For example, a single man in his early 30s was hospitalized because his auditory hallucinations became disruptive. He had heard voices since adolescence. He did not tell anyone about hearing disembodied voices because he was afraid he would be judged insane.
He lived alone and had practically no social relationships. His only contact was an older brother who lived in another city with whom he occasionally corresponded or talked on the telephone.
At work he was also isolated, but very highly respected. In fact, he was considered a wizard in programming computers. His work consisted of solving complicated technical problems. His employers would present him with a problem and then leave him alone until he solved it, which he invariably did. He had virtually no contact with his fellow employees, his office and lab being in an isolated section of the building, and he was pleased with this arrangement.
His life outside of work was also quite constricted. He went to the movies almost every evening and he saw a psychiatrist once a week. He read Variety and had amassed considerable knowledge about the cinema and knew a good deal about the personal lives of movie stars. He would sometimes talk about such topics with his brother, usually on the telephone.
He saw a psychiatrist because he felt lonely and depressed and he wanted to have a person to whom he could confide about hearing voices. The psychiatrist put him on an antidepressant and a phenothiazine, both of which had little effect on him. Later when I saw him he stated that the drugs made him feel "emotionally stiffer than usual." The interpersonal aspects of the therapeutic relationship were sparse. His therapist made many suggestions urging him to socialize and frequently gave him advice. The patient paid lip-service to what he was told but did absolutely nothing to change his circumstances and to heed the advice he was so freely given, but he never missed an appointment and was always on time for his sessions.
Life went on following a fixed routine and allowing no variability until he made a particularly important discovery. As a result of his work, his employer promoted him and gave him a raise. The promotion meant he had to have more contact with fellow employees and those that were designated as his subordinates. Rather than feeling pleased with his achievements, he had a psychotic decompensation.
The voices that had engaged him in conversation now became threatening and accusatory. They reviled him as being wicked and worthless and vowed that eventually they were going to tear him apart limb by limb. He suffered intense panic and had to be hospitalized.
After two weeks the patient was put on a moderately heavy dose of haloperidol(Drug information on haloperidol) (Haldol). His hallucinations completely disappeared and his mood stabilized. While in the hospital, he negotiated with his immediate superior to go back to his old office job. His brother arranged for his discharge and stayed with him for a week after he left the hospital. He also arranged for him to see me, feeling adamant that the patient not return to his former psychiatrist.
During our first session, he ironically remarked that he was cured, because that was what he was told at the hospital. He confirmed that he no longer heard voices but, oddly enough, he wanted them back.Underlying Factors
I learned that as a child of two elderly parents, he felt very much alone. No one ever talked to him. His much-older brother was in college and usually not available to him. He was devoid of companionship and because he did not develop any social skills and was awkward and clumsy, he made no friends. The only attention he received was from his teachers, because he was bright and an easy learner. His peers viewed him as somewhat peculiar but they did not make fun of him; they simply ignored him and the patient learned to adapt by living within himself.
He made up stories and plots and became part of the script, many being borrowed from the numerous movies he saw. During adolescence he talked to the characters he created and they began talking back to him. Soon, what were thoughts were heard as voices, either within the context of a story or fantasy, or just as another person having a conversation. He heard them with hallucinatory clarity and they seemed to fill a void.
Inasmuch as he felt miserable because he missed the voices, I suggested that he discontinue Haldol and that he could talk to me. Gradually the voices returned, but they were benign as they had previously been. I made few comments about the voices, except that he needed them and they gave him solace. In the meantime, I focused my attention on his inner life, his isolation and anxiety about making friends and moving into the external world because he felt inadequate and did not learn the adaptive skills to cope with his social milieu. He constructed schizoid defenses and created his own universe with his plots, fantasies and auditory hallucinations.
He was able to achieve his pre-hospitalization equilibrium when he stopped taking Haldol. External stresses had been reduced when his employer agreed to let him return to his old isolated office. I conjecture, however, that our relationship also contributed to his stability, because I was paying attention to him as a person as I was attempting to understand how his mind worked rather than restricting my attention to surface phenomena such as his hallucinations and lack of social involvement.
Slowly, he experimented in socializing. He increased his contacts with his brother and joined a computer club. The voices lost their significance, and his need to make up plots and fantasize diminished as he became more engaged with the real world.Psychic Versatility
Explorations of patients' psychodynamics as they determine current adjustments and symptom formation is much more interesting and fulfilling than monitoring surface behavior. Mental processes are innately fascinating and their study creates dimensions and viewpoints that expand our appreciation of the versatility of the psyche as our in-depth understanding is increased, in itself, an aesthetic experience.
I believe all psychiatrists can benefit from an adherence to the psychodynamic viewpoint. Patients are not just machines that can be regulated with drugs or behavioral manipulation. They have minds that are craving to be understood; they are looking for someone to make sense out of what appears senseless. For the general psychiatrist who is aware of some psychoanalytic principles, particularly unconscious motivation, that is the essence of the intrapsychic focus; their patients are transformed into interesting human beings rather than the passive recipients of pharmacological ministrations. How the treatment procedure fits into the therapeutic relationship is taken into account, enabling patients to pursue autonomy and mastery of their emotions. This is enhancing for both patient and therapist.