Understanding and Working With Psychosis (Part I of II)

Photo by The Fox and the Raven

by Joel Schwartz, PsyD

Psychosis is, perhaps, the most misunderstood and feared psychological phenomena – despite the fact that every person is capable of psychosis, and most of us have actively psychotic parts of our personalities.

Like many diagnostic categories – dissociation, anxiety, depression, narcissism – psychosis exists on a spectrum from everyday experiences to extreme and debilitating. And like the categories above, all are very human adaptations – coping methods that may be important for us to live well. Depression can be a signal of a life gone awry. Anxiety can be a signal that something is amiss. Dissociation protects us from emotional overwhelm and pain. When these processes go awry or get stuck, they become dysfunction. So what possible function can psychosis have? And why does it become so other-worldly and debilitating?

So let’s begin with a basic definition of psychosis. In my view, which is through a psychoanalytic lens based on the works of R.D. Laing, George Atwood, Michael Eigen, and Brent Potter – psychosis has two main components: literalization (or reification) and anti-learning. What we typically label as “psychotic” is an extreme version of these necessary and normal psychological processes.

1) Reification refers to the conversion of an abstract concept into something concrete, and comprehensible. A symbol is an example of reification; it takes an abstract idea and creates meaning in something concrete and comprehensible. Rituals are also reifications; they take a complex process or idea and break it down into comprehensible steps in which a group of people can share.

Already we can see how the above processes can be positive. Reification allows for difficult reality to be comprehended, played with, and used in a relational and cultural context. Symbols, religion, mores, laws, etc are all examples of cultural reifications that allow people to bond together – the most important adaptation for human survival. But we can also see how reification has negative component. Reification often leads to extreme rigidity – people don’t want to change their rituals or challenge their symbols. Challenges to the reification are often met with hostility and violence.

2) Anti-Learning refers to a caustic force within the psyche that seeks to stop learning from occurring, or in some cases is destructive of previously learned material (according to Wilfred Bion, similar to Pavlovian links in understanding, or linking of meaningful interpersonal experiences with oneself). We can see a breakdown in Pavlovian associations in circumstantial and tangential speech and confabulations of memory often exhibited by psychotic individuals. Examples of the latter, that is undoing meaningful interpersonal links (Bion called these “Attacks on Linking), can be seen in many non-psychotic clients: refusals of empathy or acting mean when someone is kind for instance. Another familiar example is the undoing of meaning or discounting of evidence sometimes seen in Obsessive Compulsive clients (OCD often has subtle psychotic components). I once had a client who noticed a pretty female from afar, and when she came into view, she was a young teen. The client was sure he was a pedophile despite no history of such attractions or behavior. The meaning of all his previous experiences was destroyed, unlearned in the moment.

Anti-Learning is a little difficult to understand from a positive perspective, as is all self/other-destructive parts of the psyche. Freud’s death drive – the compulsion to put oneself in harms way, Klein’s infantile sadism which seeks to destroy the mother, Winnicott’s idea of hate which is inherent in the give and take of playful relationships, and Eigen’s psychopathy – a violent part of all of us that is a key toward survival – all difficult to sit with and comprehend, and all part of being human.

What do all of these forces of destruction have in common? They are all necessary for growth and survival. Putting oneself in harms way, and mastering fear makes us brave – it builds grit and makes us capable of amazing feats. Infantile sadism requires parents to respond in a way that builds safe boundaries, containment, and mastery of our worse selves in an interpersonal space. It is the same with Winnicott’s hate. Even our universal capacity for psychopathy, our ability to do violence and cut off our feelings and empathy, is necessary for survival. We must hunt and war to survive.

And so we identify a great dialectic: Destruction breeds creation. Death breeds life. Tearing down breeds building up. Our love for our children gives us the capacity to murder the kidnapper. Destroying the forest breeds building the city. Murdering the animal allows us to live. Chipping away at the stone creates the statue. And Anti-Learning creates room for new learning. Anti-Learning also helps solidify bonds. Anyone who loyally belongs to a group and ignores its sins is refusing to learn, to let information take meaning, in order to preserve a connection. We can see this play out in the political arena all the time.

Psychosis can be a thought of as a combination of extreme Anti-Learning and reifications as a result of previous unprocessed trauma, a no longer livable existence, or current distress due to the breakdown of the mind. It has long been known that the beginning stages of schizophrenia result in a breakdown of white matter in the brain (Anti-Learning). Only recently, we have learned that for many, during the latter stages of schizophrenia (when the person’s brain hasn’t been completely dulled by medication), there is a great re-organization and regrowth of white matter – as if the brain is becoming something else. Thus we see that Jung’s long-ago concept of metanoia – a spontaneous attempt of the psyche to heal itself of unbearable conflict by melting down and then being reborn in a more adaptive form – is essentially true.

If one’s existence is chaotic and unbearable, or one is caught in a double-bind within a family system, where any option results in pain, it seems that psychosis is an almost natural response for many. The psychosis makes the incomprehensible comprehensible. The deep existentially felt terror of the breakdown of the psyche becomes a “them” or an “it.” The constant assault from within is reified as a monster, or the government. The haunting unprocessed memories and feelings associated with terrible early traumas become paranoia. And for many, during this time, the very act of connection to another brings about such psychic intensity and discomfort that the psychotic part of the personality takes over and destroys the human-to-human link. Attempts to connect are experienced as an assault, and the psychotic person will undo connection, either through a breakdown in the relationship, or holding even tighter to their own reality, which excludes others. The psychotic person often does not want to share in our reality. There is comfort in the other world because it offers an explanation, albeit a frightening one. And finally, the combination of Anti-Learning and making-literal, results is an extremely literal interpretation of events that is resistant to any evidence to the contrary.

Brent Potter, in his book, Elements of Self Destruction suggests this process is similar to one of addiction. Something that was at first a method to cope with extreme distress goes awry, and becomes a primary way to cope that gets out of hand. Just as reliance on drugs ultimately leads to self-destruction, so does reliance on psychosis as a coping processes.

So where does that leave us as clinicians? Stay tuned for part II where I get into interventions.

More related: Healing psychosis: stories, information and resources and from earlier this week: Forms of dissociation are common to all human beings

joelJoel Schwartz, PsyD treats people, not disorders. He aims to re-humanize the mental health profession. He says, “I treat people, not isolated symptom patterns or disorders. All symptoms occur in the unique context of a person’s history, temperament, experiences, and capabilities. I am a warm and compassionate therapist that goes the extra distance to sit with and humanize what others may be afraid of or view as not in the “norm.” I help people who desire to really know themselves, to understand their thoughts, feelings, and behaviors in order to make the life that is best for them. My orientation is primarily relational psychoanalytic psychotherapy, but I have a firm grounding in cognitive behavioral techniques and borrow from humanistic and existential traditions. I am a sex-positive, pro LGBT therapist in the South Bay of Southern CA.” see professional profile here

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