in the form of a transient delusional state with psychotic ideas of persecution and death threats. Through the studies of religious literature, mainly Emanuel Swedenborg’s later writings, he was brought to the understanding that it was really God who wanted to chastise him and by means of terrifying experiences lead him onto the righteous path. Thus he was led back to the Christian vision of life. These psychotic experiences were transformed, in this way, into a religious context that rendered them culturally acceptable.

In the Old Testament (Genesis 22) the story is told of how Abraham, by God’s command, is prepared to sacrifice his son, Isaac. This story would be considered to be an expression of mental illness today, but within the religious context it contains a quite different meaning. Man has a need through a kind of double bookkeeping to live under the exigencies of reality, something which can be dealt with through the Church and which has been well tried over many centuries. This can be used or abused, as with so many other institutions set up by man. The acutely psychotic individual has lost this dialectic. For such people, they have become the world and much of what occurs in the world is centred on them or is controlled by them.

God puts Abraham to the test

And it came to pass after these things, that God did tempt Abraham, and said unto him, Abraham: and he said, Behold, here I am. And he said, Take now thy son, thine only son Isaac, whom thou lovest, and get thee into the land of Moriah; and offer him there for a burnt offering upon one of the mountains which I will tell thee of.

And Abraham rose up early in the morning, and saddled his ass, and took two of his young men with him, and Isaac his son, and clave the wood for the burnt offering, and rose up, and went unto the place of which God had told him.

Then on the third day Abraham lifted up his eyes, and saw the place afar off.

And Abraham said unto his young men, Abide ye here with the ass; and I and the lad will go yonder and worship, and come again to you.

And Abraham took the wood of the burnt offering, and laid it upon Isaac his son; and he took the fire in his hand, and a knife; and they went both of them together.

And Isaac spake unto Abraham his father, and said, My father: and he said, Here am I, my son. And he said, Behold the fire and the wood; but where is the lamb for a burnt offering?

And Abraham said, My son, God will provide himself a lamb for a burnt offering: so they went both of them together.

And they came to the place which God had told him of; and Abraham built an altar there, and laid the wood in order, and bound Isaac his son, and laid him on the altar upon the wood.

And Abraham stretched forth his hand, and took the knife to slay his son.

And the angel of the Lord called unto him out of heaven, and said, Abraham, Abraham: and he said, Here am I.

And he said, Lay not thine hand upon the lad, neither do thou any thing unto him: for now I know that though fearest God, seeing thou hast not withheld thy son, thine only son from me.

And Abraham lifted up his eyes and looked, and behold behind him a ram caught in a thicket by his horns: and Abraham went and took the ram, and offer...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Contents
• List of figures and tables
• Foreword
• Preface
• Preface to the English edition
• Part I The psychotic crisis and the schizophrenic disability
• Part II In support of recovery
• Appendix Classification
• References
• Index