Psychosis and Psychological Theoryby Ann Reitan, PsyD | January 14, 2013
Although this writer relies on a commitment to cognitive-relational psychotherapy and biologically-oriented medication as the efficacious treatment for psychotic process, the following represents an attempt to unravel the theoretical and practical intricacies that can be identified as contributing to psychotic phenomena.
In terms of psychoanalytic theory, thought, overall, is experienced as free association of cognition or thoughts. The psychotic individual experiences such thought as owned, in part, by “the self”, and emanating, in part, from “the other”. The psychotic individual can engage in objectification of the mental realm, thus experiencing some part of his mind is his own, while some part of his mind belongs predominately to others, whatever these others are presumed to be by the psychotic individual. Given that the psychotic individual experiences a significant amount of alienation, it may be hypothesized that alienation is both the precipitous cause and the substantial effect of projection of this kind within one’s mental realm. It may in fact assuage loneliness to perceive hallucinations as “real.”
Because the psychotic individual’s encounter with hallucinations relies on the presentation of associative conversations with “the other”, as opposed to the comfort of intimate entities within the mind, the psychotic may also be said to experience an seriously unveiled intimacy with the projected other, an intimacy that is perceived as psychological nudity. This perception of intimacy renders psychotic processes to be construed as punitive by the psychotic individual. The situation of projection onto the mental realm may be, as a consequence, confused as a punitive self-object relationship, as it is perceived by the psychotic individual, even while it does alleviate some amount of alienation and loneliness.
The conversation within this perceived subject-object relationship allows for the reification of psychotic beliefs or delusions based upon the psychotic individual’s wandering away from conventional thought toward an allowance for magical thinking entailed by an affirmation of the assumed existence of an entity or entities within the mental realm that the psychotic individual judges to be in dialogue with the self. This represents itself as a fracturing of the mind of the psychotic individual. As the psychotic individual meanders his own fractured mind, he will construe, perhaps by chance, some interpretations or “insights” into what his hallucinations represent. This equates with projection onto the fractured and objectified part of the mind that is guided by judgments about one’s psychotic processes that are intimately experienced by the individual. There is no reason to assume that a psychotic can be objective in this situation. He does not have not objective distance from this psychotic phenomena, he has no basis for understanding his experience, partly because others say his experience essentially does not exist, and particularly as it may be imperative to the psychotic individual to perceive himself as sane. This goal may be imperative to most schizophrenics.
An assumption of free-will in terms of intentional and self-directed thought allows by the psychotic individual to create, at least in terms of paranoid schizophrenics, bizarre and systemic delusions that any clinician may be able to discern are punitive. These freely willed thoughts may enhance a delusional stance that results in efforts to avoid victimization, but attempts even to think about one’s delusions may perpetuate psychotic ideation. This may be the result of efforts to find a way to view oneself as not psychotic in terms of one’s thinking, and, as indicated, most psychotic individuals may be motivated in terms of the goal of sanity. However, this will essentially perpetuate psychosis and delusions, in particular. Hallucinations represent symbols or concepts within the mind, even if only insofar as auditory hallucinations are words as symbols that the psychotic individual “hears” in his mind.
It must be asserted that psychosis can be depicted as a process that is, in itself, a visceral experience affecting the emotions on the levels of the id, the ego and the superego. Psychosis can elicit instincts, distort reason, and devastate the conscience. This may be the result of non-normative experience of the psychotic, who feels and thinks that “others” within his mind are aware of all aspects of himself. As few non-psychotic individuals discern, a lack of boundaries from others, boundaries that are perceived as nonexistent within the mind of the psychotic individual, cause the self to disintegrate and may lead to a state of emotional and mental catatonia. For this reason, the psychotic individual may be detrimentally affected by psychotic process from which analytical reasoning, perhaps substantively, cannot and will not detract.
It has been demonstrated that psychotic individuals have limited frontal lobe activity. From this arises the question: “Is psychosis a cause or a consequence of limited frontal lobe activity?” Perhaps it is both of these. The typical psychotic individual may reason with himself: “I hear voices in my head. This means that somebody or something is talking to me in my head.” Although science has taught us not to judge mental and physical experience in terms of its face validity exclusively, psychosis, including hallucinations and delusions, represents experience about which many psychotic individuals cannot reason adequately, or, for that matter, understand rationally at all.
Freud stated: “Our present ego-feeling is only a shrunken residue of a much more inclusive — indeed all-embracing — feeling which corresponded to a more intimate bond between the ego and the world about it.” (P. 68, Freud, 1929) In terms of the therapeutic qualities of faith, as experienced through a relationship with a god, religion represents a connection with a god that may represent a re-enactment of a state so primitive that is replicates a symbiotic connection that, in a sense, precedes the connection with a mother object. The reification of such a relationship may be a primary goal of a therapeutic alliance. Yet a connection with one’s therapist in adult life is not such a re-enactment of a connection with God or the mother object or any other primary symbolic figure constructed in the infant and standing like an obelisk in the conscious or unconscious mind. The adult is not primitive in spite of the lurking id. The adult possesses an ego and a conscience, construed as reason and sense of moral obligation. For these reasons, the relationship between the client and his therapist does not require religious or maternal joining, symbiosis and extreme intimacy, or an all encompassing feeling of acceptance in order to be effective. Indeed, this would be dysfunctional and anti-therapeutic.
Due to the visceral quality that accompanies hallucinations, however, certain realities regarding psychotic experience can be understood by non-psychotic clinicians and therapists. The psychotic individual cannot reason with his hallucinations. He can not invoke in them sympathy, empathy or pity. He cannot escape the arena in which they reside whether the psychotic individual’s hallucinations occur in the physical or the mental realm. Moreover, as stated and worth repeating, psychotic experience can occur as a phenomenon that represents itself on a level of intra-psychic experience that is intolerable and unacceptable in terms of its perceived inter-psychic intimacy. These realities are not often broached by non-psychotic therapists and clinicians in terms of their own imaginations, and imagination may be the only means by which non-psychotic individuals might empathize with the psychotic individual. Psychotic individuals live experiences that most people cannot even comprehend, and if non-psychotic people were to comprehend this fact, this might enable psychotic individuals to comprehend psychotic experience much better.
Psychotherapy in the humanistic tradition can aid the psychotic individual, particularly in terms of the conveyance of empathy by the non-psychotic clinician regarding the psychotic individual’s emotional state, consequent to his cognitive state. This cognitive state may be empathized with by means of the clinician’s recognition, without agreement, regarding the psychotic individual’s world view. The experience of the psychotic individual must be accepted first, understood second, and challenged last, if this is possible in clinicians who work with psychotic people.
The most reliable treatment for psychosis remains psychopharmacological treatment, given that the effectiveness of this treatment must be understood to rely upon orchestration of experimental ingenuity in finding the right medication or combination of medications to meet the idiosyncratic biochemistry of the psychotic individual. It is interesting that, within most of our lifetimes, antipsychotic medications have been what were termed “psychiatric straight jackets”, but, more recently, newer nontraditional antipsychotic medications have the capacity to “organize the mind.” It is interesting, as well, that psychotic individuals are able to score approximately ten points higher in terms of their overall IQ when they are taking the newer antipsychotic medications, as opposed to scores obtained when they are not medicated. While this may be encouraging in the treatment of psychotic people, psychosis remains a difficult conundrum to unravel, in terms of the seeming unraveling of the psychotic mind.
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