The Psychotic Wavelength

A Psychoanalytic Perspective for Psychiatry

Richard Lucas

• Éditeur: Routledge
• Année: 2013
• ISBN:
  9781317796725
• Édition: 1
• Sujet: Psychologie
• Sous-sujet: Psychanalyse

The Psychotic Wavelength provides a psychoanalytical framework for clinicians to use in everyday general psychiatric practice and discusses how psychoanalytic ideas can be of great value when used in the treatment of seriously disturbed and disturbing psychiatric patients with psychoses, including both schizophrenia and the affective disorders.

In this book Richard Lucas suggests that when clinicians are faced with psychotic patients, the primary concern should be to make sense of what is happening during their breakdown. He refers to this as tuning into the psychotic wavelength, a process that allows clinicians to distinguish between, and appropriately address, the psychotic and non-psychotic parts of the personality. He argues that if clinicians can find and identify the psychotic wavelength, theycan more effectively help the patient to come to terms with the realities of living with a psychotic disorder.

Divided into five parts and illustrated throughout with illuminating clinical vignettes, case examples and theoretical and clinical discussions, this book covers:

• the case for a psychoanalytical perspective on psychosis
• a historical overview of psychoanalytical theories for psychosis
• clinical evidence supporting the concept of a psychotic wavelength
• the psychotic wavelength in affective disorders
• implications for management and education.

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The Psychotic Wavelength is an essential resource for anyone working with disturbed psychiatric patients. It will be of particular interest to junior psychiatrists and nursing staff and will be invaluable in helping to maintain treatment aims and staff morale. It will also be useful for more experienced psychiatrists and psychoanalysts.

Part One

Making the Case for a Psychoanalytic Perspective on Psychosis

1

Introduction

This book aims to provide clinicians with a psychoanalytically based framework of understanding to help them in their work with the major psychotic disorders encountered in everyday psychiatric practice. It is written for both an analytic and general psychiatric audience. It provides theoretical and clinical discussion material for junior doctors starting in psychiatry, nurses undergoing postgraduate psychodynamic courses, social workers, psychologists and students of other disciplines related to psychiatry, as well as analytic psychotherapists in training who are striving to make sense of their psychiatric placements. It is also intended for the wider professionally experienced analytic and psychiatric audience, since it raises for consideration the important and often controversial issues that arise from encounters with psychotic states of mind.

The current trend in psychiatry, based on a stress-vulnerability model, is for psychoanalysts to work in early onset psychosis settings, with associated favourable outcome figures linked to relapse prevention, avoidance of admission and with medication kept to a minimal dosage (Cullberg 2001; Martindale 2001).

There is a danger of a split developing between those running early onset services and those running the general psychiatric services. The latter have responsibility for many patients at the severe end of the spectrum of psychosis, who may require significant amounts of medication and repeated or protracted admissions. In working with this group of patients, who will at times require containment on the ward when in a state of relapse, avoidance of admission is clearly not an issue. The cause of the psychosis, whether viewed theoretically as constitutional or as a consequence of early trauma, is not the pressing issue, neither is the level of required medication. The primary problem is to make sense of what is happening in a psychotic breakdown.

The lament that psychoanalytic perspectives are no longer taken account of in the area of psychosis (Grotstein 2001) may be a consequence of analysts positioning themselves on the periphery rather than being prepared to share in the everyday experiences of general psychiatry. Only work within the general psychiatric setting can enable psychoanalysts to have a meaningful impact on psychosis, by developing ideas that they and their fellow professionals can make use of in this most demanding of areas. Without this vital engagement, although psychoanalytic theories of psychosis may have their own academic coherence, they will not resonate for those who are working at the coal-face.

This book is based on my forty years of experience of working with major psychotic disorders in the NHS. While also informed by individual analytic experiences, its primary concern is the role of applied analytic thinking in a busy psychiatric setting. Though the theoretical framework outlined here is based on my work in the UK, in an NHS setting in a deprived area of North London, it is hoped that a wider international audience will find that they can make use of it to inform their work in other contexts.

Psychoanalysts have understandably grown fond of referring to the pure gold standard of individual psychoanalysis. Any application of analytic thinking outside of an individual analytic setting has come to be regarded as a dilution of the pure situation. In consequence, applied analysis, such as that undertaken by many practising analysts who also work in an NHS setting, has not always received the support and appreciation that it merits.¹

In thoughtfully presented individual case studies, analysts have more often than not chosen to focus on the early infantile traumas behind the generation of schizophrenia (e.g. De Masi 2001). However, addressing the psychoses unavoidably confronts us with the need to integrate a consideration of constitutional or biological factors (Yung and McGorry 2007). We cannot rely solely on an analytic explanation in terms of early childhood trauma. Pioneers of individual psychological approaches, which include cognitive as well as analytic therapists, have tended to be optimistic about the treatability of psychosis, but the question of whether it is possible to achieve lasting change remains controversial. Pursuit of this elusive goal can detract from the requirement to provide an effective containment that addresses the psychotic patient’s intense dependency needs (Steiner 1994).

The focus of this book is not primarily on the feasibility of inducing lasting change, but rather on the vital role that applied psychoanalytic thinking can play within general psychiatry to help staff, relatives and patients adjust to the realities of living with long-term psychotic disorders.

In relation to the place for the analytic study of psychoses, Freud (1925) had the following to say:

The neuroses were the first subject of analysis, and for a long time they were the only one. No analyst could doubt that medical practice was wrong in separating those disorders from the psychoses and in attaching them to the organic nervous diseases. The theory of neuroses belongs to psychiatry and is indispensable as an introduction to it. It would seem, however, that the analytic study of the psychoses is impracticable owing to its lack of therapeutic results. Mental patients are as a rule without the capacity for forming a positive transference, so that the principal instrument of analytic technique is inapplicable to them. There are nevertheless a number of approaches to be found. Transference is often not so completely absent but that it can be found to a certain extent; and analysis has achieved success with cyclical depressions, light paranoic modifications and partial schizophrenias. It has at least been a benefit to science that in many cases the diagnosis can oscillate for quite a long time between assuming the presence of a psychoneurosis or of a dementia praecox; for therapeutic attempts initiated in such cases have resulted in valuable discoveries before they have had to be broken off. But the chief consideration in this connection is that so many things that in the neuroses have to be laboriously fetched up from the depths are found in the psychoses on the surface, visible to every eye. For that reason the best subjects for the demonstration of many of the assertions of analysis are provided by the psychiatric clinic. It was thus bound to happen before long that analysis would find its way to the objects of psychiatric observation.

(Freud 1925, p. 60)

Many points of interest are raised here by Freud. First, does therapeutic success matter in relation to the analytic study of psychoses; or is it more important to ask whether analytic insights can help those who have to manage the most difficult of patients on a long-term basis? How do we evaluate transference? Do we see it as only coming from the vestiges of a healthy part of the patient, as Freud implied?

One day, as I was walking down a hospital corridor, a long-stay patient passed me and said, ‘Hello, Dr Lucas’. She made me feel like a benevolent and important father figure, with her as one of my cared-for flock. I felt full of this warm feeling, until she brought me back to earth by adding as she went by, ‘You stupid old fucker.’

Both transference and countertransference phenomena were clearly in evidence here. The episode reminded me of the baby who builds a column of bricks only to knock them down again. The lesson is that events which can be illuminated by analytic thinking, linked to transference and countertransference phenomena, are ever-present throughout the hospital and its corridors. The challenge is what we do with them.

While we might not be able to change the habits of a lifetime in patients with chronic psychoses, we can learn a great deal from them. While Freud noted that seeing patients individually in the early stages of a developing psychosis may lead to valuable analytic discoveries, seeing patients in general psychiatry while keeping an analytic perspective in mind can also inform the clinician’s thinking in a creative way.

An underlying theme of this book is that the major psychotic disorders present different challenges from borderline and non-psychotic disorders. Since projective processes predominate in psychosis, we need to decipher the emotional meaning contained in delusions by attending not only to their content, but also to our countertransference experiences – exploring what the patient makes us feel at the time.

Using one’s ordinary sensitivities is not sufficient in trying to make sense of major psychotic disorders. One needs to learn to tune into a different wavelength, what I have termed the psychotic wavelength, hence the title for the book.

In approaching the major psychotic disorders, both schizophrenia and affective disorders, it is vital that we always think not in terms of one person but in terms of two quite separate parts to the personality, the psychotic and non-psychotic parts. Whenever we listen to the patient we have to ask ourselves whether we are listening to a straightforward communication from a non-psychotic part or hearing a rationalisation from the psychotic part that is covering up an underlying psychosis.

Bion was reported anecdotally to have said that as a non-German speaker, he had an advantage listening to Hitler on the radio before the war. As a result, he was not seduced by the words, but heard only the sounds of a raving madman. Hitler’s seductive words thus did not blind him to the dangerousness of the man.

Professionals often remain unaware of the commonest presenting symptom of psychosis and its diagnostic implication. If one consults a standard psychiatric textbook, one will find that the commonest symptom is not, as one might have expected, persecutory delusions (64 per cent) or auditory hallucinations (74 per cent), but lack of insight (97 per cent) (Gelder et al. 1998). This lack of insight typically presents as denial of any problems with associated rationalisations. In other words, if we are not aware that denial and rationalisation are the commonest presenting features of psychosis, we are in danger of succumbing to the rationalisations and missing the underlying psychosis.

This fundamental dynamic is not generally appreciated or taught within the realm of psychiatry. It remains a controversial issue even within the field of psychoanalysis, where there is a preference for thinking in the more familiar terms of defence mechanisms and the need for reintegration of split-off parts of the personality. However, the concept of the two parts is of crucial importance in everyday general psychiatric practice, for example when approved social workers (ASWs) have to decide whether a patient, who is reported by relatives to be in a dangerous state of mind, but who presents in an apparently calm and compliant state, needs to be formally admitted under the Mental Health Act 1983. Similar problems arise when mental health review tribunals have to decide whether it is safe to release a patient from a detention order.

The following serves as a striking example of denial and rationalisation:

A patient came into hospital on a section, having smashed up the contents of his flat. On admission he was in such a disturbed state that he was placed on the locked ward. I saw him for evaluation the next day. He presented in a perfectly calm state and denied having any problems. However, he asked how he could be sure that I was really Dr Lucas and not an impostor, and said that he therefore intended to call the police.

Here we can see that it is the patient who is the impostor. He behaves in an apparently calm way despite the fact that he had been brought into hospital by the police in a severely disturbed state only the previous evening. By the next day, he masquerades as reasonable, while projecting his awareness of this action into me. Through the process of projection and reversal into the opposite, I become the impostor for whom the police are needed.

With a physical illness, the patient goes to the doctor with symptoms and the doctor makes the diagnosis. With psychotic disorders, especially in relapse of chronic disorders, it is the nearest relative, not the doctor, who makes the diagnosis. It is then a question of whether the professional workers will believe the relative’s account. If the professionals succumb to the patient’s rationalisation, they may fail to take the beleaguered relative’s concerns seriously.

However experienced we are as professionals, we will often be fooled by patients’ rationalisations. It is therefore crucial to be aware of the phenomenon and be open to changing one’s mind on receiving additional information, rather than inflexibly standing by one’s initial opinion. The following incident is a typical experience.

The patient was a woman with a long-documented history of manic depression, though I previously had not known her before being asked to see her on a domiciliary visit. The community psychiatric nurse (CPN) had requested the home visit because the patient had been defaulting from her outpatient appointments. When I saw her she denied that she had any problems, and said that she would keep her next outpatient appointment and take any prescribed medication. I did not feel that there were grounds for a formal admission.

She subsequently did not keep the hospital appointment, and I saw her again at home, but this time armed with more information, which a close friend had passed on to the CPN. The friend told the CPN that while at times she presented as perfectly reasonable, at other times she would start shouting, and this was disturbing her downstairs neighbour, who was terminally ill with cancer. The CPN noted that while the patient insisted that she would cooperate with treatment, this was not the case. When I again found her in a seemingly rational state the second time I visited, I changed my view and completed my part of a compulsory admission order. It was the patient’s denial of any problems – the rationalisation – that was indicative of the psychosis.

In the following vignette, an ASW is faced with an understated psychotic state.

A patient with a history of chronic schizophrenia had stopped his depot medication (medication given by injection and slowly released into the body over a number of weeks), and was becoming more disturbed in the community. It was known that when he had relapsed in the past, he had become violent. This time, not wanting to be sectioned, he accepted voluntary admission at the last moment, so the ASW did not complete his part of the section. In hospital the next day, without provocation or warning, the patient suddenly attacked a nurse with a broom handle, and it took several nurses to restrain him.

The ASW was called to the ward to complete a compulsory treatment order, in view of the patient’s unpredictable state. The ASW saw the patient before speaking to the nursing staff and was therefore unaware that an assault had occurred. Since the patient appeared calm and said that he was willing to stay and cooperate with treatment, the ASW decided that the patient did not need sectioning. When the ASW later met with the nurses, they described the patient’s unpredictable outbursts, but having made his original decision, he felt unable to change it, although he was willing to be called back if a further incident occurred.

As patients in psychotic states of mind tend to project out and disown their disturbance, when case reviews take place, whether in hospital or in the community, it is essential to gather together all the involved professionals and the close relatives. The work of the review is like assembling the pieces of a jigsaw puzzle, and we cannot know in advance who might be bringing the most important piece.

Psychotic disorders represent the most extreme and difficult end of the spectrum of human behaviour....