Brian V. Martindale, FRCP, FRCPsych

To understand some psychodynamic perspectives of psychosis and how this relates to therapeutic approaches.

At the end of this CE activity, participants should be able to:

 Understand the unconscious mental activity that may take place during a psychotic episode

 Define how these episodes affect not only the patient but others as well

 Make treatment decisions based on the psychodynamic perspectives

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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Since the early days of psychoanalysis, practitioners and theoreticians have had an interest in psychotic conditions. Consequently, they have developed theoretical ideas about the conditions and clinical approaches for treatment. This article presents some contemporary ideas that might stimulate further research and clinical evaluation.

Although there is much disagreement about the criteria for-and even the existence of-a discrete entity called schizophrenia, few would argue against the need for words to describe the various mental states in which there is an altered relationship to reality. In the English language, “psychosis” is the commonly used, and little disputed, general word.

However, defining reality is not as easy as it first seems to be. In this article, I use “reality” in a particular way that I think has significant utilitarian value. The intact mind gathers, integrates, and processes information (realities), including emotional experiences, that at any one time may have multiple sources (both external and internal). Internal sources include memories and feelings, and their integration leads to unconscious and conscious experiences and ideation as well as to objective and subjective evaluation of those realities. This process guides the mind in its decision making. The ongoing outcome is usually in keeping with, or at least remains cognizant of, socially understood reality.

In psychosis, the mind disposes of or deflects certain (real) information-which may have external and/or internal sources-from integration. Psychoanalytic practitioners often find that the psychotic reaction is evoked by unacceptable, unbearable, or potentially overwhelming information or experience. Detached from the integrating mind, these unacceptable aspects are subject to further unconscious processes. The mind attempts to eliminate the pain by creating an alternative reality (sense of realness), which further distances the mind from information that is too disturbing. Examples of these processes are projection, denial, condensation, and displacement; repression and sublimation are associated more with nonpsychotic states.

 about World War II atrocities, at the moment of being involved in an ethnic group murder and after starting to experience too disturbing confusion and rage, the protagonist says: “. . . then my arm detached itself from me and went off all by itself down the ravine, shooting left and right, I ran after it, waving at it to wait with my other arm, but it did not want to, it mocked me.” This is a very graphic example of an easy-to-spot psychotic dissociation from the (too overwhelming) reality of the protagonist’s conflictual murderous self. The reality being dispensed with is too emotionally disturbing.

In acute situations, especially if it is possible to get a good collateral history, it is often not difficult to piece the situation together and begin to understand what aspect of the patient’s reality may have overwhelmed him or her and led to the transformation of reality. However, if one first sees a patient long after the onset of a psychotic state, the precipitating factors may not be so readily ascertained because it is inherent to psychosis that the “reality” that provoked the episode needs to be “steered clear of.” Moreover, it may not be a single factor-not uncommonly it is an accumulation of disturbing but individually meaningful factors.

We all know that when we are somewhat detached from consciousness, when we dream for example, we find ourselves “in another world.” Relatively free of reality checks, we find ourselves subjectively experiencing ourselves as, for example, fantastically very powerful or powerless, or we experience painful situations being transformed into pleasurable situations (or we wake up from a nightmare when the transformation does not work). In these situations, our unconscious allows us to disregard reality, and we can find ourselves in different places or dimensions.

During a psychotic episode, the self does not readily reintegrate with reality as happens when waking from a dream. When discussing delusions, Freud

 said, “A fair number of analyses have taught us that the delusion is found applied like a patch over the place where originally a rent had appeared in the ego’s relation to the external world.” In psychosis, the mind tries desperately to avoid experiencing the rent again.

A man who’s ego had been rent asunder for some weeks following a humiliating rejection by a girl, awoke believing that a famous actress was in love with him and that he and she made love several times a day (oblivious of the reality that she was on another continent!). The belief (Freud’s patch) persisted for some weeks and it was as if the humiliating rejection had never occurred.

An aging woman who was losing her physical capacities as well as being very short of money and material possessions, developed a fixed belief that robbers were appearing through cracks in her floorboards and stealing her possessions. She went to her psychiatrist to complain, not to the police station.

These examples illustrate well the enormous variability to which psychosis takes over the mind and how much insight exists in the nonpsychotic mind about the psychotic side and whether the insight can withstand the psychotic “propaganda.” (Michael Sinason

 is worth reading for his accounts of the relationship between psychotic and nonpsychotic internal personalities in the same person.)

Psychodynamics and psychosis: the effects on others

 wrote, “Human kind cannot bear very much reality.”

The feeling elicited in the clinician that the patient is not talking “sense” may readily lead to a too exclusive preoccupation with biological explanations if it is not understood that the psychotic mechanisms may have been somewhat successful if “nonsense” has been achieved. Sometimes people physically close to the person having the psychotic episode cannot manage the nonpsychotic reality of that person. This is often particularly true when abuse of any kind is going on.

A young woman repeatedly complained that she was being poisoned, but stated this in such a bizarre manner that she was labeled “schizophrenic.” Only much later, when a psychological history that included her environment was at last taken, was it seen that there was no way that she could have explained what was happening to her without putting herself into even greater danger from her abuser. For psychic survival purposes, the patient needed to resort to the unconscious methods of displacement of the abusive reality onto concrete sources outside of their source.

A young woman was admitted to the hospital in a psychotic state. Although she was found to be pregnant (she had been in denial), the focus was on getting the “right” dose of the “right” antipsychotic. When she tried to talk about the pregnancy (albeit in a way that was difficult to understand), she was advised to distract herself and wait for the medication to work. She withdrew and became contemptuous of the staff.

A psychological evaluation led to the recommendation of a family meeting. When the woman started to talk about her pregnancy, the family tried to distract her. The psychologist helped the family stay with the issue of the pregnancy and it transpired that there was unbearable shame about the circumstances of the conception. The hospital staff had also found it too embarrassing to attend to these issues.

The woman’s contempt makes sense because she had reasonable expectations that the mental health clinicians could tolerate her psychological issues. Once the shame was out in the open and owned by all members of the family, the psychosis lifted and medication was no longer needed, but ongoing psychological support continued. (For a more thorough consideration of the effects of psychosis on staff, see Hinshelwood.

The psychodynamic perspective that I have been describing and illustrating is potentially compatible with genetic and biological contributions to understanding psychosis, but it allows the nonspecific stress vulnerability model of psychosis to be used in a more sophisticated and individualized way. (Brent and Fonagy

 provide a further contemporary example of linking psychodynamically informed ideas with stress vulnerability and biological models.)

Disorders such as psychosis are not the outcomes of linear processes. There is evidence that the interaction of genetic, biological, and environmental factors during development can either be protective against psychosis or can increase the risk.

 It seems intuitive that the capacity for the self to bear (integrate) affects will, to a considerable extent, be a complex interaction between temperament and long-term family and other environmental factors during development-distal vulnerability factors are therefore not limited to biological factors. In some cases, careful exploration shows how closely distal factors are related to proximal factors.

A person who had had several episodes of mania and depression said to his therapist during a euthymic phase that he never experienced sadness, because he would then feel he was in a deep dark well. His difficulty with “ordinary” sadness was very long-standing. His tipping over into serious mental illness in adult life was when his capacities to defend against experiencing the emotions connected with disappointments and losses were overwhelmed (and a rent formed in his mind).

Increasing evidence is leading to greater acceptance that childhood trauma substantially increases the risk of later psychosis and that increased risks also stem from insecure styles of attachment and problems in mentalizing.

 Moreover, certain family environments increase the risk of relapse.

A psychodynamic perspective should not imply a necessary antagonism to the use of medication. However, psychodynamics have a rich part to play in identifying the specific personal and environmental vulnerabilities to psychosis. Psychodynamics can help locate where psychological “strengthening” is needed to allow the patient to face key emotional feelings or, alternatively, which issues need to be avoided to minimize the risk of a further psychotic breakdown.

Psychodynamics as an adjunct to other therapies

All human relationships are potentially influenced by previous experiences and by attachment styles. In psychosis, therapeutic relationships are especially complicated because psychotic ideation may affix itself to the clinician alongside less psychotic personality styles of relating. Sometimes psychotic features may be manifest in the relationship, but often they are hidden or interwoven with nonpsychotic transference and therapeutic alliance. Awareness of the psychodynamics of the therapist-patient relationship is always helpful no matter which therapeutic modality is used.

A patient with multiple relationship problems seemed to have a good working relationship with his therapist and was progressing well. However, he had begun to believe that he was the therapist’s only patient. When eventually he was confronted by another patient leaving the therapist’s office, he experienced his mind and body splintering into pieces.

The patient had been an only child for 8 years and had been devastated by the arrival of a sibling. It became clear that his progress was conditional on a psychotic belief of not having a rival. On the basis of this delusion, he eliminated rather than gradually integrating all the feelings and developmental issues that accompany sharing, including murderous impulses (that the splintering of his body defended against).

Trying to engage a man with serious psychosis of many years’ duration, a nurse offered “simple” practical advice about managing his debts, matters related to his housing, and taking medication. However, this was not getting anywhere. It transpired that she was not used to trying to make sense of the content of her patients’ delusions and hallucinations. Once she was helped to tune into these, she realized his audio hallucinations (“voices” that he had been wary of revealing to her) were telling him to not trust any advice.

When this man was 11, his father had had a breakdown and had never fully recovered. At that time, he had resolved to be self-sufficient, believing that needing help was a “slippery slope” from which there was no recovery. After learning his history, the nurse realized the naivety of her approach. She saw that being in need of her help was subjectively a very great danger to him-she began using a dialogue about whether any suggestion of hers was getting him onto the “slippery slope,” and he started to feel safer during their session. Feeling useless as a result of countertransference had led the nurse to seek help in understanding her patient. She learned not to be so critical and realized that she might unwittingly be causing a problem for a patient that she did not understand.

These examples show that it is only too easy to dismiss patients who do not readily engage with us and to be naively too positive about some of those who seem to engage readily. The vagaries (psychodynamics) of therapeutic relationships in psychosis are full of clues to understanding psychosis and nonpsychotic problems.

Psychodynamic therapy as the primary focus

A most important question needing a great deal more research is which psychotherapeutic settings are most appropriate for patients and whether different settings and approaches are needed for different phases of psychosis.

A therapeutic elaboration using awareness of psychodynamics can occur in settings with individuals, couples, families, and groups as well as in therapeutic settings, group homes, and hospitals. Alanen

 pioneered and researched a “need-adapted” approach to schizophrenia. This therapeutic approach is based on the assessed psychological needs of the patient, and medication is used to support the psychological work.

 has recently taken a somewhat different but predominantly psychodynamic model to therapeutic phases of therapy. She places a great deal of emphasis on the state of the self. The overwhelming of the ego in psychosis can lead to annihilation fears and experiences of not existing as a self (“my whole life is artificial,” “I think I am dead but do not know it yet”). With this approach, therapy is organized according to the sense of self that the patient is in, which Fuller delineates into 3 broad categories: surviving, existing, and living.

In their meta-analysis of individual therapy in schizophrenia, Gottdiener and Haslam

 reviewed 37 studies in which an effect size could be calculated. They found that 66% of patients who received individual therapy improved compared with 35% who had had no therapy. They found that effect size of psychodynamic therapy was similar to that of cognitive-behavioral therapy.

The Boston Psychotherapy Study compared exploratory, insight-oriented (EIO) therapy with reality-adaptive, supportive (RAS) psychotherapy.

 Study outcomes included the minimal overall difference between EIO therapy and RAS psychotherapy. The EIO therapy patients tended toward less thought disorder and greater insight and the RAS psychotherapy group had overall improved social functioning; however, the dropout rate was disappointingly high for both modalities.

 underlines the considerable variation between different cases in their suitability for a particular approach and sincerely questions the ethics of treating groups of patients identically rather than according to an assessment of their individual needs. He promotes a need-adapted approach. The research evaluates overall outcomes in successive cohorts of patients following the introduction of greater choice of therapy, especially after making family interventions available. He also highlights the great variation in the capacity of therapists to work with patients who have psychotic problems.

 have published the outcomes of a prospective multicenter trial that at 2 years showed that there were statistically significant benefits from individual supportive psychodynamic therapy conducted by supervised therapists who had not necessarily had a great deal of training. The therapy was conducted according to a manual that gave broad guidelines. (More details of the therapeutic approach are referred to in an article by Rosenbaum and colleagues

; it is important to emphasize that contemporary psychodynamic approaches for psychosis are very different from those used over the past decades for nonpsychotic disorders.)

Perhaps the most exciting outcome research using psychodynamic understanding is in family approaches to psychosis. Whatever the psychological modality, research into family approaches to psychosis has the most consistently positive outcomes, with effectiveness on a par with medication. (For a summary of the evidence base of family approaches, see the National Institute for Health and Care Excellence Guidelines on Schizophrenia.

Some of the best outcomes in the world come from the Finnish Open Dialogue approach to psychosis.

 A 10-year follow-up shows continuing outstanding results with further cohorts of patients.

 These results are partly due to the reorganization of psychiatric practice, usually taking place in the patient’s home. The focus is on very early psychosocial response to any psychiatric disturbance and the patient’s family and social network are engaged from the beginning.

The therapy is guided by the development of a shared vision of the core issues, which are worked over and over at an emotional level. The work is in keeping with the core psychodynamic hypothesis that psychosis results from an avoidance of integrating “toxic” issues as described above. This approach leads to the need for far less medication and hospitalization and a high level of reintegration into community life with the return to education and employment. The method is an evolution of Alanen’s need-adapted psychoanalytic approach of almost 3 decades ago.

Open dialogue training is now happening in several countries. In 2013, New York City initiated a related program in several districts, which integrates the best of the Finnish and Swedish psychosocial developments.

Contemporary psychodynamic understandings greatly assist in making sense of the human issues that people with psychosis have difficulty in negotiating. They take a developmental non-reductionist approach that accepts the interaction of environment with the brain. The understandings achieved point to more meaningful interventions for the patient using approaches that are very distinct from those of classic psychoanalysis. Understanding psychodynamics is also highly relevant to managing the vicissitudes of the therapeutic relationships whatever the primary modality being offered.

Research is providing evidence that applications of psychodynamic strategies can improve outcomes, especially in the realm of family and psychosocial approaches to psychosis. There are many areas ripe for further research as the limitations of medication and its long-term use are better appreciated. Much of current research tends to eliminate individual variations; therefore, it is vital that future research methods highlight differences in individual susceptibilities to psychosis and individual differences in therapeutic needs.

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Dr Martindale is Chair of the International Society for the Psychological and Social Approaches to Psychosis (www.isps.org). From 2005 to 2012, he was a consultant psychiatrist on an early intervention in psychosis team in the northeast of the UK. He is also a psychoanalyst and a fellow of both the Royal College of Psychiatrists and the Royal College of Physicians. He is Honorary President of the European Federation for Psychoanalytic Psychotherapy in the Public Sector (www.efpp.org).

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Suffering Insanity. Psychoanalytic Essays on Psychosis

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Social Cognition and Metacognition in Schizophrenia: Psychopathology and Treatment Approaches

 Tienari P, Wynne LC, Sorri A, et al. Genotype-environment interaction in schizophrenia-spectrum disorder: long-term follow-up study of Finnish adoptees. 

 Read J, Bentall RP. Negative childhood experiences and mental health: theoretical, clinical and primary prevention implications [published correction appears in Br J Psychiatry. 2012;201:328]. 

 Gumley A. The developmental roots of compromised mentalization in complex mental health disturbances of adulthood: an attachment-based conceptualization. In: Dimaggio G, Lysaker PH, eds. 

Metacognition and Severe Adult Mental Disorders: From Research to Treatment

Metacognitive capacity as a focus of individual psychotherapy in schizophrenia. In: Dimaggio G, Lysaker PH, eds. Metacognition and Severe Adult Mental Disorders: From Research to Treatment

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Schizophrenia: Its Origins and Need-Adapted Treatment

Surviving, Existing or Living. Phase-Specific Therapy for Severe Psychosis

 Gottdiener W, Haslam N. The benefits of individual psychotherapy in people diagnosed with schizophrenia. 

 Gunderson JG, Frank AF, Katz HM, et al. Effects of psychotherapy in schizophrenia: II. Comparative outcome of two forms of treatment. 

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Articles

Contemporary ideas about psychotic conditions and clinical approaches for treatment. 

Author | Brian V. Martindale, FRCP, FRCPsych

Articles

The Dynamics of Psychosis: Therapeutic Implications