Nobody is completely mad. Nobody is completely sane. On the stage of each of our lives are many players, and all of them are crazy in their own particular way.
Generally we are inclined to define madness in terms of failure to adhere to consensual reality. DSM IIIR defines psychosis as "gross impairment in reality testing and the creation of a new reality.. delusions or hallucinations (without insight into their pathological nature)" (p.404). The consensus about reality, however, shifts from culture to culture and from one period of history to another, and indeed, from circumstance to circumstance. The conventions by which we live are themselves full of contradictions. Furthermore, all of us depart from consensual reality as soon as we fall asleep and there are none of us who do not harbour phantasies which, if acted out in the "real" world, would not be considered mad by many people.
As therapist's we come into contact with many people whose views of the world are different from our own, and different from those of the people around them. Often such people wonder if they are mad, in which case they almost certainly are not. Some are quite sure that only they are sane, in which case they are almost certainly mad.
The first step we must take in learning to tap into our own psychotic imagination is to recognise that madness is a paradoxical and relative phenomenon. Those who come to be publicly declared mad are not, in most cases, fundamentally different from anyone else. Generally it is a case of their particular madness having ceased to work in the social context in which they live and their communications about it having become incomprehensible to those around them.
None of this should, however, lead us to believe that madness is a benign condition which should not worry us at all. Our imaginations are capable of transporting us to the heights of ecstasy and the pits of despair, to creativity and to destruction. It is surely our fear of the tempests which may blow within each of us which leads us commonly to try to draw a hard and fast line between ourselves and those who can be classified as "mad".
To aspire to be a therapist is equally surely to be willing to entertain the possibility that there is no such line, for a therapist is one who ventures into the other world, the world of the client. We will never be able to do this without the aid of our own psychotic imagination.
One of the first modern therapists to begin to take mad people seriously was Carl Jung. "I could never be satisfied with the idea that all that the patients produced, especially the schizophrenics, was nonsense and chaotic gibberish. On the contrary I soon convinced myself that their productions meant something which could be understood, if only one were able to find out what it was. In 1901, I started my association experiments with normal test persons in order to create a normal basis for comparison. I found then that the experiments were almost regularly disturbed by psychic factors beyond the control of consciousness. I called them complexes. No sooner had I established this fact than I applied my discoveries to cases of hysteria and schizophrenia. In both I found an inordinate amount of disturbance, which meant that the unconscious in these conditions is not only opposed to consciousness but also has an extraordinary energic charge. While with neurotics the complexes consist of split off contents, which are systematically arranged, and for this reason are easily understandable, with schizophrenics the unconscious proves to be not only unmanageable and autonomous, but highly unsystematic, disordered, and even chaotic. Moreover, it has a peculiar dreamlike quality, with associations and bizarre ideas such as are found in dreams. In my attempts to understand the contents of schizophrenic psychoses, I was considerably helped by Freud's book on dream interpretation which had just appeared (1900). By 1905, I had acquired so much reliable knowledge about the psychology of schizophrenia .. that I was able to write two papers about it. (These) had practically no influence at all, since nobody was interested....
At the beginning, I felt completely at a loss in understanding the associations of ideas which I could observe daily with my patients. I did not know then that all the time I had the key to the mystery in my pocket, inasmuch as I could not help seeing the often striking parallelism between the patient's delusions and mythological motifs. But for a long time I did not dare to assume any relationship between mythological formations and individual morbid delusions. Moreover, my knowledge of folklore, mythology, and primitive psychology was regrettably deficient, so that I was slow in discovering how common these parallels were. (Jung 1953, Collected Works, vol 18, pp353-4)
CONSCIOUS AND UNCONSCIOUS
What is the unconscious? The unconscious is whatever part of the mind is kept out of view. It is both the source of spontaneity and creativity on the one hand, and, on the other, the repository of all memories which are either too shameful to be exposed or too at odds with our conceptions of ourselves to be admitted.
It is apparent that the unconscious operates according to different principles from the conscious mind. The conscious mind is much concerned with:
Defining and limiting, exclusion
Logic, deduction, consistency
Dualistic reasoning - true/false either/or dichotomies
Temporal sequences, history
whereas the unconscious mind seems to work more by
Association of ideas, including puns
Intuition and imagination
Holistic impressions - inclusive, both/and,
Timeless, achronistic connections
The unconscious is, it seems, the more "natural" part of the mind whereas the conscious is the more "artificial" part. The conscious works things out and tries to get things done whereas the unconscious just plays, imagines, desires and fears. "It is essential to abandon the overvaluation of.. being conscious before it becomes possible to form any correct view of the origin of what is mental.. the unconscious must be assumed to be the general basis of psychical life. The unconscious is the larger sphere, which includes within it the smaller sphere of the conscious. Everything conscious has an unconscious preliminary stage.. The unconscious is the true psychical reality; in its innermost nature it is as much unknown to us as the reality of the external world, and it is as incompletely presented by the data of consciousness as is the external world by.. our sense organs" (Freud 1900/1976, p.773).
Freud asserted that the unconscious mind is governed by the "pleasure principle" whereas the conscious mind is governed by the "reality principle". This is a useful distinction. We can immediately see that a person needs both in order to function effectively but that the two may, nonetheless, be in conflict with each other. Psychotherapy has traditionally relied a good deal upon methods for accessing the unconscious such as hypnosis, free association of ideas, dream analysis, transference analysis and reflection upon the seeming irrationalities of daily life.
Each of us, however, has reason to want to keep some things out of consciousness. In order to achieve this we operate a kind of self-censorship. However, the situation is doubly complicated because clearly enough we must not only deceive ourselves about the mental contents we do not wish to acknowledge, we must also deceive ourselves about the fact that we are deceiving ourselves. The censorship is therefore operated unconsciously and takes the form of "defense mechanisms" which are commonly listed as:
It is worth noting that Freud's original term which gets translated as "defense" actually meant "warding off". We have a wide range of ways of warding off what we do not want to accept. We ward off problems which are insoluble. We ward off what we believe is shameful. We ward off whatever is painful. But this does not mean that the painful contents of our minds cease to exist. The most extreme form of warding off is catatonia. In this state the person become unable to do anything at all. A kind of catatonia is encountered in refugees. A person whose whole world has been taken away from them may simply sit down and enter a state of total helplessness. This is, in a way, rather like the way a defeated animal will roll over on its back into a totally defenceless position, the last chance of survival.
Most of us succeed most of the time in keeping our particular madnesses out of public view. When a person becomes overtly mad, this may be attributed to a failure to keep the irrational part from over-whelming him or her. Such a collapse may have been triggered by a particularly acute stress. Factors which may play a part in creating the conditions within which a psychotic condition or episode may occur include:
Drug induced states
Extreme physical stress
Emotional neglect or abuse
There are many theories about the origins of madness. There is quite a bit of evidence that some people may be genetically vulnerable to schizophrenia, or some forms of it. It seems unlikely, however, that this is the whole explanation of its onset.
Ronnie Laing suggested that psychosis may be a rational response to an insane situation and Gregory Bateson (1973) suggested the "double bind theory" as a means of explaining how this works. Melanie Klein saw psychosis as regression to the blind, uncontrollable "furies" of the new-born infant. Jung saw it as an invasion of consciousness by archetypal forces around which a massive complex may be constellated. John Rowan and Jacob Moreno have each written about sub-personality approaches to understanding mental disturbance while Paul Federn and Eric Berne each wrote about psychosis in terms of the development of different ego states. All these theories have something to recommend them. Rather than look for a single explanation, we are probably best to consider psychosis as a multi-faceted pattern of phenomena. Each theory tells us something about it from a particular view-point. Sometimes one theory will be more useful, sometimes another. This paper draws on a wide range of schools of thought.
The sorts of signs which are commonly taken as indicators of madness are a combination of several of the following:
Failure to form meaningful or lasting relationships
Failure to sustain such social institutions as employment,
Communication which is intermittently bizarre
Delusions, hallucinations and voices
Highly idiosyncratic ideas about taboo subjects such as sex,
anger, religion, contamination, food, death, power etc.
Absence of emotions and of normal social responsiveness
Ideas of extreme self-importance
All these "symptoms" are characteristics which are not unknown to us in our own lives. Madness may therefore be considered to be a matter of degree rather than a difference of kind. There is a tendency to think that once a person has become mad they will always be so. This is not true. Chronic and acute psychosis should be distinguished. The chronic form seems to be largely a product of the way society treats people who have had a "breakdown". Recovery rates from schizophrenia, for instance, are much higher in third world than in industrialized countries (Barham & Hayward 1990; WHO 1979).
Jung conceived of the mind as being organized into "complexes" of affectively linked contents. A complex therefore is a centre or collection within the mind of ideas, memories, phantasies and feelings which are associated with one another for that person. This is a model of the mind not unlike the model of matter as composed of atomic particles which adhere in clumps according to the forces of attraction and repulsion which they exert upon one another. The notion that a complex may have a "gravitational field" into which other elements may get drawn gives us a useful picture. A large, elaborate or "heavy" complex may exert a strong influence upon the life of the person.
Before the advent of psychodynamic and phenomenological psychologies, people tended to assume that perception was simply the way the outside world impacted upon the organism, a process in which the person was essentially a passive recipient. It seems, however, that perception is actually a process in which we reach out and try to grasp the world in a particular way. Our complexes are actively looking for confirmation. If we feel frightened of someone, we actively look for evidence of their maliciousness. If we are attracted to someone we actively look for good qualities in them.
Jung hypothesized that psychosis is a condition in which certain complexes exert so strong an influence over the person that perception and thinking are completely distorted whenever the person comes in contact with anything which is in any way relevant to the dominant complex(es). Psychosis is, in this view, seen as a kind of extreme hysterical obsession. Jung concluded that "schizophrenics are permanently under the spell of an insuperable complex. Anyone whose whole interest is captivated by a complex must be dead to his environment.. A person with a strong complex thinks in terms of the complex, he dreams with open eyes and no longer adapts psychologically to the environment" (Jung CW3 p.98)
This idea is quite useful since we can go on from it to ask what kind of complexes would be that powerful and what kind of conditions might give rise to them. It also, as Jung affirms, means that the methods used in dreamwork can also be used to try to make sense of psychotic imagery.
The case of the seamstress described in Jung's Psychogenesis of Mental Disease (CW3) reveals three "complexes". These are the complex of "wish fulfilment", that of "injury" and the "sexual complex". Wish-fulfilment and injury, in this case, refer to her feelings about having suffered unjustly, by, among other things, being locked up in an asylum. They are two poles of her sense of herself as tragic heroine.
Her major complexes are thus seen to be those around the questions of identity and of sexuality. These questions are no different in kind from those which we all ask ourselves. They are simply different in degree. Freud, too, in a different context, identified the tension between the ego question and the sexual question as the source of stress, trouble and maturation in the psyche.
If we imagine the psychotic person to be showing little outward engagement with the world of others on account of being locked up in an inward struggle over these basic existential questions of identity-death on the one hand and sexuality-spirituality on the other, we will probably not be far wrong. And we all have such struggles. What is different is that the psychotic person has time for nothing else. "Normal" people are distracted from these dilemmas by the thousand and one trivia of everyday existence. But when we analyse the everyday lives of ordinary people we see that very similar complexes underlie their activity. The choice of washing machine is an assertion of identity or wish-fulfilment. The minor resentments of daily life are revealed as tips of the iceberg of death-fascination. The envies and jealousies to which we are all prey in small ways betray our suppressed erotic attachments and even our creative ambitions may be seen to stand in place of more primitive procreative urges, as is reflected in the way we all recognise what is meant when a man refers to his latest business project as his "baby".
THE EGO QUESTION
While Freud was primarily concerned with the problems caused by the sexual question, Adler devoted his career to understanding the ego question. He came to the conclusion that since all humans spend the early formative part of their lives in circumstances which are dominated by their elders, we all grow up with an inferiority complex of some sort. From this perspective, the variations of personality between people represent the repertoire of possible ways of living with, crumpling under, compensating for or rising above this ubiquitous complex. We all have a mix of phantasies of ourselves as alternately victims or grand characters, readily to hand. When such phantasies are close to the surface we appear over-sensitive or "touchy". When the pressure of them becomes uncontainable, one might start to wonder if one is really a villain or, perhaps, a hero.
Society generally provides us with several acceptable identities, as the occupant of a trade or profession, as the child of such and such a family, as the spouse of somebody, as the person with such and such a reputation. And we may decide to settle for these. But what if we start to doubt that this is who we really are? Perhaps when you were a baby the hospital got the cots muddled. Perhaps you do not really belong to your family at all. Can you know for certain that this is not the case? And your history - we all misrepresent the past and there are many things we have forgotten. What if, really, you are a murderer and have simply forgotten that you did the deed? Stranger things have been known. Can you be sure it is not so? Or again, perhaps the things you did mean that you are now the target for revenge by a group of people who are out to kill you. Can you be sure you are not being hunted? Once you start to believe it may be so, you will soon find signs which may be taken as evidence in favour of this hypothesis, especially if you are at the bottom of the pecking order in society. And who can you trust to tell you honestly it is not so?
And, there again, why should one accept the identity which others thrust upon you if you do not like it? Why should you be a tramp when someone else was born to be a queen? Who is really to say that she is a queen and you are a down and out? Perhaps you are the queen. As soon as you start to believe it, life feels a lot better. "Delusions" about mistaken birth are common. And, of course, they are not always delusions. Many people have been brought up by people whom they took to be their parents, not knowing that they were actually adopted.
Ideas of grandeur are psychotic. They are also universal. We all have them and keep them hidden to varying degrees. They are the root of ambition. And insofar as we have ambition and do not fulfil it, we are ready to see ourselves as victims.
A variant upon the "delusion of grandeur" is Jung's idea of "inflation". Jung gradually realised that the material of dreams and of psychosis is also the stuff of myth. His long researches into this subject showed how certain images recur in all cultures, clothed differently but nonetheless recognisable. This led him to posit the idea of a "collective unconscious" shared by all people within which reside archetypal images. These are like deep complexes which are already embedded in our minds from the beginning of our lives. The pantheon of gods generally found in early civilisations may be taken to be an outward projection of these archetypal figures. They are the inner powers who rule our lives and they generally exist in some sort of balance one with another. It can happen, however, that a person's sense of identity become fixated upon one such archetype and the result is then what Jung called "inflation" of the personality. If circumstances allow, the person may derive great energy from the archetypal source and live out a "larger than life" existence, which will appear fascinating to others insofar as they themselves have suppressed the particular archetype in question in their own lives. This is one way of explaining the appeal of figures such as Hitler or, equally, of some pop stars. A current example of deliberate play upon a set of archetypal images is the career of the singer Madonna. Where circumstances do not permit the person to live out the archetype upon the stage of life, it may nonetheless be lived in phantasy and so we find in our psychiatric hospitals any number of kings and queens, Christs and virgin mothers. The psychotic person may not necessarily believe that he is the archetype himself, it may be that he stands in a particular relationship to the archetype, commonly, of course, that of being controlled by it. Thus, to take a common example "the space alien is clearly an archetype" (Lukoff 1988, p.123).
THE SEXUAL-SPIRITUAL QUESTION
Sexuality and spirituality are seen as opposites by many people. They are poles of experience which are related to each other. Sexuality and spirituality are also both forces (or are a single force) which disrupt(s) our sense of who we are. The sexuality-spirituality question cuts across the ego question. The transforming power of romance and/or spirituality is one of the commonest themes of literature. And the insolubility of the conflict which can arise between our spiritual or erotic aspirations on the one hand and our sense of our own identity on the other lies at the root of much psychological torment and many psychotic phenomena.
Consequently, a great many images produced in psychosis have to do with sexuality or spirituality or some amalgam of the two. "I am the devil", "The priest is the father of my child", "The angels are following me", "The homosexuals are coming through the walls", "I am marrying the virgin mother" are not untypical examples.
Lukoff (1988) describes work with a manic client who reported being carried off by space aliens and he comments that "The sequence of events in abduction reports follow the ancient mythic pattern of the shaman's journey which can be traced back to 12000-30000 B.C. The shaman is taken to 'other worlds' on a 'cosmic pillar' (which resembles being taken aboard a spaceship); is painfully dismembered.. events take place in a yurt or teepee (same round shape as UFO), and then the shaman returns with songs and other instruments of healing (a type of message).. Although there is a close correspondence between the themes and sequence of events [Lukoff's client's] specific mythic images are not from the world of the early hunting cultures, but from contemporary culture (eg. space aliens instead of spirits).. abduction experiences and shamanic journeys are archetypal fantasies.. journeys during which the individual is thrust into the world of the imagination with the goal being the education of the soul" (Lukoff 1988, p.125). Those interested in the connections between sexuality and spirituality may also see sexual significance in the "cosmic pillar" and in the act of "dismemberment" and in the entry into the dark round teepee. This kind of journey sequence unites sexual, spiritual and rebirthing imagery into a single sequence.
The repression of sexual urges is an everyday part of life. When the urge is a strong one as in instances of betrayal or of unrequited passion or of love which cannot be declared or of sexual jealousy, the emotional charge which has to be repressed may be of an intensity sufficient to destabilise the whole character. If the repression is at first successful, all may seem well for a time and then a "chance" event such as hearing news of one's lost beloved may be sufficient to trigger uncontrolled phantasies and strange behaviour which seem the more incomprehensible for the fact that to the observer there is no obvious cause.
Spirituality is the path of liberation. As such it is often earnestly sought by the person facing insoluble problems or wrestling with inner torments. The degeneration of spiritual discipline into magical ritualism, or into a persecutory force, however, is a common pitfall of the path as the soul struggles to find a way through against seemingly insuperable odds. There are many parallels between the dilemmas of mortal eroticism and those which the soul faces in its romance with the divine.
Some useful ideas in the understanding of psychosis have been developed by followers of Eric Berne's Transactional Analysis. This is a simplification of a set of ideas which originated with Paul Federn, an associate of Freud and early advocate of ego psychology. Federn suggested that the ego may not be all of a piece but may be sub-divided, each sub-division containing different introjected material. This idea allows for internal dialogue between different parts of the ego. Ideas of this kind have been found useful by therapists working with people who exhibit multiple personality.
Berne simplified Federn's schema by saying that, in effect, there are three basic ego states, which he called "parent", "adult" and "child". There is not room here to restate Berne's ideas in full. What is interesting to us are the three following ideas:
1. "Voices" may be the externalization of the "critical parent". In most cases, psychotic "voices" are critical, so much so that the client will not readily tell you what they say. This is itself a sign that the client is unwilling to own them. We may say that voices are an instance of the "internal" dialogue being externalized. More of this below.
2. "Delusions" may be a sign of weakening of the "child"/"adult" boundary. This reflects the fact that most delusional systems contain some bizarre axioms (child) but also some internal logical consistency (adult). In other words, for instance, if you were to accept that there really were Martians in the house, everything else the client says makes sense. This is, in a way, akin to the real child who wanted to know, when a man was landed on the moon, why they had not waited until it was full moon so that the job would be easier. Many of the charming and embarrassing things said by children are similar in form to psychotic ideas and this may provide us with one key to understanding the latter.
3. Energy can get locked into one ego state leaving the other impoverished. It is suggested that energy stuck in "parent" leads to paranoia; stuck in "adult" leads to mania; stuck in "child" leads to the creation of a private delusory world. The value of this sort of theory is that it gives us possible points of entry in our attempts to understand. We all have a parent ego state and when we stay in it too fixedly we do start to over value ourselves and suspect those around us. Those of us who are in adult too much of the time are vulnerable to becoming workaholic.
When we try to understand psychotic speech and imagery by reference to possible underlying psychodynamics, therefore, we may consider any of the following:
That it is the manifestation of a powerful complex which over-rides other concerns;
That it is like wakeful dreaming, and so may be worked with in the same way as dream material;
That it is like a defense mechanism, that it serves to ward off something unbearable such as a terrible guilt or knowledge that one loved in vain;
That it is a symbol for an unresolved issue, such as a humiliation or a grief;
That it is a compensation for or escape from low status, as when people whose lives are full of drudgery convince themselves they are royalty or celebrities
That it is the inflation of the personality by identification with archetypal ideas
That it is the projection of aspects of the personality which cannot be accepted onto the outside world, as when we cope with our own suppressed rage by seeing enemies on all sides;
That it is displacement of uncomfortable emotions onto an easier target, as when the person says "The BBC is killing me" and means "My parents pay no attention to me but just watch TV all the time". The TV is blamed in order to avoid blaming the parents.
That it is representative of an inner dialogue between different parts of the ego or material introjected by parts of the ego or with ego states which have been split off.
That it represents a contamination of one ego state by another.
Once upon a time, I, Chuang Tzu, dreamt I was a butterfly, fluttering hither and thither, to all intents and purposes a butterfly. I was conscious only of following my fancies as a butterfly, and was unconscious of my individuality as a man. Suddenly, I awaked, and there I lay, myself again. Now I do not know whether I was then a man dreaming I was a butterfly, or whether I am now a butterfly, dreaming I am a man. (Giles 1989, p.47).
Generally we tend to think that waking is "real" and that sleep is a departure from reality. There is at least one important sense, however, in which it is the other way about, which is reflected in the popular song line "If you don't have a dream.." The unconscious is the realm of our wishes. It is our dreams which live us, as it were (Mindell 1984; 1985a; 1985b). Too often we see that the powerful drugs administered to take away the frightening and confusing "dreams" of the schizophrenic person, deprive her also of the very dreams which give meaning to life and we see her reduced to an apathetic figure. Clients have told me how being mad may be frightening but it is not dull.
So, if our dreams live us, it is important for us to have dreams. One of the most powerful pieces of oratory of modern times was the last speech of Martin Luther King in which the refrain "I have a dream.." helped to establish a close tie between King and the audience who were carried along on his words. Dreams give sense and direction to life.
The hallucinations, both visual and auditory, which afflict some people, have a similar quality to dreams. In the aftermath of major and minor traumas, people are likely to dream and, in their dreams, to relive the dreadful events and thereby to prepare for their possible repetition. This is probably the soul's attempt to become once again its own master. The horror is rerun repeatedly until the person is able to face it with some degree of equilibrium. This is how we learn to conquer adversity. "In dreams the dream ego is rarely in control" (Kaplan-Williams 1990, p.54).
Sometimes the dream image is so out of control it invades the daytime. The resulting states are called "fugues". Therapist's who help victims to relive scenes of torture or of sexual or physical abuse should beware of these. If the work is "under-distanced" the client may become over-whelmed in this way and may lose contact with surrounding reality. There is a real danger that the therapist will, at such a time, be misconstrued as the torturer and, perhaps, attacked by the client. Such experiences are to be avoided since, apart from the danger to the therapist, they may retraumatize rather than heal. Therapy, in such cases, is not a matter of getting back into as much pain as possible but of learning how to reach a state of peace.
I worked with a client who had been diagnosed as psychotic who, among many other "symptoms", suffered from nightmares. I encouraged the client to draw pictures of the figures who appeared in the bad dreams. Initially the figures drawn had no faces. Later, as the client became accustomed to drawing them, the dreams began to reveal more and more. Then, quite unexpectedly, the client began to have daytime hallucinations. She knew that the figure who appeared in her imagination in the room was the same figure as came in her dream. We were able to work successfully with confronting this figure in the daytime too and in due course it became clear that the identity of the figure was that of a person who had abused my client in the past. This case clearly illustrated the relationship between night-time dreams and daytime hallucinations and also showed how fear plays a central part in the process of repression. Facing the persecutory figures, helps the soul to become once again master in its own house.
Dreams, said Freud, are the Royal Road to the unconscious. His book Die Traumdeutung is generally regarded as a masterpiece. The title is normally rendered as The Interpretation of Dreams but a better rendering of the German would be something like The Fathoming of Dreams. "By inviting us to follow him into the seeming chaos of the world of darkness, of the unconscious and its irrationality, Freud intended to change our views of man; but this could be done only if we changed our view of ourselves and reached an understanding also of the darkest aspects of our minds" (Bettelheim 1983 p.69)
In Freud's theory, much of the material in dreams is symbolic of wishes which we are unwilling, for shame, fear or other reasons, to face openly. Freud's method for fathoming the deeper significance of dreams is that of revealing how the dream images symbolize both the repressed wishes and the forces which keep them in check. Commonly, as you know, he saw these wishes as sexual in nature. Psychotic illusions may similarly often be understood in this same way. The psychotic vision is not to be taken literally but can be seen as symbolizing a wish. In the case of a patient who said "I have blown up the world" this wish fulfilment element is fairly transparent. In most cases the meaning is more heavily disguised or the ambivalence may be more apparent, as in the case of a patient who kept saying that "The neighbours can see me when I am in the bath". In this last case, we do not have to assume that "neighbours" is to be taken literally. We can, I think, take it that the patient has some half suppressed wish to be seen naked by somebody. Listening further to the patient's associations of ideas might reveal to us who this somebody is and also, perhaps, why the wished for encounter was taboo.
The idea of unfulfilled wishes may also be equated with the idea of defeats. We have all suffered defeats in life and when these have been acute we have found ourselves seething with feelings and struggling to rein them in.
"The dream is a great rehearsal place for dealing with the many aspects and issues of our existence. We get to deal specifically with fear, with choice-making, with violence and anger, with sexual energy, with sickness and health, with humour and joy.. Ultimately health and wholeness seems to reside with those who do not seek to control their dreams yet to work actively with them, both in the dream state and by applying dream wisdom and energy to life, thus creating congruency between inner and outer life" (Kaplan-Williams 1990, p56). "To take creative action the dream ego can:
# Keep itself in the dream as long as possible and see what
# Change its point of view in the dream and accept the situation and then deal with it.
# Face adversarial forces and interact with rather than run from them.
# Express feeling reactions in the dream to what is happening." (ibid. p.54).
The above summary of dreamwork principles seems to me to apply with equal force to working with psychotic hallucinations. I have worked with people with daytime hallucinations helping them to stay with the unfolding sequence rather than flee, helping them to take an interest in it rather than be over-whelmed by fear, helping them eventually to face threatening figures and interact with them, helping them to express the emotions which come up, no matter how daunting. The results of such work are to bring the psychotic material into ordinary reality and to reduce its dominance. This type of approach is quite different from that of those who see psychotic material as meaningless and chaotic.
A working hypothesis: If dreams help us process our defeats and prepare us to try to turn them into future victories, then it is possible that psychotic delusions perform the same function upon a larger scale. If this is so then the cultivation of courage has a central part to play in helping the psychotic person and courage is best cultivated by having someone willing to fight at one's side. This someone is the therapist. From this perspective, it is not good therapy to brush the hallucinations aside when they are pressing for attention. Client and therapist must face them together.
On the other hand, courage for the big battle may also be worked up by winning a few skirmishes on other fronts first. It is, therefore, probably not a good idea for the therapist to try to force the client to face the dragon before he is ready. Clients seem to know how much they can manage and will present scenarios matched to their current ability.
The dream world is like the world of fairy tales. Remembering the phantasy world we had as children is a useful means of accessing the atmosphere of excitement and terror which pervades the inner psychotic world.
The psychotic imagination, like dreams, works to a large extent through imagery and action. Indeed, when we are close to the limits of what our "sane" way of functioning can cope with, we are apt to say "Words fail me". A client of mine whose verbal dialogue was extremely impoverished and repetitive, came to life when given a sheet of paper and crayons. He drew a picture of his own head and produced a plan of different chambers where different mental activities and feelings took place. It was a graphic description of the fragmentation he experienced and while drawing he was able to talk to me about it with far more fluency than he had managed when we sat face to face.
Painting the images which appear to us in dreams can be revealing and seems to help the dream process forward. Representing our own lives and feelings in art materials without the constraint of any expectation to produce a "proper picture" is a very direct route for most of us to finding how completely idiosyncratic imagery is deeply moving to us.
One client had a recurring dream which always ended at the same frightening point. I encouraged her to draw the dream image the morning after the dream. She reluctantly agreed and did so. The next night the dream recurred but this time it continued beyond the point at which it usually came to an end. Again she drew it on waking. The following night the same dream came and again it went a little further still. The work became like attending to an unfolding serial story with a new episode each night.
Sometimes the world of the psychosis can be reenacted. Here the methods of psychodrama are useful and the technique is really no different from working with a dream. This is delicate and powerful work which requires great skill. There are pitfalls even for those familiar with the method. There is a danger that the client will interpret the doubling technique as people reading his thoughts and this may precipitate paranoia. On the other hand, doubling may also provide just the sense of fusion which brings the inner struggle with "the ego question" to life.
Artistic creativity and psychotic imagination are not unrelated. A number of galleries in Europe are devoted to displaying art produced by "mentally ill" people (Parsons 1986). The creative artist has to have at least one foot outside of conventional reality and, conversely, there are many accounts of madness in literature (Feder 1980). Several well known accounts are to be found in Shakespeare.
If the psychotic experience, and perhaps dreams too, can be regarded as a process of training or educating the soul, then artistic expression may be valuable not only in finding one's way through the experience, but perhaps even more significantly, in integrating it after one has returned from it.
LANGUAGE AND METAPHOR
Pictures and images come first. Language comes second. Images can be auditory as well as visual as we know from music and onomatopoeia. What sort of a creature is a swissy-wis? And what sort is a daggety-ik? And what about a prurrly? Can you imagine them even though you have probably never seen these names before? Would you like it if I were to gack chock you? Probably not. On the other hand if we were to sworderly woon it might be quite pleasant, don't you think? Language is not just about conventional meanings or logical definitions.
Sally was so worried about her interview she had butterflies in her stomach. The psychiatrist was not particularly worried about this because she sometimes got them too. Her patient Jack, however, had moths in his stomach and this was clearly symptomatic of a major psychiatric disturbance. Do you agree?
When we try to convey something of how we feel to somebody else, the task is not easy. Another patient Bill had a hedgehog in his stomach. Nobody took much notice because everyone knew he was mad. In fact Bill's duodenal ulcer had to get to a pretty bad state before anybody recognised what was happening to him. Now we might decide that saying that one has a hedgehog in the stomach is too indirect to be meaningful until we remember Sally. Should she actually have said that she had ventral palpitations? If she had, she would probably have received some askance looks. Psychotic statements about the state or contents of the abdominal area of the body are common because this is where we feel many of our feelings. When a client says that "My stomach is rotting" or "There are rats inside me" they are probably trying to convey something really felt. When I say "I feel empty", I expect you to understand and sympathize. But if I were to say "I have no insides" you might start to think I was strange. The meaning, however, is essentially the same.
From these simple examples we can see that steering a way through the common conventions of speech, even though it seems to come naturally to most of us most of the time, is actually more complicated than at first appears.
When a psychotic patient tells us that she is "the mother of China" what are we to make of it? Yet is this not actually a very succinct metaphor if what she means to convey is that she feels that a vast number of people look to her for the sort of nurturance which a mother might provide? On the other hand, the problem with metaphors is that they are always open to more than one interpretation. She might mean that her daughter is as brittle as a fine clay pot.
It is mad to try to avoid death for none can. Yet we all try to do so. If madness is a form of confusion, then we are all mad when we think of death for none of us really knows what it is, yet we all know it is our future. The attempt to avoid death, or to avoid the urge toward death within us, is often a major factor in the life of the psychotic person. Many psychotic delusions are concerned with death and this is no wonder.
We are all probably familiar with Hamlets' musing's on death. Consider, too, this account of the Chinese Sage Chuang Tzu:
Chuang Tzu one day saw an empty skull, bleached, but still preserving its shape. Striking it with his riding whip, he said, "Wert thou once some ambitious citizen whose inordinate yearnings brought him to this pass? - some statesman who plunged his country in ruin and perished in the fray? - some wretch who left behind him a legacy of shame? - some beggar who died in the pangs of hunger and cold? Or didst thou reach this state by the natural course of old age?"
When he had finished speaking, he took the skull, and placing it under his head as a pillow, went to sleep. In the night he dreamt that the skull appeared to him and said, "You speak well, Sir; but all you say has reference to the life of mortals, and to mortal troubles. In death there are none of these.. Chuang Tzu.. said, "Were I to prevail upon God to allow your body to be born again, and your bones and flesh to be renewed, so that you could return to your parents, to your wife, and to the friends of your youth, - would you be willing?"
At this the skull opened its eyes wide and knitted its brows and said, "How should I cast aside happiness greater than that of a king, and mingle once again in the toils and troubles of mortality?" (Giles 1980, pp.174-175)
Was Chuang Tzu mad to talk to a skull? Was the skull mad not to want to return to life? Are those psychotic people who believe themselves to be already dead, really so mad, not wanting to participate in life as they have experienced it? If we think that they ought to want to return to the state of those who believe they are alive, how can we know whether we are right or not?
Death can be "caused" by the mind. Apparently healthy people have been known to die abruptly under the influence of voodoo. Elderly people particularly seem to be vulnerable to death as a "result" of disruption of the circumstances of their lives. So when a person believes that something within their mind has a potential to be fatal, can we say they are wrong?
In earlier times "dying a good death" was seen as a pinnacle of human achievement. Nowadays death is kept out of sight and medicalized. Yet death anxiety has not gone away. The ability to face death peacefully is in some degree a function of having lived meaningfully. Equally the contemplation of death can give us the motivation to make our lives meaningful. Here again the psychotic preoccupation with death may be seen as an education of the psyche.
The hero of Kurosawa's 1952 film Ikiru is Kanji Watanabe, an elderly man who has worked more than twenty-five years in a city bureaucracy and who suddenly discovers that he has stomach cancer and only six months to live. Kurosawa describes his hero and the origin of the film as follows: "The hero of the film looks death in the face and for the first time realizes that his past life has been meaningless. Or rather, he realizes that he has not yet lived at all. And so he decides to live well in what little time he has left. I wanted to examine closely the tragedy born of this man's triviality." (Weimer & Lu 1987, p.134)
The confrontation with death strips the trivia in our lives of meaning and exposes us. Can we become therapists if we have not had such an encounter? Can we gain access to our own psychotic imagination without it?
CHOICE AND GUILT
Meaningfulness in life is bound up in questions of choice and guilt. In the film Sophie's Choice, we see how the surface view of a person's life and their suicide may seem incomprehensible. Surely she was mad to take her own life. Yet when we know her history, as it is unfolded to us in the film, there can be few of us who fail to understand how her life was unbearable and how death made sense for her. Yet again, we can reflect that the event which made her life hell had occurred many years before and had been over in a few moments. The hell that she suffered was the result of a choice she had made, a totally invidious choice which, we might say, nobody should ever have to make. Yet, if we were faced with such a choice, how would we fare? And, in truth, how many of us have not, in fact, made decisions in our lives, which have affected whether others would live or die? We might initially think we have not done so, but everything in the world nowadays is so inter-related that we will all, in fact, have contributed to policies and practices which have resulted in deaths elsewhere. The difference, if there is one, is that Sophie's choice was one in which the destructive effect was immediate and visible and constituted an attack upon her deepest instincts as a mother.
A patient in a psychiatric hospital persisted in telling staff that the problem was that his right foot was a murderer. He had phantasies of cutting it off and blamed it for all manner of things. The staff took this for nonsense at first. It eventually became clear, however, that many years ago when driving he had run over a child. There was a sense in which the foot on the accelerator pedal was indeed a killer. We can imagine the fatal moment when he had to choose what action to take as the child ran into the road. We can imagine the torment afterwards of recalling that he had been driving too fast. How can someone live with such knowledge? His case is very like Sophie's in some ways. But rather than kill himself like Sophie, this patient "realised" that he had not decided to drive too fast and so was not himself to blame. It was simply his foot which had pressed down too hard. When we remember Sophie, we might hesitate to disabuse him.
FEAR AND PERSECUTION
We live in a world full of threats. Many people have experienced extremes of physical or mental cruelty. Others have reason to believe that they may have to do so. And, even if one has not experienced such things oneself, it is painful to think that one participates in a world where such things are commonplace.
When one hears a client say "The lions and tigers are going to eat me up" or "The neighbours are pumping gas into my house" or "There are rats in my bed", it is not necessary to take what is being said literally. If a business man tells you he has to watch out for sharks, you know what he means. If someone were to say that he feels people are getting at him in all sorts of insidious ways, it makes sense. If another person says they cannot sleep because things gnaw away at them all night, we understand. We do not need to respond to statements of this kind by looking for lions, tigers, gas or rats, but by appreciating the fear, suspicion and worry which is being graphically described and which we all have enough experience of life to understand.
THE SUPPRESSION OF TERROR
A useful principle in understanding psychotic communication is to assume that psychotic ideas and images substitute for emotion. More than one client on the way to recovery has said to me "When I feel the feelings I do not hear the voices". This is an important process. The psychotic person, like the hysteric, seems sometimes to be characterized by "La belle indifference". We should not, however, assume that this means that there is no emotion there since we can see from the often gruesome content of the imagery presented that some powerful feelings are intended. We will do well to respond as though the emotion implied were actually present, even though it is not apparent in the client's manner.
A colleague, Garry Prouty, from the USA has talked about a case in which a woman's terror about being murdered after this fate had befallen her flat-mate manifested as a day-time hallucination of a python. The python accompanied her everywhere she went and she could keep it under control by mind power so long as she adopted particular ritualistic behaviours. This description fits well with the theory that delusions are a practice ground for the soul in its attempts to master the inner urges conjured up by uncontrollable outside events. The client could not predict when the murderer might strike but she could practise her reactions by living with the python. That way, too, her guard would not go down. As a therapist making first contact with this woman what would be immediately accessible to understanding is that the python had something to do with acute fear and it is to this powerful emotion that a response could be made even though the client might tell the therapist about the python in a totally unimpassioned way.
Clearly, if psychotic images substitute for emotions, it may sometimes be therapeutic to reverse this process. My thinking along these lines must have become apparent to one client who came for her session with me and reported "I have been crying and feeling miserable all weekend, and I know you will be pleased". She was right. When she came in a flat unaffected mood it was usually not long before she was telling about the persecutory figures who tormented her inwardly. Another client, diagnosed by her psychiatrist as manic, had a long struggle to balance the urge to only have "positive" smiling feelings with the knowledge that this generally tended to end in a further manic episode.
REACHING OUR LIMITS
We all have limits. Jaspers refers to "limit situations", thresholds beyond which lie "an army of forces" (Jaspers 1919). Once we are beyond our limits, a degree of madness is necessary for we are no longer ourselves: we are, as we say, beside ourselves.
An example from ordinary life of the principle that it is sometimes rational to be irrational is provided by the two following anecdotes. In the first case, a man who had money in his flat was tortured by burglars who wanted him to reveal its whereabouts. It is clear that if he did not tell them they would kill him eventually and if he did tell them they would kill him straight away so as to have no witnesses. This person's best chance of survival is to become psychotic immediately. Only then is there a chance that they will decide it is a waste of time bothering with him.
The second example is more prosaic and from my own life. When my first child was born she was placed in a cot in the observation room. My wife wanted her to be at the bedside but the nurses, wanting to be totally sure of their medical procedures, would not agree. Rational argument was to no avail. My wife got out of her bed and stood in the centre of the ward screaming. The baby was brought forthwith.
Jung describes the breakdown of a young woman whose behaviour became irrational when faced with the dilemma of how to tell her fiance that she had had a previous child. "The problem seemed insoluble.. hence the affect became insuperably great" (Jung CW3, p.165) and her behaviour became bizarre. Once it had begun to be so she then experienced all manner of inner doubts and regrets and the situation escalated.
We will all be familiar with some occasion of this kind when a human irrational response has won the day over rational procedures or where an insoluble situation has pushed a person to uncharacteristic behaviour, and, I think, we all also fear the emergence of a world where rationality had the upper hand to such an extent that there would be no room left for our psychotic imaginations to have play.
CONCRETISATION AND LITERALISM
We have already considered how the style of speech which most people use to express feelings metaphorically, in psychosis tends to become literalised so that, for instance, where the ordinary person might say "I feel empty" the psychotic person might insist that they have no insides. This process is reversible. Some sense can sometimes be made of psychotic speech by asking oneself what the phrase used might mean if it were a metaphor in common usage. Such a method might well have helped the man who suffered from a hedgehog in his stomach.
This aspect of the psychotic imagination may be attributed to the strength of the complex or preoccupation which is dominating the person's mentality. Thus if the client is preoccupied with a complex about death and dying, a casual remark such as "Can I lend you a hand?" may immediately conjure up a gory image for the client. The normal meaning of the phrase is lost as the complex seizes an opportunity to make its influence known. This happens to all of us in varying degrees. When we mishear someone, it is commonly because we are already preoccupied with something which affects us more personally. As therapists we need to be willing to drop our original intention at such moments and to see where the chain of associations of ideas will take us. We need to be able to put our imagination to work so as be able to, in phantasy, enter the world which might be appearing to the client, to see, in this case, in our mind's eye, the blood, to feel it hot upon us, to notice the visceral reactions within us.
The image of the severed hand must speak of some emotion at least and will connect with other similar images for the client which may now begin to become apparent.
As phenomenologists, our way of appreciating the world of psychosis may thus include:
* Adopting a positive mental attitude toward the person, no matter how strangely he presents himself. Since we will, at first, probably have some difficulty in communicating efficiently verbally, the subliminal messages we give out are even more important than usual.
* Maintaining a warm and attentive manner toward the person, taking care not to alarm, and listening carefully to what is said without mentally classifying it into mad and sane components.
* Noticing the manner in which things are said and paying careful attention to body language and behaviour. The psychotic person does not recognise the normal conventions about communication and the acting out of significant meanings may therefore be more obvious.
* Using our own imagination to conjure up the world of the client. The therapist working with the "snake woman" should soon be able to "see" the snake present in the consulting room, as it is for the client.
* Inviting the client to express herself in whatever media seem useful. Many psychotic people find it easier to convey things pictorially than verbally. Toys and other symbolic objects may be useful. Sometimes it is possible to use dramatic methods and though there are also pitfalls in using this very powerful approach and it is not for the inexperienced.
* Responding to any sign of emotional expression appreciatively no matter whether the emotion is one which is normally welcome of unwelcome.
* Making reflective responses to the implied feelings rather than to the literal content, eg "That sounds frightening, like you are being intruded on" to the client who believes gas is coming through the walls.
* Translating images back into metaphors.
* Assuming the imagined figures have something important to say in their own right and encouraging interaction with them. This is a matter of letting the phenomenon speak for itself. Clients will generally resist this initially but one can return to the idea.
* Respecting that the client's behaviour serves a need even when it is not yet apparent what that need is. Sometimes it is rational to be irrational. We are not good phenomenologists if we assume that we know best what is right for the client. Our aim is to understand the phenomenon in its terms rather than ours.
"COLLUDING" WITH PHANTASIES
I am sometimes accused of colluding with the client's madness by taking it seriously and attending to its imagery. For me it is more important to understand than to avoid "collusion". In fact I do not collude with anything, I attend to it. Gentle attention breaks the client's isolation. Reflecting and amplifying images and metaphors enables the therapist to use her own imagination and thus to build up a sense of the client's "world". By staying with the person in his/her flow of experience the terror of them is reduced and new discoveries are made by both parties. This requires the therapist to stay in the free-floating mode of mental activity in which all aspects of the client's expression can be given equal opportunity to speak.
The following are simple practical points to be borne in mind when communicating with a person who is psychotic. Many of them apply with equal force to communicating with any client:
1. This person has probably been through experiences which are terrifying. Create trust and safety.
2. He has also probably been humiliated, experienced a lot of failure and been treated as of no account many times. Treat the person with the utmost respect.
3. He/she will have come to distrust his natural emotions and may have further lost touch with them as a result of drug regimes. He/she will need help recognising ordinary emotional reactions and believing they are normal.
4. Any emotion is better than no emotion.
5. The ordinary world may seem dull and uninteresting compared with the drama of being mad. The "recovering" psychotic client may experience grief about losing his delusions and hallucinations.
6. Achieving understanding is a slow process. Be patient.
Psychosis is a process of the imagination akin to dreaming in which the person is overwhelmed by images which are compelling to a degree which takes precedence over input from the environment. Such imagery serves a purpose for the person's psychological development which may not at first be apparent but which generally has to do with coming to terms with difficult or even insoluble dilemmas in life. As such it may be regarded as an extreme form of phenomena with which we are all familiar even though the task of unravelling may be complicated in the particular case. The methods of the psychodynamic and phenomenological therapies include a wide range of approaches which may be useful. Fundamentally, however, it may be of greatest importance for the therapist to learn to recognise and use his or her own "madness" and to work at coming to terms oneself with the existential dilemmas in which the psychotic client has become enmeshed.
I would like to give the final word on this occasion to Jung:
That is how mental illness looks from the psychological side. The series of apparently meaningless happenings, the so-called 'absurdities', suddenly take on meaning. We understand the method in the madness, and the insane patient suddenly becomes more human to us. Here is a person like ourselves, beset by common human problems, no longer merely a cerebral machine thrown out of gear... we recognize insanity to be simply an unusual reaction to emotional problems which are in no wise foreign to ourselves. (CW3, p.165).
BARHAM P. & HAYWARD R. 1990 Schizophrenia as a life process. In R.P.Bentall (Ed.) Reconstructing Schizophrenia. London: Routledge.
BATESON G. 1973, Steps to an Ecology of Mind, Paladin*
BETTELHEIM B. 1983. Freud and Man's Soul. London: Chatto & Windus.#
DSM IIIR. 1987. Diagnostic and Statistical Manual of mental Disorder (3rd Edition, Revised). Washington D.C.: American Psychiatric Association.
FEDER L. 1980. Madness in Literature. Princetown: Princetown University Press.
FREUD S. 1900. The Interpretation of Dreams. London: Penguin Freud Library vol 4, Penguin Books 1976.
GILES H.A. 1980. Chuang Tzu: Taoist Philosopher and Chinese Mystic. London: Unwin.*
JASPERS K. 1919. Psychologie der Weltanschauungen. Quoted in S.Resnik. The Psychotic Crisis. British Journal of Psychotherapy, 2, (1), pp.5-19.
JUNG C.G. References are to volumes of the collected works published by Routledge, London.
KAPLAN-WILLIAMS S. 1990. Dreamwork. Shaftesbury, Dorset: Element.*
LUKOFF D. 1988. Transpersonal perspectives on manic psychosis: Creative, visionary, and mystical states. Journal of Transpersonal Psychology, 20, (2), pp.111-139.#
MINDELL A. 1984. Dreambody. London: Routledge & Kegan Paul.
MINDELL A. 1985a. Working with the Dreaming Body. London: Routledge & Kegan Paul.
MINDELL A. 1985a. River's Way. London: Routledge & Kegan Paul.*
PARSONS P. 1986. Outsider Art: Patient art enters the art world. American Journal of Art Therapy, 25, pp.3-12.
WEIMER S.R. & LU F.G. 1987. Personal transformation through an encounter with death: Cinematic and psychotherapy case studies. Journal of Transpersonal Psychology, 19, (2) pp.133-149).#
WORLD HEALTH ORGANIZATION 1979. Schizophrenia: An International Follow up Study. Chichester: Wiley.
OTHER INTERESTING READING
BARNES M. & BERKE J. 1973, Mary Barnes, Penguin*
BENTALL R.P. (ed) 1990, Reconstructing Schizophrenia, Routledge
BERKE J.H. 1979, I Haven't Had to Go Mad Here, Penguin*
COOPER D. 1972, The Death of the Family, Penguin*
FOUDRAINE J. 1971, Not Made of Wood, Quartet*
HOELLER K. 1990, Readings in Existential Psychology and Psychiatry, Rw of Existential Psychol & Psychiat, Seattle WA, includes relevant chapters by Gendlin, Laing, Rogers, Boss and others.*
LAING R.D. 1960, The Divided Self, Tavistock*
LAING R.D. & ESTERSON A. 1964, Sanity, Madness and the Family, Tavistock*
LIETAER G., ROMBAUTS J. & VAN BALEN R. (eds) 1990, Client-Centered and Experiential Psychotherapy in the Nineties, Leuven Univ Press, Belgium*
MORENO J.L. 1946, "Psychodramatic Approach to a Case of Dementia Praecox", in MORENO J.L., Psychodrama vol I, Beacon House, Ambler PA 1985*
PODVOL E.M. 1990. The Seduction of Madness. New York: Harper Collins.#
PROUTY G.F. 1990, "Pre-therapy: A Theoretical Evolution in the Person-Centered/Experiential Psychotherapy of Schizophrenia and Retardation", in Lietaer et al 1990.*
ROGERS C.R. & STEVENS B. 1967, Person to Person, Real People Press, CA*
TEUSCH L. 1990, "Positive Effects and Limitations of Client-Centered Therapy with Schizophrenic Patients", in Lietaer et al 1990.*
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