Psychoanalysis of the Psychoses

Current Developments in Theory and Practice

Riccardo Lombardi, Luigi Rinaldi, Sarantis Thanopulos, Riccardo Lombardi, Luigi Rinaldi, Sarantis Thanopulos

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9780429647505
• Topic: Psicología
• Subtopic: Salud mental en psicología

Psychoanalysis of the Psychoses brings together a distinguished international set of contributors, offering a range of views and approaches, to explore the latest thinking in the psychoanalytic treatment of psychosis and related disorders.

Drawing on findings from neuroscience, theory and clinical material from many schools of psychoanalytic thought, this book offers a comprehensive guide to understanding how psychosis is conceptualised from a psychoanalytic perspective. It looks at how to work with psychotic patients, typical problems in treating psychosis and the role of pharmacology. It demonstrates the relational dimension, capable of strengthening the patient's observing Ego and facilitating the integration of the different areas of the personality. This process can identify and work through the main psychological stress factors involved in psychotic disturbances, transforming chaotic thoughts into springboards for important insights, and offering patients the precious chance to construct for the first time a creative relationship with their own existence.

Psychoanalysis of the Psychoses will be of great interest to psychoanalysts and psychoanalytic psychotherapists as well as psychiatrists wishing to draw upon psychoanalytic ideas in their work.

Part I

General perspectives on the psychoanalytic experience with psychosis

Chapter 1

Child psychosis

An impairment in the work of representation

Didier Houzel¹

The origin of the concept of child psychosis

The word “psychosis” appeared in the context of Germanic romantic psychiatry (Karl Friedrich Canstatt, 1841; Ernst Baron Von Feuchtersleben, 1845). At the time, the issue was not the child, but rather one of describing “mental diseases”, to be distinguished from “neuroses”, nervous diseases. During the whole of the nineteenth century, mental diseases in children were ignored, with the exception of the treatise by Paul Moreau de Tours (1888), who simply recognised the possible presence, before puberty, of psychic symptoms described in the adult. When Kraepelin (1899) described “early dementia”, he scarcely envisaged a pre-pubertal outbreak of the disease, since he attributed it to a sort of brain intoxication resulting from the genital pressure of puberty, even if he accepted that 5% of future schizophrenics had already presented symptoms in childhood. It is striking to note that, for more than a century, while adult psychiatry was increasingly isolating different syndromes better, child psychopathology was limited to mental retardation and character disorders. The developing mind of the child was therefore considered as a consciousness of the present instant, dominated by uncontrolled or poorly controlled instinctual tendencies, thus incapable of developing a pathological form of functioning due quite simply to a lack of overall organisation.

The first to isolate a form of infantile psychosis was the Italian psychiatrist Sancte de Sanctis (1906) when he described “very early dementia”, which he distinguished clearly from mental retardation and regarded as a specific form of child psychosis. Eugen Bleuler (1911) acknowledged that a small proportion of schizophrenias occurred in childhood, and it was after Bleuler that the notion of “infantile psychosis” developed. H. W. Potter (1933) was the first to use the expression “child schizophrenia”, an expression that gradually gave way to that of “infantile psychosis” as a refinement of child psychiatric clinical material made it possible to isolate different forms of psychoses: autistic psychoses (Kanner, 1943; Asperger, 1944), symbiotic psychoses (Mahler, 1952), deficit-based psychoses (Misès, 1968), psychotic dysharmonies (Misès and Barande, 1963).

This spadework in the field of child psychopathology during the twentieth century was considerable. It should be noted that it was largely based on psychoanalysis which had highlighted the dynamics of psychic development; while this is admittedly dependent on the innate equipment of the child, it is necessarily deployed within relationships with the key figures around him/her in a subjective and intersubjective history. Psychic development could no longer be conceived merely in terms of maturation, but as a dynamic complex including organic factors, as well as subjective and intersubjective factors, and even social and cultural factors.

As a result of a seesaw movement, the likes of which psychiatry has been familiar with since its foundation, all this painstaking clinical and nosographical work had to yield in the 1980s to a vast nosographical catchall, mixing once again what had been patiently distinguished – autism, retardation, dementia – in an uncertain continuum baptised sometimes as “pervasive developmental disorders” and sometimes as “autistic spectrum disorders”. There were many reasons for this return to non-differentiation. I will insist on one of them that seems to me to be crucial. I will call it the aetiological a priori.

The question of aetiology

In the same year, 1979, two events combined to give an exclusive place to the organic aetiology of infantile psychoses. The first was the publication in the Journal of Autism and Developmental Disorders of an editorial written by Eric Schopler, Michael Rutter, and Stella Chess (1979) which rejected the dynamic psychopathological approach that had prevailed hitherto in the study of infantile autism in favour of an exclusively organic aetiology impeding the development of the brain (embryological, perinatal or genetic). The second event was the publication by L. Wing and J. Gould (1979) of their research based on a hereditary aetiology of infantile autism which had led them to extend their investigations to the collaterals of the child affected. This led them to define a triad of social impairments: communication disorders, socialisation disorders, and restricted and repetitive interests, a triad that has become the basis of modern classifications (DSM, International Classification of Mental Diseases).

The problem is not the hypothesis, which is entirely legitimate, of an organic, genetic or other origin of the autistic syndromes, but the hypostasis of this hypothesis as a certitude excluding any other hypothesis, giving rise to endless debates between the upholders of organogenesis and those of psychogenesis.

The aetiological a priori, which I am denouncing here, seems to me to be at the heart of the sterile debates agitating professional and associative circles. In this respect, I equally denounce the aetiological a priori of certain psychoanalysts, an a priori that has its source, moreover, in the key article by L. Kanner (1943) in which he described autistic parents as lacking emotional warmth. We know that he subsequently deeply regretted having adopted this position, one that was no doubt dictated by the fashion of that era known as “relational psychopathology” which flourished in the United States of America with the dominant figures of Frieda Fromm-Reichmann (1950) and Harry Stack Sullivan (1953).

We know the use that B. Bettelheim (1967) made of this aetiological a priori, and how he was bitterly and legitimately reproached for doing so. Other currents of psychoanalysis have brought their influence to bear in the same direction, in particular that arising from the teaching of Jacques Lacan, of which one of the chief representatives was Maud Mannoni (1964).

These a prioris must be denounced, whatever their origin. It should be added that psychoanalysis does not have a role to play in this aetiological debate. It is not concerned with “aetiologies”, but with “meaning”. Another form of causality is involved, it is true, but a form that is quite distinct from what the philosopher Aristotle (2005) called “efficient causality”, describing it rather as “final causality”, a form that modern epistemologists call “intentionality” or alternatively “reason”. This underlies what the philosopher W. Dilthey (1883) called “comprehensive psychology”, to be distinguished from “explanatory psychology”, a distinction that K. Jaspers (1913) took up by distinguishing between a “comprehensive psychopathology” and an “explanatory psychopathology”.

Psychoanalysis is concerned with meaning and not with aetiology, as S. Freud had asserted in 1897 in his famous letter to Fliess (the so-called “letter of the equinox”, dated 21 September 1897): “I no longer believe in my neurotica… . I was so far influenced (by this) that I was ready to give up two things: the complete resolution of a neurosis and the certain knowledge of its etiology in childhood” (see Masson, 1985, pp. 264–265) (my emphasis).

Psychoanalysis: an inescapable therapeutic reference

I think that the first thing to do with an autistic or psychotic child corresponds to what the American philosopher W. V. O. Quine (1960) called, following N. L. Wilson (1959) the “principle of charity”, which consists in crediting one’s interlocutor with a maximum of rationality in what he/she expresses, on the condition that we extend this requirement of rationality to the unconscious mind. In other words: the expressions of the child, whatever they may be, must be considered as carriers of meaning, most often unconscious.

An error that is often made is to treat the communication of these children in a neurotic or characteropathic way. If an autistic child creates a mess in the room, the therapist is tempted to say to him/her: “You’re doing that to make me angry”, as if a conscious intention had dictated the child’s act. In fact, it is not a matter of a conscious intention, but rather of what I propose to call an unconscious intention or alternatively a mise en scène. This links up with the notion, which I find very fruitful, of Francisco Varela, Thompson, and Rosch (1993) of énaction, derived from the English enactment, which means mise en scène in the theatrical sense of the term. The central idea defended by Varela is that the brain and the mind are not apparatuses for recording passively what the subject perceives in the external world, but dynamic systems in interaction with this external world, including the human environment, which are capable of creating and enacting new forms arising from this interaction. In the classical language of philosophy and of psychoanalysis, we speak of representation (Vorstellung), which should be understood in the sense, not of a true copy, but of a creation of the mind. The hypothesis that I want to examine is that autism spectrum disorders, irrespective of their aetiology(ies), result from a failure of this work of representation.

In the notions of enaction and representation, there is a reference to intentionality: the psychic apparatus, to use the expression that Freud borrowed from Fechner, cathects the world, not passively but actively, obeying innate requirements that govern the equilibrium and stability of the body just as much as those of the mind. The reference to intentionality is essential in psychology, psychopathology and psychoanalysis. The philosopher Franz Brentano (1874), who was Freud’s mentor, had defined psychic phenomena in terms of their intentionality: “consciousness is consciousness of something”, he said, reaccrediting thereby the thought of Aristotle and the scholastics. But for him it was obvious that all intentionality was conscious: if I perform an act, if I say something, it is because I want to obtain such and such a result or transmit such and such a message. I think that one of Freud’s fundamental discoveries was what may be called “unconscious intentionality”: I do something, I say something, I think something, I am well aware of it, but I do not know what meaning it has. Freud (1901) showed that a slip of the tongue, a bungled action, a dream or neurotic symptom had a meaning, but a meaning of which the subject himself is unaware. Each of the phenomena cited is conscious, but its aim is unconscious. It is in this sense that I speak of unconscious intentionality.

It is this kind of unconscious intentionality that we come across in autistic behaviours. It is as if the child were showing through his (or her) behaviour his inner state which, moreover, he does not clearly perceive himself. Saying to the child I mentioned earlier, “Perhaps you are showing me how much disorder you feel in your head” is much more adequate than attributing him with conscious intentionality. It is, in fact, as if he were enacting his own psychic state which he cannot think about himself or communicate. We must then be very attentive to the circumstances surrounding this enactment, circumstances that must be described in detail in order to give full meaning to what the child is showing: “You feel totally overwhelmed in your head because this or that person is not there, or because we did not do the same things as usual”. A commentary of this kind has a chance of calming the child down, at least temporarily, thanks to the meaning that it offers.

This does not mean, however, that one should let the child do anything he wants, without setting limits. Too often the error has been to think that unlimited tolerance was possible and that it would one day lead the child to reconciliation with his human environment. Experience shows that there is always a limit to an adult’s tolerance, however gifted and patient he or she may be. It also shows that leaving the child without limits helps preserve his sense of omnipotence, which is particularly frightening for him, and feeds the vicious circle in which he is caught: for him, if there is no limit, it is because any limit would be unbearable, so he has to struggle in an omnipotent way against every external constraint instead of reconciling himself gradually with the world by accepting its rules.

The containing function

One of the major difficulties in working with children belonging to the autism spectrum is to combine, in the right proportions, the indispensable psychic availability and receptivity he/she needs with the necessary limits to his/her destructiveness. This balance allows for what Wilfred Bion (1962) called a containing function, which is the psychic task that the mother must fulfil for the infant and the therapist for his/her patient. The model he proposes is based on the mother/baby relationship within the dyad: the baby has intense somato-psychic experiences but cannot deal with them psychically, that is to say, give them meaning; he can only evacuate them outside of himself through his crying, gestures, mimic expressions, muscular tensions, etc. The mother must be receptive to all these messages, which make her experience similar states to those the baby is experiencing, albeit less intensely. Above all, she has the possibility of giving them meaning and, of course, of responding to the child by giving him/her the appropriate care as she sees fit. But what is important to understand is that, in her ministrations, the mother does not content herself with satisfying the corporal needs of her baby; nor does she content herself with providing him with the psychic relaxation and bonus of pleasure associated with this satisfaction. She also provides meaning for what he was experiencing, and so gradually the child, on the basis of his past experiences, will be able to attribute meaning himself to what he is experiencing.

The studies of two experimental psychologists have recently lent remarkable support to the hypothesis of the mother’s containing function and elucidated the notion of unconscious intentionality that I am putting forward. The studies in question are those of Gergely and Watson (Gergely, 2004) on what they call social bio-feedback. These two authors were interested in studying the imitation of the infant by his mother. They have shown that mothers imitated the mimic expressions of their baby, but in a slightly exaggerated way and with a note of irony. They make the assumption that babies are not aware at the beginning of their own emotional states and that they become conscious of them only by seeing these excessive and somewhat mocking imitations of their mothers. They refer to the technique of feedback, by means of which it is possible to become aware of the variations of a physiological state of one’s own body, for example, blood pressure, by associating these variations that are normally not perceived with an external stimulus, for example, a sound which, for its part, is perceived. The subject, then, gradually perceives his blood pressure variations even in the absence of an external stimulus. Some gifted subjects are even able to control more or less the variations of the physiological state in question. This is what fakirs do. In social biofeedback it is not a matter of becoming aware of a physiological state, but rather of an emotional state that is initially unconscious. To achieve this the mother’s imitation must be congruent; that is to say, it must correspond closely to the emotional state expressed by the infant, and further it must be marked in such a way that the infant can understand that the mother is not expressing her own emotional s...

Table of contents

• Cover
• Half Title
• Series
• Title
• Copyright
• Contents
• List of contributors
• Series editor’s foreword
• Permission acknowledgements
• Introduction to the psychoanalysis of psychoses: current developments in theory and practice
• Part I General perspectives on the psychoanalytic experience with psychosis
• Part II Communication and empathy with the psychotic analysand
• Part III Particularities of thought
• Part IV Flexible integration between psychoanalysis and pharmacology
• Index