Psychodynamic Therapy

Editor Brian Martindale, mail to This email address is being protected from spambots. You need JavaScript enabled to view it.

Introduction to Psychodynamics and Psychosis

It is important to distinguish between:

1. Psychodynamic models of understanding the mind of the person with psychosis.  Psychodynamic understandings can be used to help understand a person in any situation or setting and be integrated with many therapeutic approaches.
2. Psychodynamic or psychoanalytic therapies. Psychodynamic therapies for psychosis are specially adapted therapies based on psychoanalytic theory and modifications of psychoanalytic technique.

We stress this point as an understanding of psychodynamics may be useful for anyone interested in psychosis, whereas providing therapy requires special training.

What is psychosis from a psychodynamic perspective?

A way of thinking about realities

The intact mind is able to recognise and integrate the many realities a person has to contend with at any point in time.

By realities, I mean not only the realities external to the person (e.g. how other people are behaving, the social context and 'rules' and of course the rules of the physical environment such as gravity and time) but also internal realities of feelings, conscience, memories, of one’s biology and physical state (e.g. hunger, sex, tiredness).

Much of what is being registered and integrated is unconscious. The ego is a term often applied to the ‘integrating mind’ and contributes to the sense of self (though ego and self are not the same).

In psychosis, aspects of the mind cannot integrate aspects of ‘reality’ – or aspects of the mind have been overwhelmed, perhaps shattered, leading to a feeling of annihilation or a fear of annihilation in acute situations. This may be because of something specifically too disturbing (something qualitative e.g. something very shameful or humiliating) or something that is also quantitative e.g. too many losses of key people in one’s life in a short time).

Either as a result of the mind being overwhelmed or perhaps to prevent it being overwhelmed, the mind reorganises itself or part of itself to create a new reality with the aim of circumventing the painful issue. In psychodynamic terms, both the creating of a new reality and the particular methods of doing this are what I mean by psychotic. In doing this, it uses similar devices that we all use in our dreams.

Here we give some simplified examples.

• A young man who is in danger of feeling he will never have a girlfriend, starts hearing a nice female voice (this is called hallucinatory wish fulfilment)
• A religious person who has renounced anything sexual about herself starts to feel persecuted by beliefs that there are plots to infiltrate her room with sexual chemicals
• A woman who cannot have children becomes thought disordered when relatives with young children visit (the thought disorder protects her from too painful thoughts)
• A person who did a great deal of damage in a fit of rage is admitted to hospital, and the next day has no memory of the event and claims they have been wrongly detained and accuses the psychiatrist of being an impostor!!

Common to these examples is some form of splitting (or fragmentation) of reality by the mind, denial of reality and often projection (e.g. of distorted personal issues outside of self into another or the external world). Reaction formation (turning something into its opposite) is common and linked with wish fulfilment. The intuitive person can recognise meaningful aspects of the person’s life issues in the psychotic symptoms, but one needs to be careful about reflecting this back to the person as the point of the psychosis is that something has been intolerable. When a person has been psychotic for a while all kinds of secondary phenomena and further distortions occur as well as withdrawal from aspects of life and relationships. Early intervention is therefore most important

Seven important points

1. A psychodynamic view is that psychosis can have a purpose in relation to mental pain.

   In non-psychotic problems, the person SUFFERS from mental pain CONNECTED with their reality and feelings.

   In psychosis people come to or for attention where the psychosis has not been successful enough in transforming mental pain or the person causes problem for others (e.g. in mania).

2. Psychodynamic understandings are quite compatible with hypothetical biological understandings of psychosis or vulnerability.

   For example there is no inherent reason why we may not all have different sensitivities to mental pain stemming from constitutional differences.

3. The psychological methods of dealing with pain in psychosis, fragmentation, denial splitting, projection, wish fulfilment and so on – are methods common to all of us to varying degrees.

   The important point is the degree to which the integrating mind has been overwhelmed or the area of the mind involved

4. The concept of culture wide psychosis is important where denial of reality (and projection) is shared in a population because of too painful implications.

   Examples might be the tendency to deny climate change, the belief in a physical life after death where it has the function of denying the painful reality of death and loss of self and others.

   Aspects of the nature of war and relations between nations or religions.

5. Nurture. Psychodynamic thinking is that the state of mind prior to psychosis is often relevant.

   Many people who experience psychosis in their adult lives have had earlier traumas, not only abuse but losses.

   Adult experiences may awaken earlier experiences and overwhelm the person.

   Perhaps more important but less obvious are nurturing situations in which the person has been excessively protected or prevented from experiencing feelings and do not have the mental strength to manage adult life or separation from the family. 

6. Repression and symbolisation.

   An intact mind does not just register realities, it also ‘digests’ realities.

   For example love and aggression are transformed in all of us through normal mental repressive barriers into interests and behaviours that contribute to the richness of the sense of being alive and living.

   Here psychoanalysis from its early days has hypothesised about the complex relation between somatic forces and their mentalisation. In psychotic areas of the mind,  there are difficulties in symbolisation and ideas and thoughts are taken to be realities, not representations

7. Psychotic and non-psychotic

   None of us are unitary, our sense of self can change quickly.

   It is most important for many reasons not to think of someone, ourselves included, as psychotic or non-psychotic.

   It is quite possible to be actively psychotic and yet another aspect of ourselves can be functioning very well in relationship to realities (point one). An important issues is the relation between the two which can be very variable.
   

Psychodynamics, attachment and psychosis, by Allison Summers

Attachment theory

Attachment theory originates with the psychoanalyst, John Bowlby, who defined attachment as an affectional bond with a 'differentiated and preferred individual' or attachment figure. Attachment figures are seen as providing a safe haven in times of distress and threat, as well as a secure base from which to explore the world. Further reading.

The development of psychodynamic models of understanding psychosis over the last century, by Maurizio Peciccia.

Federn, Abraham and Jung were amongst the first psychoanalysts to work with psychotic individuals. Federn, (1929) maintained that the mind was invaded by the unconscious and by dreams because the ego had become disinvested of libidinal love weakening its borders leading to fragmentation and invasion externally by reality and internally by dreams. Further reading.

Psychosis: Key Psychoanalytic Concepts" with Danielle Knafo PhD.

Danielle Knafo Ph.D. is a leader in the field of psychoanalytic approach to psychosis, so I'm very pleased she was the presenter for the ISPS-US webinar, "Psychosis: Key Psychoanalytic Concepts" that took place on 6/28/17.

In this presentation, Dr. Knafo explains key psychoanalytic concepts that help us to understand and treat psychosis or psychotic phenomena. These concepts include: regression, projective identification, psychic retreats, attacks on linking, islands of clarity, and finding meaning in symptoms. She emphasizes the discoveries, since Freud's time, that have deepened the understanding of the psyche, allowing the attribution of meaning to symptomology, and permitting human encounters that initiate profound change through insight and communication.

See youtube video.

Extract from the Norwegian Guidelines for Psychosis

The Norwegian Guidelines are unusual in that they have a section that clearly supports psychodynamic approaches to psychosis and justifies them on a number of grounds including their unsuitability for random controlled trials the usual basis for contemporary mental health guidelines.

Translation may be approximate Further reading.

The evidence

Psychodynamic therapies are difficult to study with RCT's In this article is explained why: And also what do psychodynamic therapists of psychosis think of the method?

Individual psychodynamic therapy for psychosis: A Delphi study
Swapna Kongara, Chris Douglas, Brian Martindale & Alison Summers

A Recent large study: 

The Danish National Schizophrenia project (DNS II):Prospective, comparative, longitudinal, multicentre study of psychodynamic psychotherapy of first-episode psychosis. A controlled design of non-selected, consecutively referred/admitted patients.

Harder S, Koester A, Valbak K, Rosenbaum B. Five-year follow-up of supportive psychodynamic psychotherapy in first-episode psychosis: long-term outcome in social functioning. Psychiatry: Interpersonal and Biological Processes, 2014;77(2):155-68

Psychodynamic therapies and culture

O'Lochlin, M. (2020) Whiteness and the psychoanalytic imagination. See PDF

Websites

Ann-Louise S. Silver’s website has her articles on the psychodynamic therapy of persons with psychotic disorders. www.mdpsychotherapy.com.

Articles

Karon, B. P. (2003). The tragedy of schizophrenia without psychotherapy. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 31, 89-118.f see Pdf

Charles, M. (2011). Working with Trauma: Lessons from Bion and Lacan. New Imago.

Pre-therapy and psychoanalysis article by Lisbeth Sommerbeck See Pdf

Hamm, J. A., & Lysaker, P. H. (2015, April 6). Psychoanalytic Phenomenology of Schizophrenia: Synthetic Metacognition as a Construct for Guiding Investigation., Psychoanalytic Psychology. See abstract.

Books

Fromm-Reichmann F. Principles of intensive psychotherapy. Chicago: University of Chicago Press; 1960. See book frontpage.

Jackson, M., Williams, P. (1994) Unimaginable storms: a search for meaning in psychosis. London: Karnac. See book.

Jackson, M. (2001) Weathering the storms: psychotherapy for psychosis. London: Karnac. See book on Amazon.

Williams, P. (1999) Psychosis (madness) London: Institute of Psychoanalysis. See book on Google.

Lucas, R. (2009) The psychotic wavelength: A psychoanalytic perspective for psychiatry. Hove: Routledge. See Amazon.

Karon, B.P. & VandenBos, G.R. (1981). Psychotherapy of schizophrenia: The treatment of choice. New York: Rowman & Littlefield. See book frontpage.

Charles, M. (2011). Working with Trauma: Lessons from Bion and Lacan. New Imago see book.

Working with Trauma: Lessons from Bion and Lacan by Marilyn Charles takes concepts from the psychoanalytic literature and translates them into user-friendly language. In this book, Charles focuses on clinical work with more severely disturbed patients, for whom trauma has impeded their psychosocial development. Introducing ideas from Bion and Lacan, such as “empty speech” and “attacks on linking,” she shows the reader their clinical utility. Her use of clinical moments, rather than more lengthy vignettes, invites readers to recognize that type of dilemma and imagine how they might use the concept in their own work.

Michael Eigen, Image, Sense, Infinities, and Everyday Life. See book on Karnac.

Clancy Mckenzie, Stress Disorders from Infancy: The Two Trauma Mechanisms, Clancy argues that schizophrenia is a delayed reaction on trauma’s in early childhood. See book on Amazon.